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RSV, Strep A, the flu: a range of familiar bugs are worrying doctors and parents with strange new patterns. What's behind the outbreaks? A As child after child gasping for air was admitted to the hospital, Rabia Agha gritted her teeth. In her role as director of the paediatric infectious diseases division at Maimonides Children's Hospital in New York, she had seen this before. An outbreak of respiratory syncytial virus (RSV) – a winter virus that can feel like a common cold in adults, but which can be dangerous for some young children. There was a wave last autumn – and an unexpected one in spring this year. Now, in the early autumn months of 2022, it was back again. "We've had to double the capacity of our ICU," she says, referring to the intensive care unit, reserved for the sickest patients. Some of the children there have been put on mechanical ventilators to help them breathe. RSV typically hits the youngest children hardest but the patients Agha and her colleagues have treated lately tend to be approaching school age, around three or four years old. In this age group, RSV would usually appear as a cold-like illness, with a runny nose and cough. But now, some of them were struggling. How can we prevent childhood illnesses? RSV, strep A (which can cause scarlet fever), the flu and other illnesses and infections are resurging among children, after having been mostly suppressed during the Covid-19 lockdowns. Here's what doctors and health authorities say parents can do to keep children safe and healthy in the winter. The NHS and other health authorities recommend washing your hands with soap for 20 seconds to help stop the spread of viruses and bacteria, including strep A and RSV. They also recommend being careful not to share potentially contaminated cups, towels or other items. Parents are advised to use tissues to help their children catch coughs or sneezes, then discard the used tissues as soon as possible and wash their hands with soap and warm water to stop the spread. Making sure your children's vaccinations are up to date can also protect them from a wide range of diseases – including the flu and many highly contagious and potentially dangerous diseases such as measles and polio. The step of giving preventative antibiotics, for example to protect children in the midst of a strep A outbreak at their school or nursery, needs to be carefully considered, doctors say, to avoid encouraging antibiotic resistance. Superbugs created by antibiotics overuse have posed a particular threat to newborns, highlighting the need to use antibiotics with caution. Plus, antibiotics have no effect on viruses such as RSV. "Everyone is concerned, obviously, because older children tolerate this virus quite well – why were they not?" she says. When Covid-19 rampaged across the world, many countries introduced strict lockdowns to thwart transmission of the virus. Children were kept out of schools and nurseries for weeks or months on end. Now that they are mixing again, doctors have noticed periodic surges in other diseases, including RSV, flu and illnesses caused by Group A streptococcus, a bacteria also known as strep A. Sixteen children have died in the UK since September following strep A infection. According to the UK's Health Security Agency (UKHSA), during 2017-18, the last high season for strep A in the country, a total of 27 deaths in under 18s were recorded. However, the 2022-23 season is not yet over. Epidemiologists continue to investigate whether Covid-19 lockdowns increased the likelihood of surges in other diseases, given that respiratory infections were more or less stopped in their tracks during the first year or so of the pandemic. There is also the possibility that catching Covid-19 has increased children's susceptibility to other diseases by harming their immune systems somehow – though doctors say this is unlikely, as there is no evidence for such an effect. But what exactly is going on? For weeks now, on routine conference calls with fellow doctors around the country, Ronny Cheung, a consultant paediatrician in London, has heard reports of strep A infections and respiratory viruses causing problems for children. "It's been notable," he says. You may also be interested in: What is the best way to parent adopted children? How mud boosts your immune system What's the right age to get a smartphone? Although strep A, for example, is not usually life-threatening – it might simply cause a sore throat or tonsillitis – in rare cases, it can cause invasive, potentially deadly infections including meningitis. What causes scarlet fever? As well as strep throat, strep A bacteria can also cause scarlet fever. The bacteria release a toxin that causes a bright red rash. Scarlet fever mostly affects young children, typically beginning with flu-like symptoms, and a rash appearing 12-28 hours later. For more information on scarlet fever, see the Centers for Disease Control and Prevention, NHS, or other reputable health websites. Cheung stresses that the recent deaths in the UK associated with strep A are extremely unusual: "It doesn't make them any less tragic but it is really important to bear that in mind." There's a "pretty good argument" behind the idea that infections like this are spiking as a kind of delayed impact of the Covid-19 lockdowns, he suggests. But it is difficult to unpick that from natural seasonal variability. What the data clearly shows is that, during 2020 and into 2021, the spread of respiratory viruses plummeted, explains Connor Bamford, a virologist at Queen's University, Belfast. "We saw a real reduction in viruses, mostly RSV and influenza," he says. The UK Department of Health and Social Care confirmed this trend in March 2021. And figures from Australia and Germany also show a flat-lining of respiratory viruses during the same period. Researchers then tracked unusual peaks in the months following. A study in Germany found that levels of RSV in the country reached a record high between September and October 2021 – up to 50 times the prevalence recorded in the pre-pandemic years of 2017 to 2019. Medical researchers in New Zealand also noticed a huge spike in RSV cases during 2021. We haven't seen any data to support that prior Covid infection decreases your immunity – Rabia Agha Nicole Maison at the University Hospital Munich was lead author on the German study. She, like Agha, has seen yet another resurgence of RSV this winter: "We are currently seeing a significant increase in respiratory infections, especially respiratory syncytial virus, in Germany." She adds that she is working on a new paper about the situation. Besides clinical data, scientists have other ways of monitoring disease transmission. For example, since 2021, Bamford and colleagues have been tracking the prevalence of RSV and flu virus material in wastewater, to better understand transmission of these pathogens in Northern Ireland. Outbreaks are clearly visible in this data, he says. Keeping up to date with vaccinations is one way to limit the spread of infectious diseases such as flu, as well as Covid-19 (Credit: Getty Images) Keeping up to date with vaccinations is one way to limit the spread of infectious diseases such as flu, as well as Covid-19 (Credit: Getty Images) While our view of what's going on is getting sharper, many unanswered questions remain, including whether Covid-19 infection has actually affected children's immune systems in such a way that they are less able to fight off RSV, strep A, flu and other pathogens. "We haven't seen any data to support that prior Covid infection decreases your immunity and that you will get a more severe subsequent infection of any other virus or even bacteria," says Agha. She also says she would not, in general, expect to see long-term impacts on children's health or immunity as a result of what is happening now, though those who contract severe lung disease when very young might experience ongoing effects thereof. Either way, it remains important to protect children as best as possible, she adds. Bamford suggests applying some social distancing, avoiding crowded places and wearing masks in some situations. Improving ventilation indoors could also help. Hopefully things will be back more or less to normal as early as next year, Agha suggests For strep A, it's possible to use preventative antibiotics in order to reduce the likelihood of infection within a nursery or school where there is a known risk. But one would want this to be targeted, to avoid encouraging antibiotic resistance, says Clare Murray at the University of Manchester. "Giving it to a whole school is probably over the top," she explains. "Occasionally, we'll give a whole class a prophylaxis if there's been a lot of contact – it's not a new thing." Both Agha and Cheung expect that the intermittent spikes in childhood diseases that we are seeing post-lockdown will level out. Hopefully things will be back more or less to normal as early as next year, Agha suggests. Since the Covid-19 lockdowns when many children were not able to go to school, there have been surges in certain childhood illnesses (Credit: Getty Images) Since the Covid-19 lockdowns when many children were not able to go to school, there have been surges in certain childhood illnesses (Credit: Getty Images) Does all of this mean that Covid-19 lockdowns were a bad idea, and put children at risk unnecessarily? "I absolutely refute that," says Cheung, noting that Covid-19 itself was extremely dangerous and caused large numbers of deaths. Lockdowns, being so disruptive, were likely always going to affect people in negative ways – from the economic impact to effects on mental health and, apparently, disrupting immunity to other viruses. "This is a cost that we knew we had to bear," adds Cheung. "On balance, it was still the right course of action." |
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"Oh! How few studies there are," says Kathryn Murray, a psychologist and consulting associate at Duke University, North Carolina. She does not miss a beat. The sentiment is echoed by every researcher I speak to. There are plenty of studies on the developmental risks and challenges that young adopted children face, but far fewer on the nuances of their experiences, the best parenting strategies, or the children's development over the course of their lives. You don't stop having to deal with issues related to your adoption once you grow up - JaeRan Kim "We have almost no research on adoption post childhood," says JaeRan Kim, an associate professor in the School of Social Work and Criminal Justice at the University of Washington at Tacoma, whose research focuses on the wellbeing and experiences of adoptees. "But if you're adopted, you don't stop having to deal with issues related to your adoption once you grow up," she says. "How do adopted people parent? What kind of adoptive parents do they make? How do they deal with the loss of their biological parents? And their adoptive parents? We need to better understand these questions so that we can offer them the right kind of support." Because adoption is often framed as the final stop in a neglected or parentless child's journey to safety and stability, even the most basic information about the issues that children face after their adoption is frequently missing. This can include further trauma and disruption, such as abuse or abandonment by adoptive parents. It may even involve a return to foster care if the adoptive family lacks support and cannot cope with the consequences of early trauma, such as violent behaviour. "We know that not all adoptive parents raise their adopted children to adulthood," says Kim. "We call this adoption breakdown. But, here in the States, the figure could be anywhere between 5 and 25%. We just don't know for sure because the stats aren't there." So with huge holes in the research literature, how can we, as adoptive parents, use science to become better at addressing our children's unique needs? Responsive parenting can involve extra effort, but can result in a closer parent–child relationship (Credit: Ben Fergusson) Responsive parenting can involve extra effort, but can result in a closer parent–child relationship (Credit: Ben Fergusson) "Well, what we do have is lots of great research on the kinds of things that children who were adopted are more likely to have experienced," says Murray. "We know, for instance, that risk of suicide attempts is around four times higher for children who were adopted. That sounds really scary for someone thinking about adopting." But when Murray and her team took a large sample and controlled for trauma, they discovered that trauma accounted for much of that heightened risk. "That suggests that adoption in and of itself does not raise your suicide risk; but being adopted means that you are much more likely to have experienced trauma in the first few years of your life. And the good news is that we have lots of really great interventions for trauma." She gives the example of Trauma-Focused Cognitive Behavioural Therapy (TF-CBT), an evidence-backed treatment that has been shown to be effective at reducing post-traumatic stress symptoms, and other difficulties with mood and behaviour related to traumatic life events. "Ambiguous loss" When thinking about how one can deal with the traumas experienced by adoptive children, Kim points to the work of psychologist Pauline Boss who, in the 1970s, worked with the families of soldiers who had gone missing in action. Boss was trying to come up with a way to address the specific issue of grieving someone when you didn't know if they were dead or not, and she came up with the concept of "ambiguous loss". A loss that doesn't allow for any kind of complete emotional closure, such as the complex grief one might feel for a relative with dementia or for a child that was never conceived. The focus of Boss's work was getting people grieving these complex losses to accept that what they were dealing with could be "both/and". Someone could be both here and not here. And it was possible to learn to live with that duality and still lead a satisfying life. This approach is of course highly relevant to people who were adopted who often have missing or incomplete information about their birth families as well as countless intersecting dualities in their lives: birth parents, adoptive parents, sometimes foster parents too. If they've been adopted from another country, they may also have multiple cultural identities, neither of which they may feel they can fully inhabit. Boss's approach makes it clear that these children should not be made to feel that their differences don't matter. Indeed, adoptees have suggested that they would have benefited from questions and ambiguities being openly discussed and embraced in adoptive families. "Despite the difficulties of adoption, my life with my husband and my son is defined by the everyday travails and very deep joys of family life." (Credit: Ben Fergusson) "Despite the difficulties of adoption, my life with my husband and my son is defined by the everyday travails and very deep joys of family life." (Credit: Ben Fergusson) Family Tree This article is part of Family Tree, a series that explores the issues and opportunities families face today – and how they'll shape tomorrow. You might also be interested in other stories about children's wellbeing and development: Autism: Understanding my childhood habits How pets give your kids a brain boost Why childhood myopia rates are soaring Climb other branches of the family tree with BBC Culture and Worklife. For adoptive parents, it can also be important to acknowledge their own feelings of grief or loss. Murray cites the feelings that, in particular, straight couples who may originally have tried to conceive a biological child can have if their adopted child turns out to have a disability. "Some parents have already grieved a child they weren't able to conceive. And some parents we have spoken to describe experiencing a double grief when their adoptive child turns out, for example, to have special needs that they weren't aware of when they adopted." But, Murray says, when grief is taboo or shameful for parents and it stops them seeking help, that isn't good for them or their child. This is just one example of the numerous ways in which research on what makes a good adoptive parent is often hampered by good intentions and cultural taboos, according to the experts I interviewed. People like to think about adoptive parents as moral people who are doing a good thing and who should not be told they could be doing it better. And they like to believe that parental love is salve enough to solve all problems. So they don't want to hear that, despite being loved unconditionally, an adoptive child can still struggle. For an adoptive child, you need to understand that they are trying to communicate something that they cannot express – Pedro Alexandre Costa And yet, accepting these complex emotions and experiences around adoption can help adoptive parents let go of their old expectations of what having a child was going to be like, and embrace a different way of parenting. One key approach for adoptive parents is what Pedro Alexandre Costa, a clinical psychologist and researcher from the University Institute of Psychological, Social and Life Sciences (Ispa) in Lisbon, Portugal, calls "responsiveness". This requires adoptive parents to engage with their children in a more receptive way, and focus on warmth, bonding and closeness rather than rules and discipline. "Adoptive parents do just have to make an extra effort," Costa says. "They need to be responsive to their child when they might want to be strict. For instance, if their child is having a tantrum. For an adoptive child, you need to understand that they are trying to communicate something that they cannot express." This responsiveness and openness also needs to be applied to issues of attachment and security. "Adoptive parents need to be much more explicit with their child, for instance, that they are going to be around for the long haul," Costa adds. For this to be a success, it often involves parents having to rethink their approach to parenting, and engage more deeply in how they are responding to their child. But this can also be a source of pride, and result in a closer parent–child relationship. And there is no question that this relationship is central to dealing positively with the issues faced by kids who have gone through the care system. When I ask Costa what has most surprised him about his research into adoption, he points to the positive statistics on adoption improving a wide range of developmental outcomes, saying that he had not expected that "despite the difficulties, most children and parents are doing really well". For me, the key phrase here is "despite the difficulties…" Despite the difficulties of adoption, my life with my husband and my son is still defined by the everyday travails and very deep joys of family life. Sharing a cheeky doughnut on the way back from nursery, holding hands as we watch a red squirrel traverse the willow by the supermarket, trying not to laugh as our son pulls faces at the dinner table. These moments transcend the necessary legal convolutions of adoption that marked our first years as parents. The adoptive parents and grown-up adoptees I know have experienced a very broad range of challenges, many of which are unique to adoption. But the truth is that, despite the difficulties, they have each, in their own way, created families as complex and full of joy as anyone else's. Not without setbacks. Never without loss. But joyful, nonetheless. Ben Fergusson is a writer and translator. He is the author of three novels and the non-fiction book Tales from the Fatherland, an exploration of adoption and same-sex parenthood. He lives in Berlin with his husband and son. |
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