Adequate sleep is key to good health, well-being and proper functioning across all life stages but is especially critical for children. Poor sleep can inhibit rapid growth and development in early childhood.
And it’s not just about sleep duration; the time one goes to bed also plays an important role in the physical, emotional, and cognitive development of children.
A consistent early bedtime is especially important for young children transitioning from biphasic sleep (where children still nap during the day) to monophasic sleep (where sleep happens at night).
Late sleepers don’t always get the recommended amount of sleep but evidence also suggests late bedtime is associated with sleep quality problems and difficulty falling asleep.
All this can add up to concentration, memory, and behaviour issues in children.
An early bedtime is good for physical health, too
One study of low income preschool-aged children found not getting enough sleep was associated with a higher risk of obesity. A review of academic literature on the question found
Poor sleep is increasingly common in children and associations between short sleep duration in early childhood and obesity are consistently found.
It’s worth noting that most of the studies on this question are cross-sectional, which means they look at data from a population at one specific point in time. That has major limitations that make it hard to say poor sleep habits cause the higher obesity risk.
To know more, we need more longitudinal studies that examine change over time.
That said, emerging evidence from longitudinal studies supports the idea an early bedtime may be worth the battle. One longitudinal study found:
Preschool-aged children with early weekday bedtimes were half as likely as children with late bedtimes to be obese as adolescents. Bedtimes are a modifiable routine that may help to prevent obesity.
My own research, published last year with colleagues in the journal Acta Paediatrica, analysed four years of data from 1,250 Aboriginal and Torres Strait Islander children aged five to eight years old.
The results highlight that even after controlling sociodemographic and lifestyle factors, children who had consistently late bedtimes (after 9.30pm) were on average 1.5kg to 2.5kg heavier at follow up three years later than children who go to bed early (at around 7pm).
Nobody can yet say for sure what the exact relationship is between bedtime and obesity risk. Maybe it’s that staying up late provides more opportunities for eating junk food or drinking caffeinated drinks.
Or there could be more complex physiological factors. The body’s internal clock, which regulates sleep, also plays a crucialrole in hormone secretion, glucose metabolism and energy balance.
How late is late?
Sleep habits are shaped by a range of biological and cultural factors. When parents set their child’s bedtime, they’re influenced by cultural norms, lifestyle and what they know about the importance of sleep.
There are clear guidelines for sleep duration for each age group, but the time a child should go to bed isn’t always as clearly defined. For a pre-schooler, I’d recommend a consistent bedtime between 7pm and 8pm to ensure adequate sleep (recognising, of course, that work and caring responsibilities can make this really difficult for some parents).
Develop an early bedtime routine for your child and try to stick to it, even when it’s “not a school night”. Irregular bedtimes disrupt natural body rhythms and, as many parents know from direct experience, can lead to behavioural challenges in children.
Early childhood is a critical time in which the foundations of life-long habits are built. Developing healthy sleep habits can set children on the right path for better future health and well-being.
During the pandemic, children have been separated from family and friends, schools have been closed and there have been limitations on important activities, such as play.
We know a good deal about the physical effects COVID-19 has on children. But the impact on their mental and emotional well-being is less well understood – particularly from the perspective of children themselves.
Our recently published research highlights the importance of listening to children, about what they have to say and the information they want about COVID-19.
We took part in an international study with children from six countries – the UK, Spain, Canada, Sweden, Brazil and Australia.
We recruited children through our professional and social networks, for example sporting groups and community groups.
We asked children aged seven to 12 years about how they accessed information about COVID-19, about their understandings of the virus and why they were asked to stay at home.
The survey was open when the highest level restrictions were in place across Tasmania, where the Australian arm of the study was based. In total, 49 children from Tasmania took part in the survey and 390 children internationally.
There were important differences across the countries when we conducted the survey, including the numbers of reported cases and deaths from COVID-19, as well as government responses and levels of restrictions.
For example, the reported deaths and cases were much higher in countries such as the UK and Brazil compared to Australia and children in Sweden continued to attend school, whereas most children in other countries were learning from home.
There were many similarities across the different countries in the things important to children, what they had to say and what they wanted to know. But there were also differences across countries and between children.
More than half the children said they knew a lot or quite a bit about COVID-19. Their comments included:
It is a stupid virus.
It spreads really quickly.
People play it down and tell me it can’t kill people, but I know people are dying each day.
But they also had questions:
How and where did it start?
What does the coronavirus actually look like?
How does it make you poorly?
Some said they did not want to know any more about the virus:
It is boring.
I don’t want to know about it because it’s killing people and that makes me sad.
Children expressed different emotions about COVID-19. They said they felt “worried”, “scared”, “angry” and “confused”.
Children knew the virus was particularly dangerous for vulnerable people:
It can possibly kill old and unhealthy people.
And they missed their friends and family:
When can we go back to school?
Children obtained information about COVID-19 from different sources, mostly from parents and teachers. Children also sought information from friends, TV shows and the internet, including social media.
Children understood what the community was being asked to do and they had learnt the meanings of new words and terms. So they knew what social distancing meant and that they needed to stay 1.5m apart.
Children also knew key public health messages about washing your hands, not touching your face and needing to stay at home “to save lives”.
Children have had an important role in society’s response to COVID-19. Their significant contributions to limiting the spread of the virus have included being separated from family and friends, and limitations on important activities that are part of their “normal” lives.
However, the impacts on children’s lives and well-being are largely unacknowledged. Their contributions should be acknowledged and they should be thanked for their part.
Children have a right to be provided with information in a form that is appropriate for their safety and well-being. Children need to have the opportunity to ask questions and learn about what COVID-19 means for them with adults they trust, including parents and teachers.
Children have questions about COVID-19. Questions are different for each child and not all children want the same amount of information.
Adults should make the time and space to have conversations with children. They can ask:
what would you like to know?
what would you like to ask?
This approach means children are empowered to identify their needs and concerns, and the information they are provided is relevant and meets their needs.
Andrea Chelkowski, from the Centre for Education and Research — Nursing and Midwifery, Tasmanian Health Service South and University of Tasmania, Hobart, was part of the Australian research team. The lead author of the research mentioned in this article is Lucy Bray, professor in child health literacy, Edge Hill University, UK.
It’s the first study, to my knowledge, that directly compares children and adults with mild COVID.
Children are less likely to become infected, and when they are, they are more likely to be asymptomatic. This is in contrast to other viral and respiratory infections that are more prevalent among young people.
This new research helps explain how kids’ immune systems work when confronted with the coronavirus — and gives us clues as to why they generally seem to fare better than adults.
The researchers studied 48 kids, mostly in primary school, across 28 households during Melbourne’s second wave. All children were exposed to the coronavirus in their households by infected parents.
This study focused on the “innate” immune response in children, which forms the early part of the immune system’s attack on a virus (or bacteria, or other pathogens). The innate immune system plays an important role in viral protection before the body raises antibodies.
The study found there were dynamic changes in kids’ early immune responses, compared with coronavirus-infected adults.
One key innate immune cell that was elevated in children exposed to the virus was a type of white blood cell called “neutrophils”. These cells patrol the body for infections. When they discover a pathogen, they have a unique ability to respond by trapping and killing the invading pathogen (in this case, the coronavirus).
This role may ensure the virus is not able to infect more cells. This potentially decreases the “viral load”, basically the amount of virus in your body.
For some of the kids in the study, the early immune responses kept the viral load so low that they never returned a positive test, despite being tested throughout the study and having been exposed to coronavirus.
One strength of this study is that it was “longitudinal”, meaning it studied families over time, rather than simply at one point in time. The researchers looked at immune responses of the families just after their exposure to the virus, and returned more than 30 days later to see what had changed. This allowed them to identify the key changes induced because of the exposure to the virus.
Kids vs adults
A key question arising from this research is: why did the kids show such strong immune responses, resulting in few or no symptoms, while their parents were very ill?
It’s a difficult question to answer, at least so far. But the key differences in responses are likely to lie in the early responses of the immune system.
There is some previous research that might give some clues.
One theory surrounds the fact that children have less of the receptors called “ACE2” in their respiratory tract. These receptors are the pathway of entry for the virus into our cells. In theory, less ACE2 receptors mean less chance for the virus to break in and infect our cells. Virus’ don’t survive for very long outside a cell. With less ACE2 receptors, it may give more time for the innate immune cells to control the virus as much as it can while waiting for other immune cells to come along and help.
Another possibility relates to “interferons”, which are alert signals released by cells to tell the body there’s a virus around. Researchers think higher levels of interferons during the early phase of an infection are very important for controlling coronavirus. Potentially, interferons may help promote the increased neutrophils that were seen in children, compared with lower numbers observed in adults.
The wide range of symptoms in COVID are intriguing and frustrating at the same time. Conventional wisdom was that kids are more prone to getting sick with respiratory illnesses than adults — just ask any parent! But with COVID it seems to be the opposite.
Often when we think we’ve nailed down a specific mechanism as to how this new virus works and how our bodies respond to it, it turns out such a mechanism is different across different people. We can see this in the huge range of symptoms that different people display — some get a runny nose, others get a cough, and others suffer extreme exhaustion and respiratory distress or develop “long COVID”, in which symptoms drag on for months.
Coronavirus is still keeping immunologists on their toes. Studies like this one help solve some of the puzzle in understanding who’s at most at risk of severe disease and why.
The COVID vaccine rollout has placed the issue of vaccination firmly in the spotlight. A successful rollout will depend on a variety of factors, one of which is vaccine acceptance. One potential hurdle to vaccine acceptance is needle fear.
In a study that surveyed parents and children in Canada, 24% of parents and 63% of children reported a fear of needles. About one in 12 children and adults alike said they didn’t get all the vaccinations they needed because of their phobia.
Needle phobia generally begins from around age five, and can last through to adulthood. It can be a barrier to health-care access and treatment.
So it’s important to establish positive attitudes towards needle procedures, particularly vaccination, early in life.
Although there’s no one specific reason why people develop needle phobia, people who are anxious and fearful of needles can often relate their concerns back to one poorly-managed needle experience as a child. A bad experience may result from feelings of powerlessness due to being under-informed or being “tricked” into a vaccination.
While it’s important to use a respectful approach at all ages, the four-year-old vaccinations present a particularly valuable opportunity for parents to help children feel comfortable with needle procedures.
The guide below offers a strategy to help make vaccination a positive experience for your child. It’s based on what’s called the respectful approach to child-centred health care. This focuses on the parent and health-care provider developing a cooperative relationship with the child, rather than using authority or incentives.
The aim is to help the child feel in control and reduce anxiety around needle procedures.
Expect some resistance. This is normal — there’s no need to argue, just acknowledge your child’s feelings. Let them know adults don’t particularly like getting vaccinations either!
About a week out, mention again that they’ll be having a vaccination, and give some details, such as where they will be going. Another reminder the day before is helpful.
2. Be honest and transparent
It’s important to check if your child has any questions each time you discuss vaccination with them. Answer as honestly as possible. Yes, it will hurt. But not for long — most of the pain will be gone by the time 30 seconds is up, perhaps as long as it takes to run around the house or say the alphabet.
Help children feel like they are actively part of the process by giving choices where possible. For example, can they have a choice of day, or morning or afternoon?
Check with your health-care provider in advance whether children can choose the location of the injection – normally the vaccines are administered on the outside of the thigh, or the upper arm.
In the lead up, the child might like to prod themselves with a toothpick to see the difference between how each site feels. They may also have a preference for the left or right side.
Sometimes it helps to yell out when you feel pain. Kids may find this fun if you give them free rein to call out anything they want (even “rude” words) when the injection goes in. Just let your health-care provider know in advance so they’re not taken by surprise.
4. Avoid bribes and distractions
Offering a bribe can give the child the impression there’s something terrible about the procedure. As the parent, be confident (or pretend to be confident if you have needle fear yourself). Pain-related beliefs and behaviours can be learnt through observing others, and children are very perceptive.
You can always do a fun activity or have a treat afterwards, but make this a surprise at the end rather than a bribe before the vaccination.
Distractions are common, but can leave the child wondering why they were distracted. “What was going on that was so bad I wasn’t allowed to look at it?”, they might wonder. When children feel they have been deceived, this may erode trust.
Some children may like to watch so they know what’s happening — give them the option. Interestingly, in one study, adults who chose to watch the needle being inserted into their arm reported less pain compared with those who chose to look away.
5. Use mindful parenting
Think of vaccinations as an opportunity to be 100% present, one-on-one with your child. Put aside any multitasking for the morning or afternoon of the vaccination. If you can, take the time off work, turn off your phone, and arrange for any other siblings to be looked after.
Observe your child, aim to listen with your full attention, be compassionate and aware of how you and your child are feeling. All of these things can improve the quality of parent–child relationships and are important for helping children through potentially anxious times.
A year ago, in late January 2020, Australia reported its first cases of COVID-19. Since then, we have seen almost 29,000 confirmed cases and 909 deaths.
As cases climbed in Australian cities in 2020, many students did their schoolwork from home. Australia, including Victoria, came out of lockdowns at the end of last year. But due to outbreaks in New South Wales and Queensland over Christmas and New Year, that impacted on Victoria, restrictions remain in some places.
So what now, for the new school year? Is it safe for students to go back to school?
What we learnt in 2020
Australian health officials, paediatricians, and federal and state education departments worked together to understand how SARS-CoV-2 — the virus that causes COVID-19 — is transmitted in Australian schools.
They also kept updating, as more information came to light, what schools can do to provide a safe learning environment for children and staff.
Up to the end of term 3 in New South Wales, 49 student- and 24 staff- cases were linked to schools and early learning centres. Each of these cases, and their contacts, were followed since the pandemic began. Schools had low rates of transmission — with 51 transmission events (38 students, 13 staff) out of 5,793 contacts traced (<1%) — in terms 1, 2, and 3 when COVID-19 safe measures were in place.
Key measures were:
limiting adults in the school and early learning centre grounds
staying home when unwell with cold-like symptoms
getting tested early.
Most schools and early learning centres in NSW reopened after only a few days.
In Victoria, up until the end of August 2020, 1,635 cases were associated with early learning centres and schools. These consisted of 254 staff, 599 students and 753 household members, out of a total of 19,109 cases in Victoria during their second wave.
Two-thirds of infections in early learning centres and schools did not progress to outbreaks (two or more cases) and more than 90% were small outbreaks (fewer than ten cases).
While transmission has been connected with a Victorian school in the media, transmission events often have a more complex basis than just occurring in the classroom. Schools are often located in a multi-generational community and cases in this large school cluster were linked to high community transmission rates rather than infection in the school.
These studies confirm that when SARS-CoV-2 is detected in a student or staff member, it is very unlikely for other students or staff to be infected at school with the processes put in place in 2020 to provide a safe learning environment.
In Western Australia, almost 14,000 asymptomatic staff and students were swabbed at the school in terms 2 and 3. No cases of SARS-CoV-2 were detected, consistent with the absence of community transmission in that state.
But why are other countries closing schools?
Overseas, studies have shown schools can implement health strategies to safely keep schools open and minimise SARS-CoV-2 transmission risks.
In the US, the Centres for Disease Control and Prevention noted that: “trends among children and adolescents aged 0–17 years paralleled those among adults”. However, the organisation also reported:
as of the week beginning December 6, aggregate COVID-19 incidence among the general population in counties where K–12 schools offer in-person education (401.2 per 100,000) was similar to that in counties offering only virtual/online education (418.2 per 100,000).
Other countries have chosen to close schools as a last resort in national lockdowns in the face of extremely high rates of community transmission and daily case numbers, which meant only widespread reductions in population movements could be effective. This is not the case in Australia at the start of term 1, 2021.
It is common for viruses to evolve and there have now been several new variants of concern such as those identified in the UK, South Africa and Brazil which are more transmissible. The potential of such variants entering Australia is uncertain, and so is the risk of transmission in schools.
Reassuringly, if community transmission of such a variant occurs in Australia, we have established experience to monitor, and hopefully halt, its spread.
So, what should Australia do?
Remote learning provides considerable challenges to keep students engaged, reduces the close supervision and support in the classroom, and provides an added disadvantage for children with mental-health conditions, disabilities or special needs.
For parents, it is difficult to work effectively, provide for the family and maintain their well-being when their child is learning from home.
Based on the above evidence, schools are safe to open. But states should adopt mitigation measures — including when to add masks, reduce attendance or close schools — according to a traffic light system from green (standard measures) to red (close schools) based on the degree of community transmission. The Murdoch Children’s Research Institute has recommended this approach for Victoria. Education departments around Australia can consider a similar approach.
It is important schools and early learning centres continue to adhere to their local COVID advice. Parents and guardians should check their contact details are up to date so they can be contacted easily, regularly check what restrictions are in place and, when unwell, get their child tested and stay at home.
In 2020, students and staff rapidly learned to regularly wash their hands, adapt to cleaners in the school throughout the day, socially distance and wear masks when required. These public health interventions, vaccination, and testing and tracing will remain the mainstay for the year ahead in Australia.
Monitoring well-being and building resilience will also be core educational activities in the months ahead.
Parents have faced unprecedented stress during the pandemic as they care for children while juggling paid work from home.
However, very little research so far has focused on family well-being during the pandemic.
So we asked more than 2,000 parents to tell us in their own words about the pandemic’s impact on their families. We did this in April 2020, during Australia’s first lockdown. Our publishedstudy is the largest of its kind in Australia, and one of very few internationally looking into families’ experiences of the pandemic.
Families’ responses followed six key themes.
1. Boredom, depression and mental health
Parents reported a spectrum of emotions. They said they and their children were stressed, trapped and bored. New and existing mental health conditions also challenged the equilibrium in a number of families. One mother of two children said:
My mental health has taken a really bad hit and I’m struggling to support my children.
2. Families missed things that keep them healthy
Families missed sport, extracurricular activities, visits with family and friends, playgrounds, places of worship, trips to connect with the natural world, and other family supports. A mother of three children said:
We used to see family, friends, go to church and do kids’ activities like playgroup a lot […] Cutting all of that out to stay home has been hard. We miss being able to see our family and friends, to do activities outside of home that are more than a walk around the block. We’re all tense and exhausted.
3. Changing family relationships
Family relationships changed, which we called the “push-pull of intimacy”.
Strained relationships were common, including increased conflict and arguments between parents, parents and children, and between siblings.
The demands of caring for children was a source of discord, requiring more from already exhausted parents or creating tension in the family as a result of bickering and fighting as a result of being “cooped up”. One mother of two said:
We have too much time together. We are often irritable with each other. My child wants more social interaction from me that I can’t give.
For many, there was a sense that goodwill between family members was “wearing thin”. But in some families, closer bonds emerged. A father of three said:
It’s been great. Lots of quality time together.
4. The unprecedented demands of parenthood
The loss of important structures in the community, particularly schools, reveals the extent to which such institutions play a pivotal role in raising healthy families and children, with parents alone unable to provide the proverbial village that children need. A mother of three said:
COVID-19 had turned me into a stay-at-home mum, primary teacher, speech therapist, occupational therapist, strict budgeter, with no social outlet or relief. And I’m doing this alone with my health-care worker husband being overworked.
5. The unequal burden
For people with physical or mental health conditions, lockdown restrictions were especially hard to endure. A father of one child told us about his family’s experience of being confined to a small space:
My wife is on the spectrum which makes being in a confined space with others quite difficult for her — and those around her. Confined space gives her little room for calming, so her anger events have increased.
Families living in small apartments with limited outdoor space were also highly challenged, using words such as “suffocating” and “going insane”. Families facing economic worries were also a group in need. A single mother of two children said:
Shopping alone is now a huge stress as I don’t want to expose my babies […T]he price rise in food has caused us now to only be able to buy enough food for a week so we are having less in each meal to ensure the children eat three meals a day. Most days I now miss meals so they can eat.
6. Holding on to positivity
Parents told us the pandemic provided an opportunity to cultivate “appreciation”, “tolerance and understanding” as well as “learning to cope and develop patience”.
Some parents said they were grateful for what they had and were relatively fortunate compared with others.
Parents were also grateful for access to the internet, a safe space to call home, enough food to eat, time to spend together, good health, financial stability and “having enough”. One mother of two children said:
I was quite panicked to begin with, but the kids love being with us all the time and are building relationships with each other.
Our large, diverse sample of Australian parents captured a range of experiences. Although more than 80% of our participants were mothers, we also heard fathers’ experiences.
Some of these experiences are likely to be similar to those of families around the world. However, the Australian experience may also be unique. Coming out of a tragic season of bushfires, many families may have already had stretched emotional and financial resources to handle another crisis.
The unique experiences of Victorian families, who endured a second period of longer and harsher lockdown, are worthy of follow-up research, as their resilience was likely pushed to the limit.
COVID-19 is not over, and we need to continue to ask parents and individuals how they are doing. Studies like ours, together with those comparing family experiences around the world, will also help researchers, policymakers, and service providers understand how to preserve community and family supports if we have future lockdowns or pandemics.
If this article has raised issues for you, or if you’re concerned about someone
you know, call Lifeline on 13 11 14.
While children are thankfully much less likely than adults to get seriously ill, the same isn’t true for the adults that care for them. Evidence suggests schools have been a driver of the second wave in Europe and elsewhere. This means the safety of schools needs an urgent rethink.
Researchers used an antibody test (which can detect if a person had the virus previously and recovered) to screen a representative sample of nearly 12,000 children from the general population in Germany. They found the majority of cases in children had been missed. In itself, that’s not surprising, because many cases in adults are missed, too.
But what made this study important, was that it showed young and older children were similarly likely to have been infected.
Official testing in Germany had suggested young children were much less likely to be infected than teenagers, but this wasn’t true. Younger children with infections just weren’t getting tested. The study also found nearly half of infected children were asymptomatic. This is about twice what’s typically seen in adults.
But children do transmit the virus
We’ve known for a while that around the same amount of viral genetic material can be found in the nose and throat of both children and adults.
But that doesn’t necessarily mean children will transmit the same way adults do. Because children have a smaller lung capacity and are less likely to have symptoms, they might release less virus into the environment.
However, schools did contribute to community transmission to some extent. This was made clear by the Al-Taqwa College cluster, which was linked to outbreaks in Melbourne’s public housing towers.
When researchers analysed cases in Victorian schools that occurred between the start of the epidemic and the end of August 2020, they found infections in schools mirrored what was happening in the community overall. They also found 66% of all infections in schools were limited to a single person.
This might seem encouraging, but we have to remember this virus is characterised by superspreading events. We now know that about 10% of infected people are responsible for about 80% of secondary COVID-19 cases.
Two major studies from Hong Kong and India revealed about 70% of people didn’t transmit the virus to anyone. The problem, is the remainder can potentially infect a lot of people.
What happened in Victorian schools was entirely consistent with this.
The risk associated with schools rises with the level of community transmission. The picture internationally has made this clear.
What we know about outbreaks in schools, internationally
After schools reopened in Montreal, Canada, school clusters quickly outnumbered those in workplaces and health-care settings combined. President of the Quebec Association of Infectious Disease Microbiologists, Karl Weiss, said
Schools were the driver to start the second wave in Quebec, although the government did not recognise it.
The opposite pattern has been seen when schools have closed. England just witnessed a drop in new cases, followed by a return to growth, coinciding with the half-term school holidays. This was before any lockdown measures were introduced in the country.
These observations are consistent with a study examining the effect of imposing and lifting different restrictions in 131 countries. Researchers found school closures were associated with a reduction in R — the measure of how fast the virus is spreading — while reopening schools was associated with an increase.
The risk has been spelled out most clearly by the president of the Robert Koch Institute, Germany’s equivalent of the US Centers for Disease Control and Prevention. Last week, he reported the virus is being carried into schools, and also back out into the community.
What we need to do
It won’t be possible to control the pandemic if we don’t fully address transmission by children. This means we need to take a proactive approach to schools.
School closures have a role to play as well. But they must be carefully considered because of the harms associated with them. But these harms are likely outweighed by the harms of an unmitigated epidemic.
In regions with high levels of community transmission, temporary school closures should be considered. While a lockdown without school closures can probably still reduce transmission, it is unlikely to be maximally effective.
Several COVID-19 vaccines are in late-stage clinical trials. So discussion is turning to who should receive these vaccines first, should they be approved for use. Today, we discuss two options. One is to prioritise the elderly. This article looks at the benefits of vaccinating children first.
The World Health Organisation isdiscussing how best to allocate and prioritise COVID-19 vaccines when they arrive.
It is focusing on the immediate crisis. To reduce deaths quickly when there are extremely limited vaccine doses available, vaccinating older, more vulnerable people is expected to be the best option, even if the vaccine is relatively poor at protecting them. That is because the elderly are so much more likely to die from the disease.
But as we produce more vaccines, the goal will be returning to normality where we can freely mix without increased risk. If vaccines are not very effective in older adults, we will need many more people to be vaccinated, including children. One possible strategy is to prioritise children.
Why children first?
The risks and benefits of particular COVID-19 vaccination strategies depend on information we don’t yet have. For example, we don’t yet know whether vaccines work or are safe for specific population groups, such as the young or the old.
But it is worth thinking about the ethics of different strategies in advance. In a pandemic, time can save lives.
A COVID-19 vaccine may be less effective in the elderly because their immune systems decline naturally with age, making them perhaps less able to trigger an efficient, protective immune response after vaccination.
We see this with the flu vaccine, which only reduces influenza-like illnesses by around one-third in the over-65s and deaths by around half.
If there are similar results for a COVID-19 vaccine, to return to normality, we may need to also prevent community transmission through vaccinating young people, who generally mount a stronger immune response. This would in turn protect older, more vulnerable people because the virus would be less likely to reach them.
Yes, this is controversial. Children cannot autonomously consent to being vaccinated. Adults, who make these decisions on their behalf, are also likely to benefit from a reduced risk of contracting the virus within their own household, making the decision a possible conflict of interest.
We can also apply the idea that we can restrict liberty where there is a risk of harm to others. For instance, if a child is infected with COVID-19, they need to be isolated and quarantined just like adults.
However, vaccination differs from both examples in one key respect. With vaccination, there is unlikely to be a single identified person the child will help, or whom they are uniquely placed to help. Instead, the potential benefits are collective, to the wider public.
If a child lived with a sibling who had an underlying condition that makes them particularly vulnerable to COVID-19, or lived with their grandparents, vaccination might be an easier choice.
Three factors could help us decide
When weighing up whether children should be vaccinated ahead of adults, we can ask:
1. How severe is the threat to public health?
So far, more than a million people have died from COVID-19. There’s also the risk of overwhelming health systems and the additional collateral damage in terms of economic, social, educational and risk of excess non-COVID-19 deaths as a result (for example through suicide, or delayed access to health care). COVID-19 affects everyone in society, including children.
2. Are there alternatives?
If vaccination works well enough in vulnerable people, or there are other strategies to achieve the same effect, such as general adult vaccination, we should use those instead.
3. Is the response proportional to the threat?
As we vaccinate the vulnerable, and the general adult population, even if it is not fully effective, we will reduce the severity of the crisis. We should assess at that stage whether the remaining problem warrants vaccinating children.
Assuming we meet these conditions, we argue prioritising childrens’ vaccination, on a voluntary basis at least, is the right strategy.
How about mandatory vaccinations?
Mandatory vaccination can be justified if voluntary strategies do not achieve herd immunity, or do not achieve it fast enough to protect the vulnerable.
To gauge whether mandatory vaccination is worth it, we might also need to consider how lethal and infectious a virus is.
Mandatory vaccination (of some kind) could be justified in groups who are at increased personal risk from COVID-19 — such as health-care workers, the elderly, men, or people with other health conditions — if incentives such as increased freedoms, or even payment are not sufficient. For these groups, the vaccine is win-win: it both protects others and the person vaccinated.
And mandatory vaccinations for children?
The situation is more tricky with children. Unless they have underlying health conditions or have a rare but serious inflammatory condition after infection, children are less likely to have severe COVID-19 or die from it.
So the risk of the vaccine itself (as yet unknown) weighs more heavily.
On the other hand, children benefit from grandparent relationships, and other freedoms afforded by a pandemic-free society.
there are other non-COVID benefits to children, such as return to normal social and educational life (school), and access to normal health-care services which they otherwise could not have
measures are reasonable and proportionate, for instance, by limiting child care benefits (rather, for instance, than sending parents to prison).
We are certainly not close to meeting these criteria for mandatory vaccination of children against COVID-19 yet, especially as we don’t know how effective and safe candidate vaccines are in different populations.
In some Australian states, kids have been back on slides, swings and monkey bars for months. But in Victoria, many families are only now getting back to playgrounds, after they were closed for much of the second lockdown.
With lots of kids running around, and parents looking on, how can you ensure your trip to the playground is COVID-safe for you, your children and others?
A good place to start is to understand how COVID-19 spreads, and what you can do to interrupt it.
Droplets big and small
According to the US Centers for Disease Control and Prevention, the main way SARS-CoV-2 (the virus that causes COVID-19) spreads is by droplet transmission.
Droplets containing virus particles are released from the mouth or nose when someone who is infectious coughs, sneezes, laughs, talks or even breathes. The more vigorous the activity, the greater the volume of droplets and spread (so, for example, laughing releases more droplets than breathing).
Larger droplets fall to the ground relatively quickly and within a short distance of where they were released. But you can inhale them if you’re standing close to an infected person.
Smaller droplets, or aerosols, can travel further and hang around for longer in the air. Scientists are still working to understand the importance of this form of transmission — commonly termed airborne transmission — in the spread of COVID-19.
Another possible route of transmission is contact with contaminated surfaces. This happens when infectious droplets fall onto surfaces, or contaminated hands touch surfaces. If an uninfected person touches the contaminated surface and then touches their face or food, they may ingest virus particles and become infected.
A recent laboratory study found SARS-CoV-2 particles can remain both detectable and viable (able to cause infection) on surfaces for many days, particularly if the surfaces are smooth, such as metal or plastic. As with airborne transmission, scientists are still figuring out how common this mode of transmission is for COVID-19.
The good news about playgrounds is they’re generally outdoors in parks. The risk of inhaling infectious droplets is reduced because the large volume of air has a dilution effect, compared with being in a confined space indoors with other people. Outdoor breezes can also disperse particles.
The temperature also appears to influence the risk. Warmer temperatures have been shown to reduce the viability of SARS-CoV-2 more quickly than cooler temperatures, while sunlight may also help inactivate the virus. In Australia, of course, we’re now heading into the warmer and sunnier summer period.
On the other side of the coin, public playground equipment may not be cleaned regularly. So there could be some risk of transmission via contaminated surfaces.
And while warmer weather and particularly being outdoors may protect us to a degree, as with anything during the pandemic, a small level of risk remains.
Check the restrictions and requirements in your state around mask wearing, how far you can travel, and the number of people permitted in a space before heading to a playground.
Don’t go to the playground if you or your child is sick or has any COVID-19 symptoms (fever, cough, sniffles, upset tummy).
Keep your distance (at least 1.5 metres) from anyone not in your household. While it’s tempting to socialise with other parents, avoid congregating closely with others.
Take disinfectant wipes or wet wipes with you and wipe down areas little hands frequently touch (such as swing chains) before your kids use the equipment, particularly if they’re too young to understand instructions.
Take hand sanitiser with you (minimum 60% alcohol). Ensure your children sanitise their hands before getting on the equipment, after playing, before eating and before leaving the playground. Supervise young children when they use alcohol-based hand sanitiser. Parents should regularly sanitise too.
Avoid using shared taps or water fountains; instead, bring bottled drinks. Frequently touched surfaces such as taps are more likely to be contaminated.
Remind children to avoid touching their face while using the play equipment.
Avoid physical contact between your kids and other kids in the area.
Avoid sharing toys with other children. If you bring toys, make sure they’re washable.
Use the playground outside of peak use periods to reduce the amount of contact with others.
The focus with young children should be on frequent hand hygiene and preventing physical contact with non-family members as much as possible.
With little COVID-19 transmission in Australia now, and most playgrounds being outdoors, a trip to the playground is fairly low-risk, and we know physical activity carries many benefits for children and adults alike. But we can all do our part to minimise any risk of transmission.
An ideal COVID-19 vaccine would not only protect people from becoming ill, it would also stop the virus spreading through the population. The best way to do this is to vaccinate as many people as possible.
If the best available vaccine is only moderately protective — for example, if it only prevents 50% of infections — we might need to vaccinate children as well as adults to interrupt the spread.
There is no COVID-19 vaccine being developed specifically for children. So if children are to be vaccinated, they will likely receive the same vaccine as adults. They might require a different dosing schedule, but that is not yet clear.
So what are the issues with developing a safe and effective COVID-19 vaccine for children? And where are we up to with clinical trials including them?
There is also a broader issue at stake. Delaying children’s access to vaccines could delay our recovery from COVID-19. This would prolong the pandemic’s considerable impact on children’s education, health and emotional well-being.
The way a child’s immune system reacts to pathogens or vaccines can be different to adults. Age can determine the number of required doses. For example, infants sometimes require more doses of a vaccine than older children.
So vaccine developers need to include children in their clinical trials so they can gather age-specific information on the immune response, the effectiveness of the vaccine in preventing disease, and any side-effects.
Are COVID-19 vaccines already being tested in children?
Vaccine trials are usually done in stages. They typically start with healthy, young and middle-aged adults.
Once a vaccine is confirmed to be safe in these earlier trials, developers then test the vaccine in older and younger age groups.
Several COVID-19 vaccine developers already have plans to include children in their clinical trials.
University of Oxford researchers will recruit children aged 5-12 into a phase 2/3 trial of its vaccine. This is one of the vaccines for which the Australian government has a supply agreement, should clinical trials prove successful.
How could we get more children included in trials?
We need more children included in clinical trials, an issue recognised globally. For instance, the US Food and Drug Administration announced it will work as quickly as possible with vaccine developers to set up trials for COVID-19 vaccines in children.
The US National Institutes of Health is developing a protocol for researchers to include children in vaccine trials in a safe but timely way.
Having a universal protocol, which we don’t yet have for COVID-19 vaccine trials, would make it easier for researchers to include children in future trials, and to compare different vaccines.
There are no protocols yet including children in COVID-19 vaccine trials run in Australia. Any Australian studies would only likely examine the immune response and safety in children (phase 1 and 2 trials). They would probably not examine effectiveness (phase 3 trials) because of the low rates of COVID-19 here.
Before any child is enrolled in a trial their parent or guardian will be asked to read an information sheet that explains the risks and benefits of taking part. Safety data from earlier trials in adults would need to be included in child-specific information sheets, so parents are aware of the known risks before they decide to enrol their child.
In Australia, it may be a challenge to enrol children in COVID-19 vaccine trials, as the disease burden is low compared with other countries, so parents may not want their child to take part.
However, it is important we learn as much as we can about how COVID-19 vaccines perform in children, and participating in such research helps us gather this valuable information.
How is vaccine safety assessed?
Vaccine trials are closely supervised by an independent data and safety monitoring board, who follow strict protocols and have the authority to pause a trial if there are safety issues.
Australia also has strict guidelines for the registration of vaccines. A vaccine will only be licensed if its safety has been demonstrated in large studies, usually including many thousands of people. Usually, vaccines are registered according to the age groups in which trials have been done.
Alternatively, researchers can more actively engage with the public to monitor side-effects, such as with the AusVaxSafety system.
In this system, when a GP gives someone a vaccine, that person receives a text message three days later to ask about side-effects and to complete a survey on their smart phone or computer. This is “real time”, important safety data.
We already use this system to monitor the safety of each year’s flu vaccines and will potentially use it when COVID-19 vaccines are rolled out into the community.
In a nutshell
Although there has been extraordinary progress in COVID-19 vaccine trials, only some vaccine developers have taken steps to recruit children so far. That needs to change if we are to protect children and the wider community. So we need protocols that make it easier for researchers to recruit children into COVID-19 vaccine trials.
As early data in adults accumulates, providing information to parents — and where age-appropriate, their children — to consent to their child participating in trials has a lot of benefits. It will also ultimately help us in the race to end this pandemic.