COVID-19 is daunting for all parents, but even more so for parents of children with a heart condition. During the Stanford Medicine Children’s Health “Back to School With COVID-19” webinar for Heart Center families on Sept. 22, 2021, a panel of experts from the Betty Irene Moore Children’s Heart Center answered frequently asked questions and offered parents the latest updates on COVID-19. Here are answers to popular questions about COVID-19 asked by parents of children with heart disease.

Covid-19 and heart disease

Does COVID-19 affect the heart?

Yes, we know that the virus can affect the heart. A COVID-19 infection can cause myocarditis, an infection of the heart muscle that leads to decreased heart function. And it can cause multisystem inflammatory syndrome in children (MIS-C), an inflammatory syndrome that affects the heart and blood vessels. The good news for parents of children with heart disease is that we are not seeing increased rates of COVID-19–related myocarditis or MIS-C in children with heart disease when compared with children who have a healthy heart.

Are you seeing many heart patients with COVID-19 infections?

Initially, we thought children with heart disease would be at a higher risk for COVID-19, but that has not turned out to be the case. Even those with more complex forms of heart disease, like single ventricle, are not having more illness, even with the Delta variant. Additionally, we are not finding that our heart transplant and heart failure children are getting sicker than average children, despite data in adults that organ transplant patients are at an increased risk.

If my child with heart disease gets COVID-19, what treatments are available?  

If your child tests positive for COVID-19, call your child’s cardiology team to initiate care discussions early on. In general, if children with a heart condition are not sick enough to need hospitalization, we do not have any special treatments available for them. There have been questions about monoclonal antibodies against COVID-19, which help prevent severe illness and hospitalization in adults, but there is no data on how monoclonal antibodies work in children. These are occasionally used in children in some settings. If your child develops COVID-19, please alert your providers so that an appropriate care plan can be developed.  

Attending school during the pandemic for children with heart disease

Can my child with heart disease attend school in person?  

Based on the data available at this moment, we believe that all children with heart disease can attend school in person, with precautions. If your child is in a very high risk group—such as an immunocompromised transplant patient—check with your child’s cardiologist to learn if he or she has any additional recommendations to keep your child safe while learning in person. Whenever possible, it’s much better socially, emotionally, and academically for children to attend school in person rather than remotely. Also, the COVID-19 pandemic doesn’t change the type of health information your child’s school needs about his or her heart condition.

Should my young child with a heart condition wear a mask to day care or preschool?  

Children under age 2 should not wear a mask in any setting. When it comes to health safety at school, the more layers of protection that are present, the less risk there is of passing and catching COVID-19. These layers include staff that are vaccinated, requiring sick children to stay home, reliable COVID-19 testing, good ventilation, good hand hygiene, and wearing masks.

What type of mask should my child wear?

The right mask for your child is the one that they are willing to wear and that fits well. Masks should cover the nose and mouth comfortably. Any mask is better than no mask. We are seeing that when children wear a mask, it helps prevent transmission, along with the other layers of safety that are in place. Cloth masks offer reasonable protection. For some children at highest risk, such as those who are immunocompromised, a surgical mask may be preferable to a cloth mask as long as the mask fits and is worn appropriately.

Does wearing a mask cause a decrease in oxygen levels for my child with heart disease?   

There is no reason to think that wearing a mask lowers oxygen saturation from your child’s normal baseline. Masks can take getting used to, especially for kids with sensory processing disorders or developmental delays. But masks do provide protection, and it’s preferred that children with heart disease wear a mask. If you have concerns, talk with your cardiologist.

How can my child reduce their exposure to COVID-19 at school?  

There are ways to reduce risks at school, including masking, social distancing, and washing hands frequently or using hand sanitizer. Transmission can happen when children touch something, a desk or doorknob, then touch their eyes or pull their mask down and scratch their face. That means the more your child washes his or her hands, the less risk of contracting the virus. If your child is sick, keep him or her home and advocate for a culture that supports sick kids staying home in your child’s school community. Vaccinations are also something to advocate for among teachers, staff, and school volunteers. Vaccinated adults at school will reduce virus circulation, which in turn will reduce your child’s exposure to the virus at school. Another change to push for at school is having kids eat lunch outside instead of inside. Since masks come off while eating, kids can be at a higher risk of exposure. Some parents are offering to organize shifts of volunteer parents to supervise school lunch so that it can be held outside. 

How can I support my child emotionally and socially as they return to school?

If your child is nervous about going back to school, your child might need a little extra love, patience, and help getting used to separating from you, especially if you have been home with your child for a while. Support your child in getting used to a new school routine, and build in time to practice that routine. Stick to a set bedtime to ensure that your child is getting enough sleep, and build in plenty of time for him or her to get ready in the mornings. Also, manage your own emotions around fears of your child returning to school because he or she will pick up on those emotions. Make the transition matter-of-fact. Finally, find safe ways for your child to socialize with other kids to help him or her get used to socializing again.  

The COVID-19 vaccine for kids with heart disease

How safe is the vaccine for kids? Are there side effects?  

The vaccine is the best way for you to protect your child. There is plenty of scientific data that’s been reviewed by experts to say that the COVID-19 vaccine is safe for children 12 years and up. The scientific advisory teams from the Food and Drug Administration (FDA) and the Centers for Disease Control and Prevention (CDC) are constantly monitoring vaccines for safety.

What is COVID vaccine–associated myocarditis, and is it something I should worry about with my child with heart disease?    

Because physicians have been monitoring the vaccine so very closely, they discovered that a small number of children develop some inflammation in their heart after the second dose of the COVID-19 mRNA vaccines (both Moderna and Pfizer). COVID vaccine–associated myocarditis typically presents with chest pain and fever about two days after the second dose of the vaccine. It’s predominantly seen in adolescent boys ages 12 and up and young adult males. In these children, we are seeing elevations in some inflammatory markers on blood tests and elevations of other heart disease markers. They may have an abnormal electrocardiogram (EKG), but often their echocardiogram (ECHO) is completely normal. This means the function of their heart is normal, but there is some mild swelling that we can see on cardiac MRI imaging. When followed over time, the vast majority of these patients have had complete resolution of swelling of the heart after three months. Our knowledge of COVID vaccine–associated myocarditis is evolving, but it seems to be different than standard myocarditis. The rates of COVID vaccine–associated myocarditis are extremely low, so it is still a very rare event.

Also, we know that the COVID-19 illness can significantly affect the heart and lead to decreases in heart function and changes in the heart rhythm. This vaccine complication is rare and self-resolved. We have not seen any children with COVID vaccine–associated myocarditis who have had significant adverse outcomes so far. For that reason, we recommend COVID-19 vaccines for all eligible children, even those with heart disease. In fact, these cases of COVID vaccine–associated myocarditis have not been in children with heart disease. That means that even if your child has congenital heart disease, cardiomyopathy, heart transplant, or heart failure, or has had myocarditis in the past, there is no reason to think at this moment that there would be an increased likelihood of this complication. Far and away, it’s best to get the vaccine to protect your child against damage to the heart from a COVID-19 infection.

How should I approach the flu vaccine this season?

We recommend the flu vaccine, and it’s OK to get the flu vaccine and COVID-19 vaccine at the same time. The way our bodies produce an immune response with vaccines is the same whether we get them at the same time or spread them out.

If my child gets COVID-19, does he or she still need the vaccine?

If your child has had COVID-19, we still recommend the vaccine when they are eligible. We don’t yet know how long natural immunity lasts after contracting the virus. As with other coronaviruses that cause the common cold, immunity against COVID-19 doesn’t last forever. There is also evidence that being vaccinated provides better protection against COVID-19 than natural immunity. Some studies show that unvaccinated people are twice as likely to get COVID-19 again compared with vaccinated people.  

When can we expect a vaccine for children 5 to 11 years old?

It’s still not known when a vaccine for younger children will be available. Pfizer has announced that they submitted data to the FDA for review. But it’s a process. It first goes through the scientific advisory at the FDA, then to the FDA itself. It also goes through the same process at the CDC. We hope it will be this fall or winter, but we’ll have to wait and see.

What do you recommend in regard to the booster shot for children with heart disease?

The FDA and CDC recommend a third vaccine dose for people who are severely immunocompromised. So, a child who has had a heart transplant would be eligible. At the Betty Irene Moore Heart Center, we do recommend a booster dose for our heart transplant patients. Children with milder immune compromise, like a missing spleen, are not currently eligible for a third dose. Ask your cardiologist if you’d like more information.

Please note that these answers were recorded Sept. 22, 2021, and that this information is current as of this date. Since the COVID-19 pandemic is ever-changing, follow our social pages and our coronavirus news page for updates. For specific information on your child’s condition, consult with your child’s cardiology team.

Watch this entire webinar on our Betty Irene Moore Children’s Heart Center Facebook page.