American Board Certified Pediatric Cardiologist
Founder Trustee, Child Heart Foundation
Children are the largest unvaccinated group worldwide. There is a prediction that they may get affected most during a possible third wave. There are several aspects when it comes to Covid and heart involvement in children. Let us focus on the heart of kids in 3 different scenarios’ with Covid. We will conclude with a discussion on vaccination and its effect on the heart in children.
Children with pre-existing Heart disease
Natasha is a 15-year-old girl, was born with a hole in the heart, a ventricular septal defect. She has not required surgery or medical treatment because the hole is exceedingly small. During the second wave, in May, their whole family got covid. She also suffered from covid, albeit was mild, like for all in the family. Her parents were most worried for her, though she ended up fine and recovered completely. So did several hundred other children.
Riya is 16 years old and makes her YouTube videos on makeup. As a small child, she underwent 2 valve -related surgeries, the second one being valve replacement, at the age of 4. She has been on blood thinners since then. She got covid in April last week. Her mother was in touch with the cardiology team on a daily basis, several times a day. Riya did well, did not need hospitalization, and has subsequently, recovered.
The real cases mentioned above exemplify that these and several hundred other children, with pre-existing heart problems, when get affected by covid, usually do well, and are not at a higher risk of ICU admission or hospitalization. I would urge parents with children of heart disease not to get worked up about Covid infection. This includes babies, who are awaiting surgery and during the waiting process, have ended up getting Covid.
Normal children with Covid: More likely to get heart involvement?
Severe covid in normal children has been reported but the percentage of children getting covid is few. Amongst these severe covid cases, (who have no pre-existing disease) heart involvement may be present only in lab tests than clinically. This implies that very little heart muscle got affected. Few specific lab tests would show it, but the patient may not manifest any symptoms. This type of involvement is also known to recover very fast and recover completely.
Multisystem Inflammatory Syndrome in Children or MIS-C
It seems that most kids with covid are going to do well. The worry stems from a condition that seems to happen a month or a few weeks after they have got Covid.
Parissa, a 9-year-old female, is a part of a family where everyone got Covid and recovered. All had mild disease. A month after the infection, she started getting fever which continued in spite of medications. She also developed a rash and some swelling on her body, especially her limbs. Her hands became cold, and she was sweaty. On consulting their pediatrician, they were told to rush to a hospital and get her admitted to the ICU. She received heart support medications and a specific treatment called IVIG. She recovered over the next 2 weeks and is doing well.
This condition is referred to as MIS-C. The child develops fever and may also have a rash. Once the parent ends up with a pediatrician, they may ask: Was there anyone in the family who had Covid? Did the child have Covid? Usually, one may get a history of Covid in the family 4 weeks prior to the presentation.
The child may or may not have manifested covid symptoms i.e., may have had an asymptomatic infection 4 weeks back. This is usually checked with antibody levels and the child would then be noted to have high antibody levels.
Other manifestations may be redness of eyes, diarrhoea, cold clammy hands, even low BP or low pulse volume. In the presence of the last 2 symptoms, the patient should be moved to a hospital with a pediatric ICU, at the earliest.
So, what is happening here? This is very unlike what we have heard or seen in adults! What really happens is that a small percentage of kids who got a mild form of the disease reacted with an extremely high immune response. The immune response caused antibodies to increase, resulting in the manifestations mentioned above.
Since multiple systems are involved, the condition is referred to as Multi system Inflammatory Syndrome in children.
In addition to the involvement of the organs mentioned, there may be a mild or rarely severe form of involvement of the heart. The heart involvement may be in the form of the decreased pumping action of the heart. This itself could be mild and may respond to few medications and reverse rapidly.
But rarely, the involvement may be dramatic, and the heart muscle may get so affected that immediate heart medications and ICU management needs to be initiated.
Another more common form of involvement of the heart may be the swelling of coronary arteries. These are arteries that supply blood and oxygen to the heart muscle itself. This is like another condition, relatively rare, seen in children under 5 years, called Kawasaki Disease, where the coronary arteries swell up as well. These may or may not be reversible and may result in a lifelong medication.
In most cases, children have recovered, including their hearts.
The treatment of this condition is a combination of steroids and immunoglobulins. The response is dramatic, and recovery is very fast after the diagnosis is made and treatment is given. Increased awareness amongst doctors of this condition is needed for early diagnosis and also, to avoid over-diagnosis or treatment.
Vaccines and Heart Involvement
One has heard of adults getting a heart attack a day or two after the vaccine. This has not happened in children and is not expected to. Even in adults, it is not proven yet that it’s the vaccine that is causing it. It is mainly because of pre-existing heart disease, especially in cases where it is severe.
Many trials have already been conducted in children for vaccines and few countries have started vaccinating children above 12 years of age (not in India yet). Trials are being conducted with vaccines in children under 12 years and even as young as 2 years, and above. Most of these vaccines have by, and large, been found to be very safe.
Of all the vaccines, 2 are made with a technology not used before: the Pfizer and the Moderna vaccine. These 2 vaccines use an mRNA technology. These vaccines have been found to be amazingly effective in preventing severe disease in adults, and the results suggest the same in children.
But there has been a trend noted in the United States of America where the Pfizer vaccine has been used in children who are 12 years, and more. They have noted that in an exceedingly small percent of children, the heart muscle and the layer on the outside of the heart (pericardium) are getting swollen. This is temporary and usually self-resolving. In none of the kids, this has worsened to requiring medication or ICU stay. In fact, most of them have not required admission to a hospital, either.
The Centre for Disease Control has been monitoring very intensely the side effects of vaccines through their Vaccine Adverse Event Reporting System (VAERS). The side effect we are discussing has happened mainly in male adolescents and young adults.
Considering this side effect of vaccine, many of us might think not giving vaccines is an option. However, calculations have shown that if unvaccinated, several millions would get heart involvement from Covid, which could be severe. But if vaccinated, only a few 1000 will get a minor heart muscle swelling which would reverse and not require treatment.
Incidentally and interestingly, this particular side effect has not been reported with the traditionally manufactured and designed vaccines (e.g., Covaxin and Covishield).
In conclusion, children are very rarely likely to get heart involvement with covid but are uniquely prone to a condition called MIS-C which may have heart involvement. The newer technology mRNA vaccines (not available in India) are prone to affect a very small percent of kids’ hearts by causing swelling and this, also, is very mild.