One of the few silver linings of lockdown? The total lack of snotty noses in my household.
With three kids aged 6, 4 and 1 in my family, we’d usually have a merry-go-round of sickness happening between us. In an ordinary year we’d average at least 1 to 2 visits to the doctor per month for chest-checks and cold medications (no exaggeration).
But lockdown was eerily sniffle-free. No scrunched up tissues, no splutters or fevers. Just delightfully clean button noses, all the way from March until August. It’s been a real-life demonstration on the principles of disease epidemiology, and could not have drummed home the efficacy of lockdown for preventing the spread of a communicable virus more loudly for me.
However, one of the reasons I used to be pretty relaxed about our family’s common-cold-carousel is that I know exposure to regular childhood illnesses is all part of building up their immunity.
“We come to this world with an inexperienced immune system,” says Dr Mamata Bothra, Specialist Pediatrician at Medeor Hospital. “Slowly children improve or develop their immunity by battling against a series of germs, viruses, and other organisms. This is why battling mild colds, flu and ear infections every year is considered normal.”
It’s along the lines of how vaccines work: we inject ourselves with a small amount of a pathogen to trigger the body’s immune response, which produces antibodies that are primed to fight it if and when we encounter the same pathogen again in the future.
It’s also believed that exposing babies and young children to different kinds of micro-organisms early in life can help prevent them from developing illnesses like asthma, allergies, and other autoimmune disorder, says Dr Bothra.
And there’s even some evidence that growing up in a too-clean and sterile environment, without exposure to the normal microbes, can cause the immune system to respond abnormally - potentially resulting in certain types of cancer in pre-disposed children. “Cancer Research in London has previously identified a possible link for Acute Lymphoblastic Leukemia to the lack of exposure to germs in children,” says Dr Zuhair Shihab, Consultant Pediatrics and Neonatology at Burjeel Royal Hospital in Al Ain.
So is the lockdown lack-of-sickness really something to be celebrated? Or could the protection from one virus end up putting kids at risk of other, possibly more long-term, illnesses in the future?
Has there really been less childhood sickness because of lockdown?
Global studies back up the findings of my own anecdotal evidence. “There has been a considerable reduction in common childhood illnesses both in the UAE and globally during the lockdown period,” says Dr Bothra.
“There has been a noticeable decrease in paediatric emergency room visits, the number of hospital referrals, and admissions due to the decrease in Viral Respiratory Infections, Upper Respiratory Infections, Lower Respiratory Infections, Middle Ear Infections, and Gastrointestinal Infections. The number of Influenza and RSV infections has gone down considerably since the lockdown.
“Surveys and reports suggest that globally there has been a reduction in paediatric cases presenting with Gastroenteritis, Common Cold, Bronchiolitis, and Acute Otitis Media.”
And it’s all down to us staying away from each other: “Public-health measures such as movement restrictions, social distancing and increased personal hygiene likely had an effect on decreasing influenza and other respiratory virus transmission,” said the World Health Organization in a statement to Nature.
While this all sounds great, COVID-related lockdown comes with its own set of health-risk factors – scientists have worried that quarantine behaviours could lead to an increase in weight gain and diabetes, not to mention the negative impact of social distancing on our mental health - including, of course, its effect on our children's immune systems...
Avoiding disease sounds good but there may be a down side
So could we be putting our children at a disadvantage by not giving them immunity-building exposure to common childhood illnesses early in life?
It is believed that some early encounters with bacteria and viruses are good because microbial exposure helps in the development of the immune system. “As our immune system is exposed to repeated viral and bacterial infections, the system also grows and becomes stronger to defend the body of the child,” says Burjeel Royal Hospital in Al Ain’s Dr Shihab.
There is evidence to back this up. Ever noticed that kids get sick all the time when they first start nursery or school, but that this tends to peter off with age? A large study in the Archives of Pediatrics and Adolescent Medicine found that babies who attend large-group child-care centres before they are 2 ½ years of age do get more respiratory and ear infections than those cared for at home, but they are less likely to come down with these ailments once they start primary school.
“Microbial exposure trains the immune system to differentiate between commensals (organisms commonly found and mostly harmless) and harmful pathogens,” says Medeor Hospital’s Dr Bothra.
It also depends on the illness in question. There are some childhood diseases which it pays to get later in life: “RSV [respiratory syncytial virus] is a common respiratory viral infection that kids typically catch before their 2nd birthday,” says Dr Bothra.
Acute lower respiratory tract infection (LRTI) caused by RSV is one of the leading causes of morbidity and mortality in children less than five years of age globally, according to a 2019 UAE study printed in the Canadian Respiratory Journal.
“RSV leads to many Pediatric hospitalizations per year. It can precipitate an Asthma attack also. So for RSV infection the younger the child, the higher the risk.”
Whereas in adults and older children RSV infection is usually mild and mimics symptoms of the common cold, studies have found that children who developed severe RSV infection in the first 12 months of life were at a heightened risk of developing asthma or a recurrent wheeze in later life. So, for babies and young children who have avoided catching RSV this year because of lockdown, this can be seen as an advantage.
However, there are some other illnesses that are much less serious in children than they are in adults. “Mumps, Measles, and Chickenpox, Cytomegalovirus (CMV) and Epstein-Barr virus (EBV) if contracted early in life have fewer complications and are usually less serious,” says Dr Bothra. While the first three diseases may be prevented by vaccines, CMV and EBV tend to causes mild to no symptoms in little children, but can cause infectious mononucleosis in teenagers and adults, which can cause chronic fatigue and malaise.
The role of microbe exposure in auto-immune conditions
There are other potential benefits to children being exposed to the manifold microbes of group environments however, which is not to do with catching a full-blown disease necessarily, but with developing a broader microbiome.
Your microbiome is a collection of harmless microorganisms, which live on your skin, saliva and mouth, eyes, and gut, consisting of bacteria, fungi and single-celled eukaryotes ('protozoa'). It is believed that the richer and more diverse your microbiome, the more robust your immune system is.
Rates of childhood allergies and other autoimmune conditions such as asthma have been rising dramatically in recent years, and some scientists believe this is because of modern habits - such as rising rates of C-section births and the frequent use of antibiotics – that alter our gut bacteria and upset our microbiome.
This is related to the Hygiene Hypothesis, a controversial theory first formally proposed by a British scientist in 1989, which states that “as kids in developed countries grow up in a cleaner environment with fewer microbial exposures, they suffer from more allergies and autoimmune diseases later in their life,” says Dr Bothra.
“Parasitic infections, in particular, are usually counteracted by the same mechanisms involved in combatting allergies," says Dr Carlos Baptista, a paediatric specialist at Novomed in Dubai who has a special interest in childhood allergies. “With fewer parasites to fight, the immune system turns against elements that should be harmless.”
Whereas paediatricians used to advise against exposing children to potential allergens such as peanuts, eggs and shellfish until later in life, there is now ample evidence that this delay actually increases the risk of children becoming allergic to them, and that it is better they are exposed as early as possible - from four months onwards. The theory is that with repeated exposure from an early age, children’s bodies build up a tolerance.
By the same principle, some researchers believe that the immune system needs exposure to infections in early life to learn to function properly. Babies who receive antibiotics, which destroy the good bacteria as well as the bad bacteria in their microbiome, are at a higher risk for developing asthma, eczema and allergies, while children who grow up on farms or are exposed to animals early on in life have a lowered risk of these same autoimmune diseases.
Putting it into perspective
The interplay of our immune system with pathogens and how that shapes our bodies’ ability to fight infections is extremely complex, and genetics also plays a large part, so there is no one answer for everybody.
“Younger age people will have more impact as their immune system and social milestones are both in the developing phase,” says Dr Bothra. “However, staying indoors for a short period may not have a long-term impact as we build our immune system throughout the lifetime and not over a couple of months."
While it’s possible that children being kept in hermetically sealed sterile bubbles their whole lives may suffer problems with their immunity as a result, most of us do not realistically live this way, even if we are totally physically distancing from others.
There are also ways to counteract any possible negative effects of staying indoors – one of which is ensuring the whole family’s vitamin D levels are sufficient, as not only can vitamin D deficiency lower immunity, recent studies have shown that adequate vitamin D levels can help our bodies to resist COVID-19 infections.
“Staying at home may lower the overall strength and vitality, but following a proper healthy schedule and having a good, nutritious diet may help reduce the side effects,” says Dr Bothra.
From exposing your child to the microbes outside in nature, to breastfeeding longer (if applicable), to even adopting a pet for your home, there are many ways to boost your child’s immunity and microbiome without having to take risks you don’t feel comfortable with.
As all of the emirates venture back to physical school this week, the immune-boosting benefits of being around other children (and their related sniffles) will no doubt return. And yes, my family has already had our first doctor-visit in 6 months as a result.