Sept. 26, 2023 — Fall is here, schools are back in session, and pumpkin spice is in the air. So is the annual reminder to parents to ensure their children’s respiratory infection vaccinations are up to date, especially against the flu and respiratory syncytial virus (RSV). This year, too, the CDC recommends an updated COVID-19 shot for everyone ages 6 months and older.
The new recommendations are that children 5 and older receive at least one dose of the updated Pfizer or Moderna vaccines, and those 6 months to 4 years get two doses of either vaccine (with one of the doses being the updated shot).
This year’s jabs are slightly different from prior COVID vaccines. Not only do they target a specific mutation of the virus called XBB.1.5 and its related variants, but they are also expected to provide protection against strains linked to an uptick in cases and hospitalizations over the summer.
Still, more than half of U.S. children between the ages of 6 months and 17 years have not received a first COVID-19 shot, according to the American Academy of Pediatrics. What’s more, concerns – often misguided– about the safety of the COVID-19 vaccines and the potential for long-term side effects in children and adolescents – like an inflamed heart muscle (myocarditis) or multisystem inflammatory syndrome (MIS-C, a severe immune response that affects multiple organs) – continue to impact parents’ and caregivers’ choice whether to vaccinate their children or not.
Despite those concerns, research has found that the risk of myocarditis is much higher in children who develop COVID than in those who are vaccinated against it. It has also mostly occurred in boys. MIS-C in children after COVID vaccination is also extremely rare, and research shows those who develop it may have a specific genetic marker making them more susceptible.
Yet some parents remain skeptical.
“I’ve seen the articles, especially in boys about the heart issue stuff, and that’s terrifying to me especially because my boys are super active,” said Sarah Weaver, a 40 year-old mother of three and high school English teacher in the Detroit metro area.
“I’m not a risk taker. The risk of what could happen if they got [COVID] seems to outweigh the risks [of vaccination] because kids were not seriously affected for the most part.”
But experts point out that COVID is now one of the top causes of pediatric deaths and that most deaths have come in children with no preexisting medical condition.
Is Myocarditis Still a Concern?
Early in the pandemic, questions over vaccine safety increased as researchers started to track reports linking the COVID-19 mRNA vaccines to myocarditis in young adult males and adolescents, mostly after the second dose.
Since that time, however, the CDC’s surveillance efforts have demonstrated a significant decline in these cases.
“It seems that the risk was highest after that second dose of the initial series and we’re not seeing it at this point,” said Sean O’Leary, MD, professor of pediatrics at the University of Colorado School of Medicine and Children’s Hospital, Colorado, and chair of the American Academy of Pediatrics’ Committee on Infectious Diseases.
“We’re not anticipating with the new booster that MIS-C is going to come back based on what we’ve seen in the past year and a half,” he said.
Shelby Kutty MD, PhD, director of pediatric and congenital cardiology and professor of pediatrics at Johns Hopkins University School of Medicine in Baltimore, agreed.
“There were substantially more patients in the first wave than in recent times; frequency has come down overall,” he said.
But Kutty also had an important message for parents and caregivers.
“When we talk about myocarditis, we think about a very scary infection of the heart and complications. … But it is not a new disease; it can happen with different viral infections,” he said.
“Most of the reported [vaccine-related] cases overall were clinically mild and most people recovered in 3 to 5 days with no other problems after that. They just required supportive treatment — like anti-inflammatory drugs — and almost 90% had resolution of symptoms when they were discharged from the hospital,” he said.
In contrast, the SARS-CoV-2 infection has been and continues to be associated with “a substantially increased risk of myocarditis, other heart rhythm problems, pericarditis [inflammation of the tissue surrounding the heart], and increased risk of hospitalizations and death,” he said, also emphasizing that “the actual infection is increased by nearly 10- or 11-fold if the person is not vaccinated.”
What About MIS-C (Multisystem Inflammatory Syndrome)?
Another concern that arose early in the pandemic (and remains top of mind among many parents) is MIS-C, a condition that mimics Kawasaki disease and mostly occurs in young children, causing the blood vessels to become inflamed. Initially, most MIS-C cases developed 2 to 4 weeks after infection with COVID. Since that time, cases have followed the peaks of overall COVID-19 infection cases by about a month.
Robert W. Frenck Jr., MD, director of the Vaccine Research Center at Cincinnati Children’s Hospital in Ohio, explained that MIS-C is basically an overexuberant immune response.
“You get fevers, you get conjunctivitis, enlarged lymph nodes, rash, etc. But if you look at the rate and severity of MIS-C from the infection versus the rate and severity from the vaccine, it’s about 7 to 8 times higher,” he said.
Thus far, rates with both previous bivalent mRNA vaccines continue to be quite low, according to CDC data.
Pediatric COVID in Perspective
The flurry of information and headlines and numbers since the start of the pandemic has overwhelmed many parents and caregivers who, like Weaver, only want what is best for their children.
“Parents want to keep their kids healthy; they want to keep their kids safe,” said Frenck. “They’re weighing the evidence and saying, ‘I don’t think that it’s important to vaccinate my child, it’s a mild disease, the risk is low.’ The problem is that I have no way to know if it’s their child or that child or the other child who’s going to have severe disease.”
Both he and O’Leary said not only is COVID now one of the top 10 causes of pediatric deaths, but more than half of COVID-related deaths in children have occurred in children with no underlying or preexisting medical conditions, meaning that they were preventable had these kids been vaccinated.
“You know, when you look at the lists of causes of deaths in kids like cancer and motor vehicle accidents and suicide, if we had a safe, simple, effective intervention to eliminate any of those, we’d jump at it, right?” said O’Leary.
“We have that in this case, in the vaccine. It’s really tragic when kids die or get really sick from something that could have been prevented.”