Q&A: MIS-C Means Kids Not Out of the COVID-19 Woods

The general trends for coronavirus disease 2019 (COVID-19) are looking great these days: infections, hospitalizations and deaths have been plummeting, as more vaccines are administered and—perhaps more important—vaccine hesitancy seems to be diminishing at least slightly. But children’s hospitals are seeing something that has given medical experts pause: a surge in multisystem inflammatory syndrome (MIS-C) and it happens to children who’ve gotten COVID-19. Linda Spaulding RN, BC, CIC, CHEC, CHOP, is a member of Infection Control Today®’s Editorial Advisory Board. Spaulding tells ICT® that the effect that COVID-19 has on children hasn’t been given much attention, but it’s a serious matter. According to the Centers for Disease Control and Prevention (CDC), MIS-C “is a condition where different body parts can become inflamed, including the heart, lungs, kidneys, brain, skin, eyes, or gastrointestinal organs.” The CDC admits that it does not “yet know what causes MIS-C. However, many children with MIS-C had the virus that causes COVID-19, or had been around someone with COVID-19.” Spaulding says that MIS-C can do irreparable damage to the heart. “It can be fatal in kids.” 

Infection Control Today®: What’s your take on multisystem inflammatory syndrome?

Linda Spaulding RN, BC, CIC, CHEC, CHOP: Infection preventionists have been watching this since the beginning of COVID. It is called MIS-C, which is, as you mentioned, multisystem inflammatory syndrome in children. And it can happen when they first get infected with COVID or it can present after they’ve recovered from COVID; two, three, four weeks after they’ve had COVID. It’s very important that parents are watching for this and that they get the kids to the hospital for proper treatment. Essentially, the kids will show up usually with a red rash. They don’t have COVID anymore. Parents aren’t thinking COVID. But it’s being compared to a disease called Kawasaki disease, which is also the same inflammatory…. The difference is this is related to COVID, whereas Kawasaki is not. But we still in the health care facility, we’re still diagnosing it as Kawasaki, but we know it is MIS-C. And then that’s how we identify it in order to report it to the department of health who goes on to report it to Centers for Disease Control and Prevention (CDC). And essentially, the kids will have a rash. They’ll run a fever. They might get low blood pressure or hypertension. G.I. symptoms such as diarrhea. And it can lead on to myocarditis, which is an inflammation of the heart. And that’s when we start seeing more of the kids being

Linda Spaulding RN, BC, CIC, CHEC, CHOP

admitted; when it gets a little bit more involved. And with COVID we know we’re looking for the majority of the time the beginnings of a respiratory tract infection or runny nose. Just slight congestion, some people have. Other people go on to develop worse respiratory issues. With Kawasaki or MIS-C, we aren’t always seeing the respiratory involvement. It’s more of the rash and the G.I. symptoms leading on to myocarditis, the inflammation of the heart, but it can be fatal in kids. And I don’t think it’s really been getting enough publicity. Everybody’s been focusing on the vaccine. “When are we going to have the vaccine out there?” The unfortunate thing is there is no vaccine for children. And we’ve seen this MIS-C in as many as, well thousands of children to at this point, and they can go all the way up to age 17 or 18. So it’s not just the small children. And the kids that we have to worry the most about are the kids that have cystic fibrosis or sickle cell anemia; other underlying health issues, because that’s going to make a difference related to the recovery.

ICT®: You mentioned inflammation of the heart. And I know from talking to you and other experts that that’s one of the things people are worried about. Young people may get COVID-19 and appear to bounce back. But 10 or 20 years down the road they might get heart problems. Is this one of your concerns also?

Spaulding: People keep talking about, “Well the young kids. They’ll get it. They’ll get over it. It’s no big deal.” But that’s not the reality of it. There are many young kids that have gotten COVID and are now dealing with what they’re calling long-haulers disorder. And that’s when they do have heart damage, or they have lung damage. And it appears right from what we know is that will be lifelong. The young people that think, “Oh, I can go do what I want to do. And if I get COVID, that’s fine. I’ll get over it.” That’s not the case. And the information needs to be gotten out to younger people. And it’s very difficult to change young adults thought processes, but they could actually get COVID and that could change the rest of their life. If you end up with heart damage, there’s no going back from that. They end up with lung damage, and you’re having problems breathing when you’re just walking, how are you going to work? You’re 19 or 20 years old. It could affect your life forever. And that’s one of the things that I don’t think is really getting out to the young people. And if it is, you know, when I was that age: “Nothing’s going to affect me.” You think you’re invincible.

ICT®: You just mentioned an age group of 19 to 20 years old. When you talk about the children who could get MIS-C, are we talking about infants on up to young adults?

Spaulding: As far as MIS-C, we’ve seen it from a year old to sometimes 14 or 15, maybe the 16-year-old population. Over that is just when they get COVID and they get the lung damage, heart damage.

ICT®: An epidemiological question: Is this a disease that’s caused by SARS-CoV-2 that’s not COVID-19?

Spaulding: MIS-C is related to COVID-19. That’s why it’s called multisystem inflammatory syndrome. And then the C stands for COVID.

ICT®: And it’s just how COVID-19 can affect different people in different ways, right? Officials at children’s hospitals are quite concerned about this. What are the protocols for helping children in this situation? Is it the same as how you would help an adult suffering from COVID-19?

Spaulding: Yes. You’re just going to support them with IV fluids, support them with whatever medications that are needed for however they’re presented. If they’re presenting for fever, we give them antibiotics to bring their fevers down. If they need a ventilator, because of breathing issues, we put them on a ventilator. The majority of them, if they don’t have underlying diseases like cystic fibrosis, or some of the other childhood issues, then they do pretty good. But there are children who have died from MIS-C. And I think that’s an important thing for parents to know. Prevent your kids from getting COVID. You don’t have to worry about whether or not they’re going to get MIS-C.

ICT®: I’ve seen statistics. I’m sure you’ve seen statistics … and there are a lot out there. As you always say, go to the CDC or go to the World Health Organization to get updated information and even then, check twice. I’ve read that kids don’t get COVID-19 and they don’t spread it. Does MIS-C put that in doubt?

Spaulding: I’m glad you brought that up, because: one, kids do get COVID. And when I was getting ready to talk to you, I decided to look up just how many kids have had COVID since the beginning of this. And I think this is where, the public isn’t getting this information, because this will be a surprise to quite a few people. And when I looked it up, there have been 3,104,010 cases of COVID-19 among kids between the ages of zero and 20. So that’s 3 million kids. That means that 13.1% of all the cases of COVID-19 that we’ve seen in the US have been children. And the problem with that is the numbers could be much higher because of at any given time, we might have 10 states reporting, you might have 24 states reporting. Rarely do all the states report how many children they have. Rarely do states report how many children have died of COVID. Every single state has decided to publish their information differently. It’s very difficult to pull a number together and look at it. But right now, it looks like the case rate for children: there is about 4124 children per 100,000, they get COVID. We have a population of 100,000, 4124 of those will be kids.

ICT®: And you’re getting those statistics from where?

Spaulding: It’s from the American Academy of Pediatrics.

ICT®: I’ll go back to the question you asked, I wonder why this is not getting out?

Spaulding: Well, I think it gets out once in a while, but it’s not a hot topic. We’re focusing so much on should kids go back to school, but nobody’s talking about the issues around that; in the number of kids that have had COVID already. And I don’t know why the numbers aren't reported out more. It may be because they’re reported so differently in every state, that it’s difficult to get a good grasp on what we’re looking at. Or it’s just not newsworthy, so to speak, but it is talked about in hospitals every morning. “How many kids do we have? How many adults do we have?”

ICT®: Let me circle back to something you mentioned earlier about how children aren’t eligible for vaccinations.

Spaulding: They are not. Kids from the age of—I think it is—16 and up can get the Pfizer and Moderna. I don’t know what the age limit is going to be on the Johnson and Johnson, but I think it’s probably going to be pretty much the same area. They are doing studies now. I know Pfizer’s doing studies on younger children. And so hopefully in two or three months—probably more likely three months—we’ll have some data on that, on the efficacy and the safety. I’m sure right now they’re trying to figure out what is that dose that’s safe for kids.

ICT®: You and I have talked about this offline; how we’re all dying to get our old lives back. To do what we used to do before we were hit with COVID 19. Now, that has to be weighed against the risk. Taking that into account: school openings. I’m asking you to step into a public policy debate here: but school openings and just opening society in general. Do we still know too little about COVID-19 to do that? Or is the harm of closing or at least social distancing starting to exceed the harm caused by COVID-19?

Spaulding: I think it depends on where you are in the country. So much of COVID is: It depends, unfortunately, because we still don’t know that much about it. But what we do know is that children that get COVID don’t spread it as easily and as fast as adults do. OK? Probably part of that reason, the kids are so short, and adults are up here. So, if they’re coughing, they’re coughing down here, and then it hits the floor. But when you get into the teenagers, then that’s different. But teenagers you can work with to have them wear masks to have them wash their hands a little bit easier than you can with 3-, 4- or 5-year-olds, or even kindergarteners. I think there is a smart way to do it. And I think if you’re in an area where you have only a few cases of COVID—and there are those areas, because the United States is so vast—then kids could go back to school safely, teachers could wear masks. And most likely there wouldn’t be any transmission. If you go to a place like New York, or even Florida here where the numbers are still in the thousands every day, then that increases the risk more. But there are schools out there that have opened up and have had absolutely no transmission within the school at all. You have to look at your geographical area and is it safe or is it not safe? My niece is a teacher in Cleveland, Ohio. And we’ve been talking back and forth, she finally got her second vaccine today. And so, she feels more comfortable going back to school now. She was concerned about it before. Because there was so much COVID in Ohio. Now, all the numbers are starting to come down. And the great news is that it’s starting to come down in the kids as well. I think over the next few months, it’ll be easier to open the schools. I think more teachers will be comfortable with it if they get vaccines, which I don’t blame them. If you have a high COVID population still in your area, then you do want to get vaccinated. But we have to look at each community: What is the circulating COVID in those communities? And open up all those communities that have low cases right now. Rural areas: Some of them have virtually no COVID right now, and other rural areas have high numbers. There is a way to open schools safely now. Just not all schools.

ICT®: Is there anything I neglected to ask that you think is pertinent and that people should know about?

Spaulding: Be patient. We keep saying that. This will eventually come to an end at some point. Children will go back to school. And you do have to, when you’re making those decisions, you do have to think about the mental health of the children. Some of the hospitals that I’ve worked with, they have had an increase in children coming into their psych units, because of suicidal thoughts, because they’ve had enough of this. And they can’t tolerate it. But to know that the cases among children are coming down just like they are in adults. If you look at January 7, there were 171,079 cases among children reported. On February 18, there was only 70,640. It is starting to come down, things will get better. Health care workers have to get the information out to parents. Watch your child. If they come down with a red rash, post-COVID or when they have COVID or even if they don’t think they have COVID, that they don’t know, get the kids to a physician to take a look at them. Because that’s the important thing.

ICT®: On what part of the body does the rash usually appear?

Spaulding: It’s on the entire body. It can be just on the trunk or it can be on the face, but the majority of the time, it’s everywhere. It’s a very noticeable rash.

This interview has been edited for clarity and length.