Why is it critical to think deeply about COVID-19 in children now? Children make up half of our population on the African continent and the maintenance of good physical mental and emotional health for them demands that we consider this major disruption to their overall health and wellbeing. We need to understand exactly what our roles should be as parents, healthcare providers, and education experts as they navigate this new reality.
As the pandemic made its way towards us, across Africa we were bracing for an onslaught. It seemed inevitable that we would be faced with significant morbidity and mortality as the pandemic hit our shores given that social determinants of health* had played a major role in the outcomes of the COVID-19 pandemic across the world. The most obvious negative outcomes were death disability, loss of income and livelihoods and breakdown in family and social structures.
Therefore, as we launched The African Children’s Hospitals Foundation (AfCHF) it was important to do so on a note of relevance to our continent. We decided to converge around the loud silence on children’s health as it relates to the pandemic, and so convened practitioners and frontline stakeholders to begin the much needed conversations on preparing for COVID19 infections in children, leaning heavily on the experience of practitioners that had gone through a wave of the pandemic.
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Lessons learned:
Several important lessons have been learned from experienced frontline practitioners in other countries.
Admission rates for children remained low even when they began to present with the Post Inflammatory Multi System Disease now referred to as Multisystem Inflammatory Syndrome in Children (MIS-C). However, Dr. Rhonda Acholonu emphasized a need for cautious optimism: While children are not presenting with physical manifestations of disease, they need to be intently followed up. She posed the question paediatricians were asking “where are the children?” Indeed, it turns out that many of them were having serious psychological and emotional issues.
Of further relevance to the frontline healthcare workers is cross-discipline collaboration, flexibility to adapt to rapidly changing protocols and a flattening of the hierarchy because junior professionals might have more relevant experience than their more seasoned seniors. Flexibility around healthcare provider’s needs is important also: as healthcare providers on the front lines, team members emotional needs are paramount for whole team success
Psychological and Emotional Concerns
According to Dr. Nicole Brown, co-Founder of Strong Children Wellness, the children “were at home, struggling to make sense of their new world”. Children and adolescents reported increased anxiety, depression and situational stress during the lockdown and ongoing pandemic. These are of great concern as they are more readily missed and could lead to long-term psychological disturbances. Many children are faced with severe illness and deaths of family members; parents’ job losses, layoffs and furloughs, (forced leave with no pay), and the resultant stresses of that on the family. Some children with underlying mental illness have had relapses or setbacks, and some presented with new onset symptoms possibly aggravated by prevailing stressors.
Routine and structure in children’s lives influence regulation and behaviour. Many children have begun to report poor sleep, poor feeding, tantrums and behaviour change related to disruptions in their schedules with the abrupt end of the school year, effectively tearing them suddenly from the safety and the regularity of their structured routine, friends, favorite teachers, school meals and their only constant access to peers, books, and listening engaged adults..
A concurrent pandemic of fear followed on from the constant traffic of bad news including the ongoing daily tally of people sick and dead, graphic television stories and extensive 24/7 coverage. According to Dr. Yewande Oshodi, some children also bought into their parents’ biases and stigma around mental illness – resulting in delayed identification of issues. Adolescents reported being ashamed to admit to being afraid, anxious and unsure of the future.
A further contributor to mental health concerns is excessive screen time due to inability of children to leave home, unregulated by parents who are busy and pre-occupied with survival. This is perhaps another reason why virtual learning should not entirely replace in-person learning, as this could worsen anxiety and depression as it encourages isolation.
Ongoing considerations: maintaining “normal”
An important provision therefore has been the continuing access to healthcare providers to encourage ongoing conversations with and within families about children’s experiences and their health and the continued need for vigilance. Dr. Brown exemplified this through her emphasis on telemedicine and access through sms, with Dr. Oshodi agreeing and also encouraging ongoing family unit conversations.
Across the world, major examinations were cancelled or postponed indefinitely, and the anticipation of predicted grades added a layer of anxiety for parents and children alike. Dr Acholonu acknowledged the digital, education and socio-economic divides given social disparities common to all geographies that prevent some children from accessing learning tools and opportunities. As practitioners, we all acknowledge the need to determine the impact of some of these disparities on children’s development in the years ahead, and Dr Acholonu emphasized the ongoing need to address children’s needs for virtual and remote learning.
Many adolescents are rebelling against the new normal when families have not taken the time to create new supportive routines, including time set aside for talking, explaining and checking in with the children. In our home, we adopted community meetings introduced by our youngest who insisted on continuing his school routine at home. In the early days of the lockdown we did them at noon, and now that we both have returned to work we have set aside weekend afternoons to check in, acknowledge one another, voice concerns, read and share, and then study the Word of God.
As Dr Yewande Oshodi communicated, the children whose parents took the time to discuss all that was going on including the need for admission to the isolation centers, coped better than those whose parents did not. This is a very relevant observation and a most important consideration across Africa as children prepare to return to school.
Back to school.
Very many children have expressed a desire to return to school- and specifically in-person education – some for the routine and the safety it brings, some to get back to normal, to their friends or just to get out of the house and away from “annoying siblings”.
Parents must engage with their children and wards as well as with educators and community providers- doctors, nurses, community health officers and district leadership to determine when and how to safely return to in-person schooling. The role of each stakeholder in this ecosystem will be to ensure that we continue to protect children from the immediate and the long-term effects of this pandemic.
Dr. Janna Patterson of the American Academy of Pediatrics shared her thoughts on various ways to think about a return to school citing the need to be innovative and consider a mix of virtual and in-person school, staggering attendance whilst maintaining safety for all in the school ecosystem. I will speak to suggested considerations and conditions for return to in-person learning in a subsequent blog. It is sufficient to note at this point that this needs to be tailored to local conditions.
What is important now?
One of the learnings for many of us who attended this webinar was that children have very different needs from adults around this pandemic. Their parents and healthcare providers need to focus on their mental and emotional health and their coping skills for dealing with this disruption and what it means for their childhood and their learning. We should emphasize achieving emotional and mental health balance. Resilience is a key tool for survival and thriving. The digital, social and economic divides may contribute to worsening or paradoxically improving these outcomes- children from homes who practice gratitude and spend time together in positive settings may overall deal better with setbacks during this period. Parents and significant adults’ attitudes and approach may be a major influencer, and this may be one area where we need to focus much of our efforts.
Social determinants of health are defined by WHO as the conditions in which people are born, grow, live, work and age.
Dr. Orode O. Doherty is a Peadiatrician and Public Health Physician. She runs Ingress Health Partners, a primary healthcare franchising facility in mainland Lagos. She is the Founder of the African Children’s Hospital Foundation, whose mission is to optimise training, research and infrastructure development for care in hospitals in Africa dedicated to the well-being of children, while coordinating and integrating these into the wider healthcare systems.
