Since the Covid-19 pandemic hit Singapore in early 2020, there were no children among the around 1,400 deaths. Then, three weeks ago, two children under the age of five have died from complications due to the infectious disease.

On June 27, an 18-month-old boy became the first patient below the age of 12 to die from Covid-19. The cause of death was encephalitis (inflammation of the brain) due to Covid-19, as well as viral infections caused by the respiratory syncytial virus and enterovirus.

Then last Sunday, a four-year-old girl who contracted Covid-19 died from pneumonia. Like the boy, she was previously well and had no past medical history, the Ministry of Health (MOH) said.

The two deaths of young children, coming so close together in recent weeks after zero such deaths since early 2020, have triggered concerns among some parents.

TODAY spoke to infectious disease experts and other medical practitioners on how these cases could have happened, and what warning signs parents can watch out for if their children are infected with Covid-19.

OMICRON SUB-VARIANTS ‘UNLIKELY’ LINKED TO DEATHS

Given that there have been no cases of paediatric deaths from Covid-19 until the last three weeks, TODAY asked medical experts whether the latest subvariants of the coronavirus, which have been causing the most recent wave of cases, could be to blame for the two recent deaths.

Professor Paul Tambyah, president of the Asia Pacific Society of Clinical Microbiology and Infection, said this is unlikely.

In the case of the boy, the respiratory syncytial virus and Covid-19 may have been incidental.

As for the four-year-old girl, he said he did not have the full details of her case and symptoms but noted that there were reports in the media about her vomiting and frothing at the mouth when she collapsed.

This suggests that she might also have had a brain inflammation, which has been reported in children with viral infections in the past, he said.

Prof Tambyah added that deaths from pneumonia due to Covid-19 is extremely rare, especially among children.

 “A large review of the early Covid-19 studies found an incidence rate of fatal pneumonia of around 0.01 per cent. A more recent study of the Omicron subvariants in South Africa found only four deaths out of 6,287 infected children, all with underlying medical conditions,” he said.

Deaths in children from pneumonia in Singapore, while uncommon, are not entirely unknown.

In 2019, when seasonal influenza was still circulating widely, there were two boys and four girls under the age of 10 who died from pneumonia deaths here, he noted.

"These tragic childhood pneumonia deaths are rare but regular occurrences here, even before the pandemic.” 

Dr Loh Jiashen, an infectious diseases specialist at Farrer Park Hospital, said there is not enough data to suggest that the current variant of Covid-19 is more deadly in the general or paediatric population, adding that it is best to avoid speculation in the matter of the recent deaths.

“There are not many clues which could have predicted such a rapid decline (n the condition of the two deceased children, although myocarditis and cardiac-related illness are possibilities in rapid collapse and demise,” he said, referring to an inflammatory condition of the heart.

Associate Professor Thoon Koh Cheng, a senior infectious disease consultant at KK Women’s and Children’s Hospital's paediatrics department, also noted that complications among paediatric Covid-19 cases are rare.

If they do happen, pneumonia, myocarditis and inflammation of brain and spine are possible complications, he said.

RELAXED SAFETY MEASURES UNLIKELY TO BLAME

TODAY also asked the experts whether the deaths could have been due to overall infection numbers rising since the relaxation of pandemic safety measures from April 26.

Health Minister Ong Ye Kung, in a Facebook post made on July 6, noted that Singapore was in the midst of another Omicron wave, saying it was "the first time we are going through a wave without much SMMs (safe management measures) – no circuit breaker, no heightened alert, no group size limit, no capacity limit".

He also told Parliament earlier this month that Singapore would avoid tightening these measures unless it was hit with a serious infection wave.

According to MOH data, the proportion of children aged zero to 11 out of the total daily number of hospitalised Covid-19 patients hovered between six and nine per cent over the past month, from June 22 to July 19. This is in spite of the recent wave of coronavirus cases.

Children aged zero to 11 have made up nine to 13 per cent of overall daily reported Covid-19 cases during the same period.

These were similar to the numbers seen in the period of March 26 to April 26.

Some experts said the recent deaths of the two children cannot be attributed to the relaxed safety measures.

Dr Loh noted: “Generally children are less likely to develop severe symptoms with Covid-19 even if unvaccinated."

Prof Tambyah pointed out that data from all over the world and Singapore show that the coronavirus is behaving like every other pandemic virus in history, including the deadly influenza pandemic that started in 1918.

“By 1920 and up to 1957, the flu pandemic virus had mutated to become more transmissible and less virulent. It became the dominant strain of seasonal influenza for nearly 30 years. Official figures from the World Health Organization illustrate this well. There were many more cases but no increase in deaths.”

But some general practitioners are urging parents to take more precautions.

Dr Liew Woei Kang, medical director of the Paediatric Allergy Immunology Rheumatology Centre, said: “I think we are still a bit too lax about our infection control. When we have more patients infected with the virus, we are going to expect some of these children to die from the infection."

Dr Liew suggested that unwell children ought to have more time to fully recover before resuming school.

This, he says, has a downstream effect in reducing the overall incidence of chronic cough and other associated childhood illnesses.

“I believe parents were more cautious in the previous two years, making sure that the children are well before they return to school," he said, noting that this attitude appears to have changed with the easing of Covid-19 restrictions.

Dr Liew remarked that while it is currently unclear whether a vaccine would have prevented the two recent deaths, vaccines have been shown to significantly reduce severe Covid-19 complications such as multisystem inflammatory syndrome (MIS-C) in older children.

Dr Sunil Kumar Joseph, a general practitioner of more than 20 years, believes that despite children being less susceptible to serious illnesses when infected by Covid-19, the current unavailability of vaccines to those under five "make this group of children especially vulnerable".

He said the authorities should consider allowing this group of children to get inoculated.

MOH had said on Tuesday that notwithstanding the fact that  Covid-19 infections can result in severe disease among children, they are generally more resilient to Covid-19 infections than adults and the elderly.

The ministry, the Health Sciences Authority, and the expert committee on Covid-19 vaccination, are also studying the safety and effectiveness of coronavirus vaccines that have been formulated for young children under the age of five.

WHAT CAN PARENTS DO?

Unfortunately, in cases where the coronavirus causes severe complications, Dr Liew noted that the brain, heart and lungs may exhibit symptoms that may not be easy to spot.

“Brain-associated symptoms include seizures, abnormal jerks, irritability and drowsiness of the child. Symptoms for the heart include abnormal heartbeats.”

Lung symptoms, he added, may include breathlessness.

Dr Liew also noted that these symptoms would have worsened quickly in the case of the children who died, and there was likely nothing their parents could have done any differently to avert the tragedy.

“But for the rest of the parents who are worried, I think we can reassure them, this is not something that will happen to most children. Probably there is something that we haven't really discovered in these two children, who reacted to the virus in a very fulminant manner,” he said.

Assoc Prof Thoon urged parents to get their children vaccinated “when nationally recommended”.

“We also would recommend parents and caregivers to continue to encourage children to wear masks where possible, stay at home or see a doctor if they are unwell, and practise safe management measures,” he said.

He added that should children develop worsening symptoms they should consult a doctor.

These symptoms include “persistent fever, lethargy or drowsiness, persistent cough, breathlessness, chest pain, poor oral intake, poor urine output, or seizures”.

Source:
courtesy of TODAY

by JANARTHANAN KRISHNASAMY

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