Addressing the Long-Term Effects of the COVID-19 Pandemic on Children and Families (2023) / Chapter Skim
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5 Health Effects
5 Health Effects
Pages 137-200
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From page 137... ...
Evidence on the effectiveness of interventions to buffer those effects is coming to light as the pandemic evolves, largely based on prepandemic supports for children and families who are at higher risk of poor health due to structural racism, poverty, and limited opportunities. Children and families in racially and ethnically minoritized groups and those in underserved and marginalized communities have been disproportionately affected by COVID-19 because of the direct and indirect effects of the infection and the public health preventive measures, which reflect gaps in societal safety nets for these children and families (Cheng et al., 2020)
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From page 138... ...
The reasons for this difference are not completely understood; they may reflect the expression of the upper airway angiotensin-converting enzyme 2 (ACE2) , a receptor for the SARS-CoV-2 (severe acute respiratory syndrome coronavirus 2)
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. Black, Latino, and Native American children have experienced higher rates of COVID-19 infections, hospitalizations, and deaths than White children (Kim et al., 2020; Wiltz et al., 2022; Woodruff et al., 2022)
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Rates of MIS-C hospitalization were higher among Black children, and Black children had higher relative risks than White children for poor MIS-C outcomes (Encinosa, 2022)
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diagnosis up to 30 days after infection in comparison with children without COVID-19 and children with prepandemic acute respiratory infections. Non-SARS-CoV-2 acute respiratory infection was not associated with an increased risk for diabetes.
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. A recent Kaiser Permanente study of children and adolescents aged 5–17 years in Southern California also found increased obesity prevalence and significant weight gain during the pandemic (Woolford et al., 2021)
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The direct impact of COVID-19 infection during pregnancy is well documented: pregnant women infected with COVID-19 have a higher risk of preeclampsia, intensive care unit hospitalization, and death than both noninfected pregnant women and nonpregnant women of reproductive age (Allotey et al., 2020; Joseph et al., 2021; Joseph et al., 2021; MyClymont et al., 2022)
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From page 144... ...
Surprisingly, during the early months of the pandemic, populationlevel measures of infant health -- including preterm births and low birthweights -- appear to have improved in the United States and other wealthy countries (Berghella et al., 2020; Gemmill et al., 2022)
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From page 145... ...
, many pregnant women were hesitant about COVID-19 vaccination (Simmons et al., 2022) , leading to low vaccination rates, which prompted recommendations for vaccination for pregnant women by the American College of Obstetricians and Gynecologists and the Society for Maternal-Fetal Medicine in July 2021 (American College of Obstetricians and Gynecologists, 2021)
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. CDC also released a statement to assure the public that COVID-19 vaccines were safe for pregnant and breastfeeding women, and in September 2021, issued an urgent health advisory to increase vaccination rates among pregnant women (CDC, 2022d)
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2021 COVID-19 vaccine April 27 CDC updates the ACIP recommendations for the use of Janssen (Johnson 2021 & Johnson) COVID-19 vaccine because of reports of thrombosis with thrombocytopenia syndrome among recipients May 10 FDA expands EUA of Pfizer-BioNTech COVID-19 vaccine for adolescents 2021 aged 12–15 May 14 CDC publishes ACIP interim recommendations for the use of Pfizer2021 BioNTech COVID-19 vaccine for adolescents aged 12–15 June 25 FDA revises EUA Pfizer and Moderna patient and provider fact sheets 2021 regarding concern for increased risks of myocarditis and pericarditis associated with their vaccines July 6 CDC updates the ACIP recommendations after reports of myocarditis 2021 Aug 23 FDA approves Pfizer-BioNTech vaccine for youths and adults 16 and older 2021 (the EUA remains in effect for those 12 years of age and older and for the third dose for immunocompromised individuals 12 years of age and older)
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From page 148... ...
Among all children aged 5–17, survey data indicate that vaccine coverage with at least one dose was 73.4 percent among Asian children, 49.0 percent among Latino children, 45.0 percent among White children, and 44.7 percent among Black children (Valier et al., 2022)
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. Vaccination During Pregnancy: Effectiveness and Uptake Since September 2021, CDC, as well as other national medical and health organizations, has recommended that pregnant women receive COVID-19 vaccination to prevent maternal and infant morbidity and mortality (CDC, 2022d)
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. Evidence shows that COVID-19 vaccines are highly effective during pregnancy, inducing an immune response comparable to that in nonpregnant women (Gray et al., 2021)
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These factors all worsened or were increasingly visible during the COVID-19 pandemic. This increased need for behavioral health among low-income and racially and ethnically minoritized children cannot be met with the current workforce shortage of child behavioral health providers (American Association of Child and Adolescent Psychiatry, 2018; Health Resources and Services Administration, 2022)
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. Studies have found that risk factors for an increase in mental health symptoms during the pandemic included being a member of a racially or ethnically minoritized group (Xiao et al., 2022)
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• Fully fund comprehensive, community-based systems of care that connect families in need of behavioral health services and supports for their child with evidence-based interventions in their home, community or school. • Promote and pay for trauma-informed care services that support relational health and family resilience.
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From page 154... ...
These mental health symptoms and conditions are rooted in the substantial traumas and loss experienced by children, which have been more prevalent or more magnified among children from historically underserved communities. Depression and Anxiety During the COVID-19 pandemic, children were confronted with continual reminders of illness and potential death; experiences of fear and perceived threat; economic and social instability; and physical and social distancing from loved ones, friends, school, and communities, putting them at increased risk of experiencing symptoms of depression and anxiety.
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From page 155... ...
A systematic review estimated a pooled prevalence of 25.2 percent for depressive symptoms and 20.5 percent for anxiety symptoms among children (Cheah et al., 2020; McGuine et al., 2020; Glynn et al., 2021; Luthar et al., 2021; Murata et al., 2021; Racine et al., 2021)
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From page 156... ...
Data on suicide risk screening among those patients seen in primary care settings may give a less biased sample than those seen in emergency departments. Two different studies examining suicidality on suicide risk screenings among primary care patients found a modest but significant increase in the rate of suicidality (from 6.1% to 7.1% and from 11.1% to 12.2%, respectively)
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. Post-Traumatic Stress Disorder PTSD is a serious mental health condition with significant emotional, cognitive, behavioral, biological, and developmental consequences.
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Bereavement and Prolonged Grief Disorder As discussed above and in Chapter 1, the COVID-19 pandemic has led to loss of a parent or caregiver for over 265,000 children, and racially and ethnically minoritized children were disproportionately impacted by this loss and related grief. For most, the grief reactions, while profound, diminish in strength and frequency gradually over time. There is a subset of children, however, with grief reactions that remain severe, extended, and accompanied by significant impairment in several domains of daily life.
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From page 159... ...
; this includes a tiered public health approach described at the end of this chapter.6 Sleep Disturbance Sleep disturbances are ubiquitous in situations of ongoing danger. Danger- and trauma-related sleep disturbances are among the most insidious of PTSD symptoms for children and adolescents.
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, social media use has been associated with adverse mental health consequences and impaired sleep quality among children; sleep disturbances can further contribute to negative mental health outcomes (Alonzo et al., 2021; Marciano et al., 2022)
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At the same time, however, CDC reported a 53 percent decrease in emergency department visits related to child abuse, though this decrease was in the context of a 72 percent overall decrease in pediatric emergency department visits (Swedo et al., 2020)
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Historically, rates of interpersonal violence at the community level have disproportionately affected underserved racially and ethnically minoritized populations. Endemic rates of violence, characterized by firearm injuries, aggravated assault, and homicide, apparently rose as a direct consequence of the systemic inequities and structural conditions amplified by the pandemic.
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. It is important to note that intimate partner violence and child abuse often co-occur given the increased risk for maltreatment when children are isolated at home (Humphreys et al., 2020)
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. Unemployment benefits and income supports during the pandemic have also been critical to addressing food insecurity: studies have demonstrated that pandemic-related expanded child tax credits were associated with a decrease in food insecurity (Shaffer et al., 2022)
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health systems in the Vaccine Safety Datalink showed that as of September 2020, child vaccination rates and the proportion who were up to date remained lower than 2019 levels, with the lowest rates among non-Latino Black children across most age groups (DeSilva et al., 2022; Jenssen & Fiks, 2022)
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. Caregivers' reports of emotional distress, depressive symptoms, anxiety, and stress increased after the pandemic began and were higher for those in households with children who have special health care needs (Liu et al., 2021)
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. Racially and ethnically minoritized children were disproportionately covered by Medicaid, with 61 percent of Black children, 55 percent of Latino children, and 59 percent of Native American and Alaska Native children covered by Medicaid/CHIP in 2021 (Artiga et al., 2021)
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From page 168... ...
These factors result in "churn" -- as Medicaid beneficiaries lose coverage and then reenroll within a short period of time, creating consequential gaps in coverage. Studies have shown that churn in Medicaid is associated with higher health care costs, delayed care, less preventive health care, more emergency department visits, unfilled prescriptions, and less access to health care (Brantley & Ku, 2022)
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From page 169... ...
At the end of this twomonth postpartum period, new mothers could suddenly become uninsured; this is a particular risk for women who live in states that have not expanded Medicaid, as income eligibility ceilings for parents are much lower than income eligibility for pregnant women (Ranji et al., 2021) .7 Some states have adopted what are known as express lane eligibility and presumptive eligibility (Park et al., 2023, 2021)
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, 39 states and Washington, DC, had adopted Medicaid expansion as of November 2022, which expanded coverage to adults aged 18–64 with incomes up to 138 percent of the federal poverty level and provided states with enhanced federal matching rates for this new population (KFF, 2022a)
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Under the ACA, individuals and families in expansion states with incomes of 100–400 percent of the federal poverty level can purchase coverage in the ACA marketplace; in nonexpansion states, they can do so with incomes of 138–400 percent of the federal poverty level. The American Rescue Plan temporarily increased the value of premium tax credits for those already eligible for subsidies on the ACA marketplace and expanded eligibility for subsidies to adults and families who were previously not eligible because their incomes were higher than 400 percent of federal poverty level (Sommers & Haffajee, 2021)
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From page 172... ...
. There has been a recent focus on pediatric readiness of emergency departments in the United States and, by extension, assessment of the continuum of care needs for pediatric patients in hospital inpatient and critical health care settings, including the need for transportation to specialized levels of care (Ray et al., 2018)
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everyday readiness: prehospital, pediatric readiness, trauma and burns, mental and behavioral health 3. disaster preparedness: capacity and capability; deployable assets; infectious diseases; chemical, biological, radiological, and nuclear threats; reunification 4.
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Two federally funded initiatives can provide a coordinated vehicle to support pediatric and child mental health capacity building and enhanced delivery of tiered interventions for locally implemented disaster response. The Pandemic Centers for Excellence11 are engaged in planning regional approaches and helping communities address surges in behavioral health crises.
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They also include children with disabilities and preexisting behavioral health conditions who had delays in receiving adequate services during the pandemic. Partnering with those groups that have been disproportionality affected by COVID-19 to identify effective outreach strategies and messaging is critical.
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, such as the Child Adult Relationship Enhancement training (Gurwitch et al., 2016) .13 Tier 2 interventions include the incorporation of youth trauma-informed suicide prevention programs directed at youth identified to be at risk in emergency departments, primary health care settings, and schools (Tunno et al., 2021)
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From page 177... ...
Conclusion 5-2: An adequate and robust, coordinated, federal health response is needed to address the physical and mental health and well-being of children who have been and may continue to be most directly affected by the COVID-19 pandemic. These children have suf fered traumatic stress from serious illness, hospitalization, or the loss of a family member or loved one during the pandemic, as well as fear and isolation resulting from the pandemic and the measures taken to combat it.
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. Clinical manifestations, risk factors, and maternal and perinatal outcomes of coronavirus disease 2019 in pregnancy: Living systematic review and meta-analysis.
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. Association of COVID-19 acute respiratory distress syndrome with symptoms of posttraumatic stress disorder in family members after ICU discharge. JAMA, 327(11)
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Morbidity and Mortality Weekly Report, 71(2)
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Morbidity and Mortality Weekly Report, 71(Suppl.
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. Pregnancy and neonatal outcomes in SARS-CoV-2 infection: A systematic review.
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. Mental health, substance use, and suicidal ideation during the COVID-19 pandemic, United States, June 24–30, Morbidity and Mortality Weekly Report, 69(32)
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Morbidity and Mortality Weekly Report, 70(7)
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. A national assessment of pediatric readiness of emergency departments. JAMA Pediatrics, 169(6)
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Morbidity and Mortality Weekly Report, 71(7)
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. Suicide ide ation and attempts in a pediatric emergency department before and during COVID-19.
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. Trends in psychiatric emergency department visits among youth and young adults in the US.
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Morbidity and Mortality Weekly Report, 69(32)
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. COVID-19 trends among persons aged 0–24 years -- United States, March 1– December 12, 2020. Morbidity and Mortality Weekly Report, 70(3)
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. The ef fects of Medicaid expansion under the ACA: A systematic review.
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. Preterm birth among pregnant persons with severe acute respiratory syndrome Corona virus 2 infection.
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Morbidity and Mortality Weekly Report, 62(02)
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Morbidity and Mortality Weekly Report, 71(46)
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Morbidity and Mortality Weekly Report, 69(19)
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Morbidity and Mortality Weekly Report, 70(36)
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emergency department visits related to suspected or confirmed child abuse and neglect among children and adolescents aged <18 years before and during the COVID-19 Pandemic -- United States, January 2019– September 2020. Morbidity and Mortality Weekly Report, 69(49)
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Morbidity and Mortality Weekly Report, 71(3)
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mRNA vaccination against multisystem inflammatory syndrome in children among persons aged 12-18 years -- United States, July–December 2021. Morbidity and Mortality Weekly Report, 71(2)
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The Pediatric Infectious Disease Journal, 40(12)
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