Hong Kong Med J 2021 Jun;27(3):175–6  |  Epub 7 Jun 2021
© Hong Kong Academy of Medicine. CC BY-NC-ND 4.0
Impacts of the COVID-19 pandemic on the physical and mental health of children
Winnie WY Tse, FHKAM (Paediatrics)1; Mike YW Kwan, FHKAM (Paediatrics)2
1 President, Hong Kong College of Paediatricians, Hong Kong
2 Consultant, Paediatric Infectious Diseases Unit, Department of Paediatrics and Adolescent Medicine, Hospital Authority Infectious Diseases Centre, Princess Margaret Hospital, Hong Kong
Corresponding author: Dr Winnie WY Tse (president@paediatrician.org.hk)
 Full paper in PDF
The total number of new cases of coronavirus disease 2019 (COVID-19) is decreasing in Hong Kong, but two recent paediatric cases have attracted immense public attention—a 4-month-old baby who contracted the viral infection from his family and a 4-year-old boy who was likely infected in the community several months before, possibly concurrently with roseola infantum, and tested positive despite the long interval between infection and testing.
Since the outbreak of COVID-19 in Hong Kong in January 2020, there has been a great deal of research by local paediatricians on the clinical manifestations1 2 3 and scientific findings4 5 of the paediatric cases, including comparative studies with paediatric cases in South Korea,6 Wuhan,6 7 8 and other regions of mainland China,6 7 8 and with those of children infected with severe acute respiratory syndrome in 2003.9 Collaborations with local and overseas researchers have also contributed to a deeper understanding of COVID-19.10 11 12 13
The overt effects of COVID-19 on children are known: severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection generally causes mild illness in children and adolescents, with 99.2% of paediatric patients with COVID-19 experiencing mild symptoms8 and 26% to 38% asymptomatic.3 8 However, serious complications have occurred in children in Hong Kong, such as PIMS-TS (paediatric inflammatory multisystem syndrome temporally associated with SARS-CoV-2), post-COVID-19 autoimmune haemolytic anaemia, and COVID toes.8 These patients required lengthy hospital management including intensive care and prolonged follow-up after recovery.
In order to protect vulnerable individuals in Hong Kong, such as children and older and/or chronically ill adults, social distancing measures to mitigate the spread of infection have been enforced. Intermittently, schools have been closed and were fully open for <3 months in the entire year of 2020, and school closures have continued into 2021. Schools are fundamental to child and adolescent development and wellbeing, providing academic instruction, social and emotional skills, safety, reliable nutrition, physical/speech and mental health therapy, and opportunities for physical activity, among other benefits. Schools also play a critical role in addressing racial and social inequity.14 In the past 15 months of school suspensions, online teaching has played a central role in ensuring academic provisions but other aspects of development and wellbeing have been compromised.
In addition to providing a learning environment, schools serve to satisfy students’ non-academic needs and school closures have serious consequences on the physical and mental wellbeing of students.15 Internationally, studies have found that obesity16 and myopia17 among school-age children have increased because of longer screen times, lack of physical activities, and the small living and learning spaces at home. These indirect consequences can affect all children, but some are disproportionately more likely to be affected, such as those with special educational needs or those who are financially deprived. Tso et al18 conducted a large-scale cross-sectional population online survey of 29 202 Hong Kong families with children aged 2 to 12 years. The authors found that, amid the COVID-19 outbreak and the resulting related school closures and disease containment measures in Hong Kong, the risk of child psychosocial problems was higher in children with special educational needs, and/or acute or chronic disease, mothers with mental illness, single-parent families, and low-income families. Delayed bedtime, inadequate sleep, inadequate exercise, and extended use of electronic devices were associated with significantly higher levels of stress among parents and more psychosocial problems among pre-school children. These indirect impacts of COVID-19 could potentially create a social crisis because school closures are likely to widen the learning gap between children from lower-income and those from higher-income families.19
In Hong Kong, Chua et al3 found that household transmission was the main source of infection for children and youths, and the risk of being infected at school was small. On 10 May 2021, the Hong Kong College of Paediatricians, The Hong Kong Paediatric Society, and the Hong Kong Society for Paediatric Immunology, Allergy and Infectious Diseases jointly issued an appeal to adult household members and carers (aged ≥16 years) to receive the COVID-19 vaccine for the benefit of the younger generation.20
However, this is only the first step in the appeal from paediatricians. The ultimate goal is to boost the overall immunisation rate in the community and to restore societal normalcy. On 24 May 2021, whole-school half-day face-to-face classes resumed for all school grades in Hong Kong. However, students were still not permitted to interact with peers at lunch, enjoy many of the non-core subjects that have to be missed due to shortened class time, nor socialise outside of “class bubbles”.
The United States, Canada, Singapore, and Israel have approved COVID-19 vaccination for those aged 12 to 15 years. This is a welcome development in the efforts to protect the population from COVID-19, and we look forward to newer scientific evidence for vaccine safety and efficacy in even younger children.
The take-home message remains: community-wide immunisation is safe and effective—and much more desirable than closures of educational and leisure facilities—for protecting the physical health and long-term psychosocial and emotional development of children, and for reducing social inequity.
Author contributions
All authors contributed to the editorial, approved the final version for publication, and take responsibility for its accuracy and integrity.
Conflicts of interest
All authors have disclosed no conflicts of interest.
1. Mak PQ, Chung KS, Wong JS, Shek CC, Kwan MY. Anosmia and ageusia: not an uncommon presentation of COVID-19 infection in children and adolescents. Pediatr Infect Dis J 2020;39:e199-200. Crossref
2. Duque JS, Mak PQ, Wong JS, et al. Discharging coronavirus disease 2019 (COVID-19) patients with faecal viral shedding and prolonged hospitalisation. J Hosp Adm 2020;9:26-30. Crossref
3. Chua GT, Wong JS, Lam I, et al. Clinical characteristics and transmission of COVID-19 in children and youths during 3 waves of outbreaks in Hong Kong. JAMA Netw Open 2021;4:e218824. Crossref
4. To KK, Chua GT, Kwok KL, et al. False-positive SARSCoV- 2 serology in 3 children with Kawasaki disease. Diagn Microbiol Infect Dis 2020;98:115141. Crossref
5. Chua GT, Wong JS, To KK, et al. Saliva viral load better correlates with clinical and immunological profiles in children with coronavirus disease 2019. Emerg Microbes Infect 2021;10:235-41. Crossref
6. Chua GT, Xiong X, Choi EH, et al. COVID-19 in children across three Asian cosmopolitan regions. Emerg Microbes Infect 2020;9:2588-96. Crossref
7. Xiong XL, Wong KK, Chi SQ, et al. Comparative study of the clinical characteristics and epidemiological trend of 244 COVID-19 infected children with or without GI symptoms. Gut 2021;70:436-8. Crossref
8. Xiong XL, Chua GT, Chi SQ, et al. Haematological and immunological data of Chinese children infected with coronavirus disease 2019. Data Brief 2020;31:105953. Crossref
9. Xiong X, Chua GT, Chi S, et al. A comparison between Chinese children infected with coronavirus disease-2019 and with severe acute respiratory syndrome 2003. J Pediatr 2020;224:30-6. Crossref
10. Cowling BJ, Ali ST, Ng TW, et al. Impact assessment of non-pharmaceutical interventions against coronavirus disease 2019 and influenza in Hong Kong: an observational study. Lancet Public Health 2020;5:e279-88. Crossref
11. Zhang Q, Bastard P, Liu Z, et al. Inborn errors of type I IFN immunity in patients with life-threatening COVID-19. Science 2020;370:eabd4570.
12. Bastard P, Rosen LB, Zhang Q, et al. Autoantibodies against type I IFNs in patients with life-threatening COVID-19. Science 2020;370:eabd4585.
13. Sancho-Shimizu V, Brodin P, Cobat A, et al. SARS-CoV-2-related MIS-C: A key to the viral and genetic causes of Kawasaki disease? J Exp Med 2021;218:e20210446.
14. American Academy of Pediatrics. COVID-19 guidance for safe schools. Available from: https://services.aap.org/en/pages/2019-novel-coronavirus-covid-19-infections/clinical-guidance/covid-19-planning-considerations-return-to-in-person-education-in-schools/. Accessed 28 May 2021.
15. Hoffman JA, Miller EA. Addressing the consequences of school closure due to COVID-19 on children’s physical and mental well-being. World Med Health Policy 2020;12:300-10. Crossref
16. Jenssen BP, Kelly MK, Powell M, Bouchelle Z, Mayne SL, Fiks AG. COVID-19 and changes in child obesity. Pediatrics 2021;147:e2021050123. Crossref
17. Wang J, Li Y, Musch DC, et al. Progression of myopia in school-aged children after COVID-19 home confinement. JAMA Ophthalmol 2021;139:293-300. Crossref
18. Tso WW, Wong RS, Tung KT, et al. Vulnerability and resilience in children during the COVID-19 pandemic. Eur Child Adolesc Psychiatry 2020 Nov 17. Available from: https://doi.org/10.1007/s00787-020-01680-8. Accessed 28 May 2021. Crossref
19. van Lancker W, Parolin Z. COVID-19, school closures, and child poverty: a social crisis in the making. Lancet Public Health 2020;5:e243-4. Crossref
20. Hong Kong College of Paediatricians. Appealing to adults to receive COVID-19 vaccination for the psychosocial and physical health of our children (updated 10th May 2021). Hong Kong College of Paediatricians. Available from: https://www.paediatrician.org.hk/index.php?option=com_content&view=article&id=427&catid=2&Itemid=26. Accessed 28 May 2021.