Coronavirus (COVID-19) and GI symptoms in kids
April 30, 2020
Children in COVID-19, thankfully at this time, for what we know are not as affected as adults. Though there are more reports that children are obviously affected, as well. From a gastrointestinal standpoint, from a GI standpoint as far as the symptoms, that probably have not been paid as much attention to as really diarrhea.
So number of patients, whether they're children or adults, present with diarrhea rather than the traditional, as we talked about, with respiratory symptoms, having runny nose and breathing issues, and so on. So the GI symptom that's most common with this population having COVID-19 is diarrhea more than anything else.
I think, again, diarrhea can be due to so many reasons. I mean, it can be if someone is stressed, someone has eaten something that didn't sit right with them, but there is concern that one needs to think about diarrhea as well as a symptom of COVID-19.
From a GI standpoint, a lack of appetite, not feeling hungry, not eating as much, but abdominal pain is always a feature of any illness, but not specific to COVID-19. But really, nothing else that's as predominant from a GI standpoint.
As I mentioned earlier, we really don't have as much experience about children and COVID-19, so I would start with the teens and adolescents. They're probably behaving more like the young adult symptoms. So you would look at the same in terms of fever, diarrhea, looking at runny nose. A typical viral sort of upper respiratory infections would be something that I would say should alert us to think about COVID-19 in a teenager. The middle schooler would be the same.
One of the other symptoms that probably hasn't been discussed as much-- at least I haven't seen-- is also this sense of smell. A number of people who have COVID-19 have said that they actually don't have that sense of smell. They lose their sense of smell, so even if you're in a room that's stinky, they don't really smell it. Onions, none of that seem to be as well. It's not specific for children, but it's something that COVID-19 has seen. But really not from a symptom standpoint, does not vary whether you are a young child or a young adult.
So absolutely I think that if a child has an underlying condition, so for example, from a GI standpoint, if a child has liver disease or inflammatory bowel disease like Crohn's disease, children who have celiac disease and other chronic conditions, the concern from the parents is definitely much heightened. Some of it is justified and some of it is not.
So in general, I think all of us need to practice the handwashing technique. It is so important and so critical because, again, we've heard, and it is true, that if you can wash your hands successfully-- and not just wash the palms, but really going in between fingers and the back of the hands and up to the wrist is really, really important. So that's a key, regardless of what your underlying condition is.
The other mechanism that we've found besides hand washing and spread from somebody sneezing and coughing has also been from the stool. So if someone is having diarrhea or not even diarrhea, handwashing after you've had a bowel movement is extremely important because the transmission for this virus is not just from people sneezing or something in the air, but can also be from saliva and it can also be from the stool. So if you have a baby and you're cleaning the diapers, it should be second nature.
But again, we have to remind people wash your hands just like you were washing hands as if you were with someone with COVID-19. If you are going to the bathroom, having a bowel movement, absolutely the same hand-washing technique needs to happen. If someone is having diarrhea, it's really important that all the members of the family, and the same bathroom is being used, that there is a good hygiene and cleaning of everything, whether you do use Clorox wipes or whatever hand sanitizers, washing hands is really the key because there is a transmission that happens from stool as well. So it's very important to do that.
Having said that, if you have a child who has, for example, Crohn's disease and they are on many different medications that affect their immune system, we do know that the children should stay on the medicines. Don't stop the medicines. If the child goes and the disease gets more out of control, meaning that the child develops a flare, they are actually at more risk. So very, very important that people don't stop the medications they are normally on.
There is an international group of GI people, both adult and pediatrics, who are looking at children and adults with inflammatory bowel disease and really have not found any increased risk. If you are on any of those medications, like [INAUDIBLE] and so on. Don't stop the medications. It's much higher if you go into a flare and then you have to be admitted into the hospital. Or you have to get started on steroids.
A small link has been found that if you get started on steroids for a flare and inflammatory bowel disease, you might actually be at a higher risk. So once again, it goes back to, please don't stop your medications even though you know they are immunomodulator medications.
Now, having said that, if you're on those medications and you develop a fever, even when COVID-19 was not there, we would always tell the families, if you develop a fever while you're on these medicines, you need to call your physician team. So that still holds. If [INAUDIBLE] has inflammatory bowel-- if your child has inflammatory bowel disease, they're on the immunomodulators, they develop a fever, more diarrhea, doesn't mean they have COVID-19, but it does mean pick up the phone and call your gastroenterologist.
At [INAUDIBLE] we are open for any of the telephone health visits. We are open for any phone calls, any MyChart messages, we are absolutely open for business for that. We've also started a pilot with telehealth, so we are embarking on that, where we will actually be able to have telehealth visits. So please don't hesitate to call your provider if there is fever, diarrhea, or anything. Don't stop the medication.
Children with celiac disease, if you've been on a gluten-free diet and you're practicing handwashing and all that, you're really not at a much higher risk. You're OK. Monitor your symptoms, stay with a gluten-free diet, don't start eating gluten because that will start giving you symptoms.
Again, if you develop any symptoms, call, practice handwashing, and practice social distancing. That's important. People with liver disease, children with liver disease, again, depending on what medications they are, might be at a slightly higher risk than other medications. But again, practice the same thing that anyone else is practicing. And if symptoms arise, call. We are open for business. Please call.
Sure. So, you know what happens to all of us when we are shutting ourselves in our homes, we go to our comfort foods. So we all end up probably eating a lot more of potato chips and things that we really shouldn't and we forget that we need to drink fluids. So very important that at the beginning of the day you fill up you know what a jug and have a goal that by the end of the day, you will have finished your 32, 64 ounces of water. Not pop, not juices, but water.
So make a goal every morning for every child, this is the x number of ounces I'm going to be drinking by the end of the day. The second thing that you want to do is make a schedule for yourself. It's so easy just to lay in bed and get caught up with social media or get caught up with watching movies and not getting out of bed or up from the couch and walking.
So again, build in breaks for yourself where you're going to-- even if it's just walking within the apartment, even if it's just doing some push-ups or whatever, make a schedule for yourself. If you don't have a schedule, it's very, very easy for all of us, including myself, it's very easy to just fall into a slump and sit on the couch the whole day.
So starting with the morning, make a schedule. This is the amount of water I'm going to drink, these are the healthy pieces of fruit I'm going to have, or you can help your child make that, and I'm going to have a break every few hours when I'm going to walk around or do something different than sitting around. Exercise, water, and healthy eating is going to be really, really, really important.
We don't have too much of the outside to go to right now, we don't have a lot of people that we can sit down and hug and talk to, but we can talk to them on the phone. So again, socialize over the phone, face-time, any of those things.
People are getting very much depressed and not feeling good about themselves. Please reach out. Reach out to your friends. Sometimes children have a hard time communicating with their parents because the parents have their own set of rules. So again, build in the time where you want to be talking to your friends, where you could have a chat and have your friends on the same chat. Do that. Really, really important while we are hunkered down in our apartments and our homes.
As far as vitamins, again, I don't think there is a whole lot of research done about vitamins at COVID-19 except for vitamin C. So I think people should take the vitamin C. We're not outside that much, there isn't a whole lot of sun. Vitamin D is important. So those are vitamins that I would say you should take. And do healthy eating-- fruits, vegetables, water, and exercise.
I always start off by saying that if as a parent you have a question, pick up the phone. There is no point in sitting at home and worrying and worrying and worrying and worrying again. So pick up the phone and it can be a nurse triage. If you are worried about anything, just [INAUDIBLE]
Having said that, if your child has a cold, there is no reason-- cold and fever, runny nose, a little cough, no reason to call, especially if there hasn't been any contact with anyone, you've been in your apartment or your home for the last one week and no one else has any symptoms, no reason to call. If you have a child who has an underlying condition and develops a change in their bowel movements, which is the norm, no reason to call.
Make sure they are hydrated. Make sure they're drinking enough fluids, they are eating, and everything else is fine. No reason to call at that time. If your child has a fever, if the cough is significant, hacking, and they are not able to do their normal routine or even just significant going on for some days, diarrhea, which is, again, waking them up at night, you're not able to keep up with their hydration, pick up the phone. Call sooner rather than later, so someone can give you phone advice and help you with that.
The person who triages, the nurse who triages the phone, will be able to tell and assess with a clinical team on whether this is a video visit or not. But most of the time, I think you can handle a lot of things on the phone, by just giving practical advice or changing medications or something.
If the clinical team feels-- and most of the time, most of us are feeling that, that we are trying to triage this early enough so that the children don't have to come to the emergency room. So the children don't have to be admitted.
The reasons for admission would be if someone is not able to keep up with the hydration despite advice from your clinicians, it looks like they might be getting dehydrated, fevers are not coming down, [INAUDIBLE] there is a lot of blood in the stool, those would be reasons to get admitted. The reasons that you may need a visit in person in the office would be if the clinician feels like they're not getting a good handle on, for example, being able to feel the belly.
So the one thing that we need to do sometimes in GI is you feel the belly and see if t here is a particular spot that is more painful than the other. Now, we can ask the parents; help with the video visits is to have them feel the belly and we could watch the child and see. If we can manage it that way, we will, we will not stress the family out to say you need to come into the office.
If on a video visit it just seems that we just cannot get a good handle, then we will ask for an in-person visit, but we are barely being aware that no one wants to travel, we don't want them to travel, and we don't want anyone to land in the ER if not necessary. But if you are dehydrated, your fevers are not coming down, a lot of blood in the stool, those kind of things would then definitely warrant coming into the hospital.
At the University of Chicago Medicine Comer Children’s Hospital, our team provides specialized care for digestive diseases in kids of all ages. We want to help you understand what you need to know about COVID-19 and your child’s gastrointestinal (GI) symptoms.
Is diarrhea a symptom of COVID-19 in kids?
Although we don’t hear about diarrhea as much as the more common signs of COVID-19 — fever and respiratory symptoms (i.e., runny nose, difficulty breathing) — diarrhea is seen in a number of children and adults with the disease. But remember, diarrhea can be due to many reasons, such as stress, something you ate, etc. There’s probably no need for concern unless your child has diarrhea in addition to the other COVID-19 symptoms.
What should parents know about coronavirus prevention in kids with digestive diseases?
Parents who have a child with a chronic gastrointestinal (GI) condition, such as celiac disease, inflammatory bowel disease or liver disease, may have heightened concern related to COVID-19. Some of this is justified, but the most important thing to remember is the importance of thorough handwashing. COVID-19 can be transmitted through stool, so it’s extremely critical to practice good hand hygiene when changing a diaper and after going to the bathroom.
If you have a child with a chronic GI illness, he or she should stay on their medicines. There has not been any evidence that Remicade, or the other medications that help regulate the immune system, put an adult or child at a higher risk for COVID-19. So don’t stop taking them. This could cause the GI disease to get out of control, which could raise the risk of contracting COVID-19.
What do I need to know about MIS-C and GI diseases?
Multisystem inflammatory syndrome in children (MIS-C) is a condition unique to children where different body parts can become inflamed, including the gastrointestinal organs, kidneys, heart, lungs, brain, skin or eyes. The cause of MIS-C is yet to be determined; however, it is likely an excessive or inappropriate immune response related to a recent infection with the virus that causes COVID-19, or exposure to someone with COVID-19 within four weeks before MIS-C symptoms occurred. There are a variety of symptoms associated with MIS-C including fever, severe illness, stomach pain, vomiting and diarrhea. Like with COVID-19, stomach pain, vomiting and diarrhea alone are not symptoms of MIS-C; however, if your child has been exposed to COVID-19 and is presenting GI symptoms out of the ordinary, contact your pediatrician.
When should parents call a child’s doctor about coronavirus symptoms, GI symptoms or both?
As always, if your child is on one of the medications that affect your immune systems, and develops a fever, diarrhea or a significant cough, get in touch with your physician team. Many issues can be resolved over the phone or through a telemedicine visit, preventing the need for a hospital visit.
Comer Children’s patients can contact the pediatric gastroenterology, hepatology and nutrition team at 773-702-6169 or through MyChart. You can also access the expertise of our specialists without having to leave home through our remote second opinions program.
Ruba Azzam, MD, MPH
Ruba Azzam, MD, MPH, specializes in pediatric hepatology, gastroenterology and nutrition, including hepatobiliary diseases, liver transplantation, pancreatic disorders and more.Learn more about Dr. Azzam
Ritu Verma, MD
Ritu Verma, MD, is a highly respected pediatric gastroenterologist who provides care to children suffering from complex gastrointestinal conditions, and serves as the Medical Director for the UChicago Medicine Celiac Disease Center.Learn more about Dr. Verma