Despite reports that children and young people may be less likely to get coronavirus disease 2019 (COVID-19) than older adults, there may be substantial indirect adverse effects of the disease on their physical and mental health, according to an analysis in CMAJ (Canadian Medical Association Journal). http://www.cmaj.ca/lookup/doi/10.1503/cmaj.201008

"While children and young people seem rarely to be victims of severe COVID-19, we should anticipate that they will experience substantial indirect physical, social and mental health effects related to reduced access to health care and general pandemic control measures," says Dr. Neil Chanchlani, University of Exeter, United Kingdom.

The authors describe a range of potential adverse effects and contributing factors as well as mitigation strategies for health care providers and health systems. 

Adverse effects include

• Delays in seeking care for non-COVID-19-related illnesses, which can lead to severe illness and even death

• Widespread delays or omissions of routine childhood vaccinations, which can threaten herd immunity 

• Missed detection of delayed development milestones, which are usually identified during routine child health checks

"Delays in bringing children and young people to medical attention may be due to parental fears of exposure to COVID-19 in hospitals or on public transit, lack of childcare for other children, lack of access to primary care due to closures, or changes to hospital visitation policies," says Dr. Peter Gill, The Hospital for Sick Children (SickKids), Toronto, Canada. 

However, reduced social contact because of travel and quarantine restrictions may reduce transmission of other commonly acquired illnesses.

Factors affecting social and mental health

• Families living in inadequate or crowded housing may experience heightened stress or conflict, which can affect the mental and physical health of children. Refugees, some Indigenous communities and low-income families living with financial strain and food insecurity are particularly vulnerable. 

• Restrictions and cancellations of child welfare visits to at-risk families can reduce visits of birth parents and children in foster care, leading to harms.

• Forced isolation and economic uncertainty may lead to increases in family violence, contributing to mental and physical trauma.

• School cancellations may heighten food insecurity for children who depend on meal programs and increase vulnerablity with the loss of school as a safe place. 

• Lost social interaction and lack of structured routines may lead to increased screen time, decreased physical activity, lack of concentration, anxiety and early depression.

• Reductions in support for children with additional health care needs, such as those with developmental delays, can lead to delayed diagnosis and support.

""We need to better understand what goes into the decisions families make regarding the complex needs of their children during this pandemic and how we can better support them," says Francine Buchanan, a coauthor and Research Patient & Family Engagement Coordinator at SickKids. "Both practical and personal considerations need to be taken into account."

The authors suggest several mitigation strategies, including

• Clear communication that health services are open for children and young people if needed

• Alternative ways for hospital-based programs to deliver vital services, such as different locations or online 

• Adequate data collection to assess readiness to return to school, how children and young people contract and spread COVID-19, and hospital use and admission.

"We owe it to our children and young people to proactively measure the COVID-19 pandemic's indirect effects on their health and to take steps to mitigate the collateral damage," urge the authors. 

"Addressing the indirect effects of COVID-19 on the health of children and young people" is published June 25, 2020.