27.FEB.2020 10 MIN READ | 10 MIN READ

You’ve read the articles and followed the news. The COVID-19 coronavirus disease doesn’t look like it’ll be going away very soon. How then do we live with the COVID-19 and continue caring for our little ones?

As of 27 February 2020, there has been more than 80,000 confirmed cases of COVID-19 and more than 2,800 deaths from the virus worldwide. Experts have likened COVID-19 to the H1N1 influenza pandemic rather than the deadly Severe Acute Respiratory Syndrome (SARS-CoV). What does this mean for us and our children? Dr Mohana Rajakulendran, paediatrician and mother of 2, provides evidence-backed answers to 10 practical questions parents might have on COVID-19.

Q1: What are the symptoms of COVID-19 in children?

As of February 2020, only 416 (0.9%) out of a total of 44,672 confirmed COVID-19 cases in China were children aged 10 years and younger. 549 cases (1.2%) were older children and adolescents aged 10 – 19 years. These were children who had close contact with an infected person, or were part of a family cluster of cases.

A study detailing the first 28 cases in children in China as of 30 January 2020 tells us that most children displayed symptoms such as dry cough, fatigue, nasal congestion, runny nose, abdominal pain, nausea, vomiting and diarrhoea. Only half of them had fever. A majority of these children did not have pneumonia and they recovered within 1 – 2 weeks of the onset of illness. Several of them also did not show any obvious symptoms when diagnosed with the virus. Data from 34 paediatric cases from Shenzhen, China showed similar findings.

In summary: Dry cough, fatigue, nasal congestion, runny nose, abdominal pain, nausea, vomiting and diarrhoea are the most telling symptoms.

Q2: How should you seek help if you think your child has COVID-19?

Coronavirus children medical help
The symptoms in children are similar to that of many common childhood viral illnesses.

It is important to bring your child to a doctor if they are unwell with any rapid breathing, poor feeding, drowsiness or lethargy. Your doctor will assess your child for signs and symptoms of pneumonia and may recommend a chest X-ray for confirmation.

If your child is diagnosed with pneumonia and requires hospital care, they may be referred to a hospital with a paediatric unit. If admitted for their pneumonia, they will be isolated in hospital pending confirmatory test results for COVID-19 while receiving treatment for their pneumonia.

As a majority of COVID-19 cases are mild, the Ministry of Health in Singapore has advised those with mild flu-like symptoms to remain home for 5 days to prevent the potential spread of any viruses, including COVID-19. It is crucial for us to play our part as parents to curb the spread of viruses, especially during this period.

Tips to curb the spread of viruses:

  • Ensure that your child has adequate rest and drinks lots of fluids.
  • You can give your child medication to relieve their symptoms of fever, nasal congestion, runny nose or cough to keep them comfortable.
  • Keep your child in a room separate from other household members.
  • Wear a face mask, if necessary. If your child is above the age of 3, they can wear a face mask to reduce chances of virus transmission. If your child is under the age of 3, wearing a face mask is not recommended. Instead, other family members can wear masks to protect themselves.
  • Avoid sharing utensils, food or drinks. Try to keep your child in their room and away from communal areas of the house since the virus is spread via droplets and contact.
  • Both you and your child should practise good hand hygiene by regularly washing hands with soap and water.
  • Avoid sharing toys during this period of illness.
  • Do disinfect your child’s toys and their surroundings with 75% alcohol (eg. ethanol and isopropyl alcohol solutions) or chlorine-containing disinfectants rather than anti-bacterial wipes.
  • See a doctor if your child’s condition doesn’t improve after 5 days.

In summary: Bring your child to a doctor for assessment if they exhibit symptoms such as rapid breathing, poor feeding, drowsiness or lethargy.

Q3: Will you be allowed to stay with your child if your child needs isolation for COVID-19?

Most hospitals are adopting a single accompanying parent policy for all unwell children who are admitted to hospital. If your child is isolated for suspected COVID-19, one parent is allowed to accompany the child. Since your child will be isolated, you will need to remain in the isolation facility throughout your child’s stay as well. If your child tests positive for COVID-19, you will be placed under quarantine and closely monitored for the development of any respiratory symptoms.

In summary: Yes, one parent will be allowed to accompany your child.

Q4: Is COVID-19 fatal for children?

Of the 28 confirmed cases of children infected in China, all were mild and no deaths were reported. In Singapore, all 3 infected children have since been discharged from hospital. Statistics show that the elderly and those with underlying chronic illnesses are more at risk of complications than children.

Data shows that in severe cases, adults developed breathlessness after 1 week of disease onset and this rapidly deteriorated to acute respiratory distress syndrome (ARDS). Although this has not been observed in children, ARDS-related deaths in children occurred during the SARS and Middle East Respiratory Syndrome (MERS-CoV) epidemics. Therefore, parents must be vigilant about the deterioration of symptoms in their children. Such symptoms include rapid breathing, lethargy, drowsiness or poor feeding in a child.

In summary: No cases of death in children due to COVID-19 have been reported, although parents should still be vigilant.

Q5: What treatment is there for COVID-19?

Coronavirus children treatment
As COVID-19 is a viral infection, treatment is largely supportive. Examples include rest and drinking lots of fluid. In severe cases, supplemental oxygen or respiratory support may be provided. Antiviral, HIV and immune-modifying drugs have also been used with some success.

However, the safety and efficacy of these drugs have not been evaluated in children and the use of these medications will likely be at the discretion of the child’s doctor.

In summary: There is no approved cure or vaccine at present. Treatment consists of supportive care.

Q6: Will the influenza vaccine protect your child from COVID-19?

No. The influenza vaccine protects against seasonal influenza A and B strains of viruses, and not COVID-19.

However, it is still recommended to get yearly vaccinations for influenza. The Centers for Disease Control and Prevention in the United States have reported a worrying increase in the number of deaths in children in the current 2019 – 2020 influenza season.

In summary: Influenza vaccine cannot protect your child from COVID-19, but it is still important to get influenza vaccines to protect against the flu virus.

Q7: Could your child be a silent carrier of COVID-19? Can other members in your family get infected even if your child displays no symptoms?

Yes, from the experience reported in China, a number of children of close contacts were asymptomatic carriers. However, this suggests a milder and weaker form of infection in children who were directly exposed to the virus. Currently, there is no evidence that healthy children without close contacts are transmitting COVID-19. In fact, even as Singapore diligently expands the criteria for testing for COVID-19 to include all children with pneumonia, no non-contact cases have been found to be positive to date.

Therefore, if your child has been found to be a close contact of someone with COVID-19, or has returned from a high-risk country, there might be a possibility of asymptomatic carriage prior to onset of symptoms. In these cases, your child would have been served a 14-day Leave of Absence or Stay-Home Notice. Keep them at home with a face mask, if they are old enough to wear one. You may want to take additional precautions within the household by isolating them in a separate room from vulnerable family members such as infants, toddlers, elderly or those with pre-existing chronic illnesses.

Even so, bear in mind that there is a low likelihood of asymptomatic carriers transmitting the virus, as shown in studies of other respiratory diseases such as influenza. In these studies, low levels of viral transmission occurred 1 – 2 days before the onset of symptoms and peaked with the onset of respiratory symptoms. Asymptomatic spread in respiratory diseases in general does not account for a majority of respiratory infections.

In summary: Yes, if your child is a close contact of someone who has COVID-19. However, transmission of virus is unlikely if your child has no symptoms.

Q8: Should you keep my child away from preschool, and for how long?

Coronavirus children preschool
Unfortunately, there is no right answer to this as the COVID-19 outbreak is still in its early stages with minimal data on preschool spread. Do consider all facts available, and make a decision based on how comfortable you are with letting your child remain in preschool. If you do decide to keep your child at home, bear in mind that the COVID-19 outbreak could last for a few months.

What we do know: Children in preschools, especially those below the age of 3, are at higher risk of acquiring acute respiratory infections because of prolonged and close proximity contact with large numbers of children. The frequency of viral infections acquired at preschool reduces significantly after the first 9 months to 1 year of continued attendance. In addition, it has also been shown that improved standards of hand, surface and air hygiene measures can help prevent the spread of viral infections within these environments.

Personally, I continue all routine activities for my children, with added hygiene precautions. I take the COVID-19 outbreak as a good opportunity to teach my children how to take better care of themselves and to watch out for others who may be more vulnerable.

It is important not to perpetuate unfounded fears in our children as it is very easy for children to pick up on emotions around them. I would advise keeping to a normal routine and highlighting certain added precautions which are necessary for your child.

If your child’s preschool reports a COVID-19 case, it would be reasonable to keep your child home for the average cycle of 1 incubation period (ie. 14 days) from contact with the last positive case, in order to:

  1. Observe for any symptoms in your child; and
  2. Watch for any further reported cases of spread within the preschool.

In summary: There is insufficient evidence available to guide this decision. In the unlikely situation that there is a COVID-19 case in your child’s preschool, you are advised to keep your child at home for 14 days since their last contact with the infected person.

Q9: Can you breastfeed your child if either yourself or your child contracts COVID-19?

Based on experience with other respiratory viruses, the transmission of viruses via breast milk is likely to be less significant in comparison to the benefits of breastfeeding. Breast milk samples from 6 pregnant women with COVID-19 in China tested negative for the virus.

However, if you have been diagnosed with COVID-19, you should take extra precautions to prevent transmission of the virus to infants through respiratory droplets and contact. This would include wearing a face mask when breastfeeding and taking strict hand hygiene measures when handling your baby. Take adequate hygiene precautions when handling expressed milk as well.

If your child is diagnosed with COVID-19, you can continue breastfeeding. Wear a mask to protect yourself and practise good hand hygiene. You will be placed on quarantine and should seek medical attention early if you develop fever or any respiratory symptoms.

In summary: Yes. Chances are low that the virus can be transmitted via breast milk. However, precautions must be taken to avoid external transmission of virus between you and your infant.

Q10: Should you avoid hospitals or continue with hospital follow-ups for vaccinations or my child’s chronic illnesses?

It is important to continue routine vaccinations for your child and regular follow-ups to monitor your child’s chronic medical conditions. You can postpone other non-urgent medical consults.

Some paediatric clinics provide time slots in the mornings only for routine health assessments (for growth and development) and vaccinations. It is recommended that advanced appointments be made so clinic staff can make the necessary arrangements. Routine vaccinations will protect your child from acquiring childhood diseases such as measles, diphtheria, Haemophilus influenzae, pneumococcal pneumonia, all of which have much higher mortality rates in children than COVID-19.

In summary: Do continue routine vaccinations and follow-ups for chronic conditions. Non-urgent medical consults can be postponed.

If you have respiratory symptoms (eg. cough, runny nose or fever), please visit your nearest Public Health Preparedness Clinic. It is important to receive timely treatment for your condition.

Article contributed by Dr Mohana Rajakulendran, paediatrician at Parkway East Hospital


Characteristics of and Important Lessons from the Coronavirus Disease 2019 (COVID-19) Outbreak in China. Retrieved 24 February 2020, from https://jamanetwork.com/journals/jama/fullarticle/2762130

Chen, H., Guo, J., Wang, C., Luo, F., Yu, X., & Zhang, W. et al. (2020). Clinical characteristics and intrauterine vertical transmission potential of COVID-19 infection in nine pregnant women: A retrospective review of medical records. The Lancet. doi: 10.1016/s0140-6736(20)30360-3

Coronavirus disease 2019 (COVID-19) situation report - 36. (2020, February 25). Retrieved 26 February 2020, from https://www.who.int/docs/default-source/coronaviruse/situation-reports/20200225-sitrep-36-covid-19.pdf?sfvrsn=2791b4e0_2

Influenza. (2020). Retrieved 20 February 2020, from https://www.cdc.gov/vaccines/pubs/pinkbook/flu.html

Lai, L. (2020). Coronavirus: Docs to give 5-day medical leave to patients with respiratory symptoms; subsidised rates for S'poreans at designated clinics. Retrieved 20 February 2020, from https://www.straitstimes.com/singapore/health/coronavirus-docs-to-give-5-day-medical-leave-to-patients-with-respiratory-symptoms

Patrozou, E., & Mermel, L. (2009). Does influenza transmission occur from asymptomatic infection or prior to symptom onset?. Public Health Reports, 124(2), 193-196. doi: 10.1177/003335490912400205

Roberts, L., PhD, E., Smith, W., Jorm, L., PhD, B., & Patel, M. et al. (2000). Effect of infection control measures on the frequency of upper respiratory infection in child care: A randomized, controlled trial. Pediatrics, 105(4), 738-742. doi: 10.1542/peds.105.4.738

Schuez-Havupalo, L., Toivonen, L., Karppinen, S., Kaljonen, A., & Peltola, V. (2017). Daycare attendance and respiratory tract infections: A prospective birth cohort study. BMJ Open, 7(9). doi: 10.1136/bmjopen-2016-014635

Shen, K., Yang, Y., Wang, T. et al. Diagnosis, treatment, and prevention of 2019 novel coronavirus infection in children: experts’ consensus statement. World J Pediatr (2020). https://doi.org/10.1007/s12519-020-00343-7

Updates on COVID-19 (Coronavirus Disease 2019) Local Situation. (n.d.). Retrieved 21 February 2020, from https://www.moh.gov.sg/covid-19

Wang, X. F., Yuan, J., Zheng, Y. J., Chen, J., Bao, Y. M., Wang, Y. R., Wang, L. F., Li, H., Zeng, J. X., Zhang, Y. H., Liu, Y. X., & Liu, L. (2020). Zhonghua er ke za zhi = Chinese journal of pediatrics, 58(0), E008. Advance online publication. https://doi.org/10.3760/cma.j.issn.0578-1310.2020.0008

Weekly U.S. Influenza Surveillance Report (FluView). (2020). Retrieved 20 February 2020, from https://www.cdc.gov/flu/weekly/index.htm

Mohana D/O Rajakulendran
Parkway East Hospital