Her name is Teresa Bandeira and she is one more member of the Faculty with a long connection to the campus. Invited Assistant Professor of Paediatrics and Coordinator of the course Introduction to Children’s Medicine, she graduated in Medicine in 1982. Having entered Paediatrics in 1986, in 2011 she completed her Ph.D. on “Contribution to the Study of the Paediatric Origins of Chronic Obstructive Pulmonary Disease in Adults. Post-infectious bronchiolitis obliterans”.
Currently a Graduate Hospital Doctor in Paediatrics, she is the Coordinator of the Paediatric Pulmonology Unit of the Paediatric Service and Department of Paediatrics at Hospital de Santa Maria, CHULN. She was President of the Portuguese Society of Paediatrics (2014-2016) and until last year she was also President of the Portuguese Society of Paediatric Pulmonology and Sleep (2017-2019).
Teresa Bandeira is responsible for the Working Group for the Control of Exposure to Smoking (sTOPPagE) of the Portuguese Society of Paediatrics.
Author and co-author of 50 scientific articles and 10 books or book chapters, it was mainly due to her dedication to the field of respiratory diseases in children that finally made us speak to the Professor, albeit with a digital barrier.
In a month when we wanted to ask "where do some medical areas stand amidst covid?", the truth is that Paediatrics is one of the largest and most intriguing areas. Why do children continue to “escape practically unharmed” from the great wave of covid that affects adults and now so many young people?
A very informative conversation, which without yet being able to present conclusions, already shows several scientifically based ways of reflection.
How have your hospital routines been in a period as severe as this?
Teresa Bandeira: The absence of routines has been the most demanding feature in this phase, which implies adapting to new practices and attempting to forecast and anticipate the situation, in order to better prepare the environments, both for health professionals and for giving an appropriate response to children with respiratory disease and their families. Then, it requires permanent updating in view of the dynamics of the published information, its critical analysis and sensible implementation on the ground. Finally, the recognition that we are all learning to deal with an unusual situation, not because it is the first pandemic, but because we are living it in an online world with access to information and artificial intelligence means that requires a challenging effort of interpretation and adaptation...
We know that most of the answers are still to be given, but what has made children escape from covid-19?
Teresa Bandeira: Children indeed represent a small proportion of confirmed cases of SARS-CoV-2 disease in the current pandemic. Luca Cristiani et al cite 2 articles describing the report by the Chinese Centre for Disease Control and Prevention, which informed that there were only 416 confirmed paediatric cases between 0 and 9 years old (0.9%), with no deaths, and 549 cases between 10 and 19 years old (1.2%), with one death (0.2%), in a total of 44,672 confirmed cases1. An Italian report showed similar results, with 318 (0.5%) confirmed cases among the 0 and 9 years of age and 386 (0.7%) confirmed cases from 10 to 19 years old. In this report, no children were admitted to the intensive care unit and there were no reported deaths.1
The President of the Spanish Paediatric Association, María José Mellado, says that COVID-19 affected less than 1% of all diagnosed cases at paediatric level, that is, about 1,400 children in Spain, which represented 25% of child hospitalization in the same period. The Portuguese experience is also being recorded and soon the Portuguese Society of Paediatrics will release it, but the results will most likely overlap with those reported. Nicholas G. Davies et al recently suggested that susceptibility to SARS-CoV2 infection in individuals under 20 years of age is about half that of adults over 20, and that clinical symptoms are manifest in 21% of infected people between 10 and 19 years of age, increasing to 69% (57-82%) in people over 70 years of age.2
The reasons for this apparent benignity in the interaction between children and the virus responsible for the current pandemic are unclear. The key may lie in the interaction between the host's immune response, in this case the child, and the pathogenic mechanisms induced by the virus, either due to the higher concentrations of ACE receptors in children's pulmonary pneumocytes, or because of the innate immunity response, or because there is a constitutional lymphocyte predominance in the first years of life. But the real causes of the phenomenon of less serious clinical expression of COVID-19 in children, so far, are still an unsolved mystery...1
Even so, we have some cases of children whose diagnosis was made and where the same respiratory problems were found. Are they profiles that already presented some weakness?
Teresa Bandeira: Children with respiratory disease are, as a rule, considered to be at increased risk, both for viral infections and for those toxic to the environment, such as exposure to tobacco smoke. Once again, there is some ignorance regarding the concrete risk for these patients induced by SARS-CoV-2.
There are few published series and they only include a small number of children. Of these, in one of the series, the majority (65%) had common respiratory symptoms, 26% had mild illness and 9% were asymptomatic. The most common symptoms were fever (50%) and cough (38%).3 As far as is known, children are usually infected in their family environment and have less frequent and less severe symptoms. However, there are reports of cases with more severe presentation, such as pneumonia, with residual mortality, especially in series from groups in China. Also in the US, according to the Centres for Disease Control (CDC), the number of cases in children in the beginning of April represented 1.7% of the total number of known infected people, with 2% admitted to the ICU and 3 deaths. The Bulletin of 17 June, from the same entity (CDC), presents a laboratory confirmed infection rate of 7.4/100,000 in children between 1 and 4 years of age and 3.5/100,000 among 5 and 17 years old children. Asthma, chronic lung disease, neurological disease and obesity are associated with higher frequency of hospitalization, but the majority of hospitalized children did not have any known clinical condition (46.7%).
What is surprising is what was described by our colleagues in a Dublin Hospital. The cases in hospital emergency, in the months of March and April, were halved, when compared with the previous 2 years, in all clinical situations, including respiratory ones.4 The authors' interpretation suggests that there is a representation in hospital emergency of more serious cases, as seen in the distribution of colour codes, with a significant reduction in “false” emergencies, factors that should dictate a learning process to be replicated in the future.
But there are two aspects of extraordinary relevance that result from these findings.
The first is that the disease associated with SARS-CoV-2 is an infectious disease with high transmission ability by particles inhaled through droplets and/or aerosols. This aspect requires the preparation of extraordinarily demanding circuits, structures and protection features, especially in situations that induce the spread of these aerosols, such as inhalation therapies and ventilation. Additionally, there is the need to adapt the therapeutic protocols and devices used in order to reduce the impact of transmissibility and to ensure the maintenance of therapies for patients. These adaptations, necessarily made in a short period of time, are extremely demanding for services and professionals.5
The second is that the child is the centre of activity for all paediatricians and the main focus of their work. Although much of the COVID-19 pandemic preparedness and response is properly focused on adults, paediatricians must ensure that children are not overlooked. Paediatric Services around the world, and also locally, have adapted diagnostic and therapeutic circuits and guidelines and Scientific Societies have issued specific guidelines.
Additionally, it is necessary to reinforce that there are conditions, at various levels, for the Child and Youth Health and Vaccination Surveillance Programmes to be strictly followed, and for children with chronic diseases or situations to maintain the access and care that their clinical situation requires.
Finally, one of the great challenges anticipated by Paediatrics is the autumn, given the possibility of a new outbreak of infections by SARS_CoV-2, in association with bronchiolitis and flu, so it is important to prepare, with everything we have learned, for those months.
Recent studies stated that despite the great majority of children escaping covid-19, they could nevertheless have collateral damage from other pathologies, such as Kawasaky disease. Are there bases to support these situations?
Teresa Bandeira: As previously mentioned, in children, the diseases associated with infection by SARS_CoV-2 are mild and with a predominance of respiratory manifestations. There are, however, consistent case reports, albeit rare, of hyperinflammatory syndrome and involvement of several organs, provisionally called paediatric multisystem inflammatory syndrome temporarily associated with SARS-CoV-2 infection (PIMS-TS) in Europe and multisystemic inflammatory syndrome in children (MIS-C) in the United States. Given the variable prevalence of SARS-CoV-2 infection in Europe, the possibility of an association between Kawasaki disease and the positive SARS-CoV-2 test needs confirmation.6
References used by Professor Teresa Bandeira:
- Cristiani L, Mancino E, Matera L, et al. Will children reveal their secret? The coronavirus dilemma. Eur Respir J. 2020;55(4). doi:10.1183/13993003.00749-2020
- Davies NG, Klepac P, Liu Y, Prem K, Jit M, Eggo RM. Age-dependent effects in the transmission and control of COVID-19 epidemics. medRxiv. 2020:2020.03.24.20043018. doi:10.1101/2020.03.24.20043018
- Zimmermann P, Curtis N. Coronavirus infections in children including COVID-19: An overview of the epidemiology, clinical features, diagnosis, treatment and prevention options in children. Pediatr Infect Dis J. 2020;39(5):355-368. doi:10.1097/INF.0000000000002660
- Dann L, Fitzsimons J, Gorman KM, Hourihane J, Okafor I. Disappearing act: COVID-19 and paediatric emergency department attendances. Arch Dis Child. 2020;0(0):archdischild-2020-319654. doi:10.1136/archdischild-2020-319654
- Ladhani SN, Amin-Chowdhury Z, Amirthalingam G, Demirjian A, Ramsay ME. Prioritising paediatric surveillance during the COVID-19 pandemic. Arch Dis Child. 2020;0(0):1-3. doi:10.1136/archdischild-2020-319363
- Toubiana J, Poirault C, Corsia A, et al. Kawasaki-like multisystem inflammatory syndrome in children during the covid-19 pandemic in Paris, France: prospective observational study. BMJ. 2020;369:m2094. doi:10.1136/bmj.m2094
Joana Sousa
Editorial Team