COMMENT | Malnourished children at higher risk of Covid-19

COMMENT | Up until last week, the consensus in the medical community is that Covid-19 does not seem to significantly cause severe symptoms or deaths among young children. They do, but it is highly unlikely. 

In Italy for example, mortality rate among young children between the age of zero and nine is roughly 0.2 percent. The rate seems to be much lower in the US as well as in China where the outbreak began.

However, since then, we have learnt a few more things about the coronavirus. More and more young (and seemingly healthy) children in Europe and the US were reported to have experienced a multisystem inflammatory reaction to Covid-19 known as Kawasaki’s Disease. As such, it seems that children are not wholly “spared” from the virus.

To begin with, there is no suggestion that children should be less likely to harbour and transmit the virus. In fact, young children, theoretically, could be at a higher risk of contracting pathogens from the environment compared to adults. 

This is because they are less likely to practice regular handwashing, especially if they are left unsupervised. As a result, they could contract practically any pathogens such as the coronavirus from another person or from the environment.

On May 16, we were given the news that 317 children in Malaysia, almost half of them below the age of six, have been infected by the coronavirus so far. Fortunately, however, there were no deaths or severe cases reported. Still, Malaysia may need to be very vigilant about this.

The medical community in general has not been reporting a lot of severe cases among young children but that may simply be due to a statistical problem of selection bias. 

So far, the coronavirus has only severely affected developed and developing countries where children on average are much healthier compared to their peers from poorer countries who are more likely to be under or malnourished. 

While Malaysia is certainly not considered as a least developed country, our track record in the nutrition front among young children is not remarkable.

Nutritional status among young children in Malaysia is not as good as we may have imagined. Based on available data from 2016, one in five children in Malaysia is stunted – a strong indicator for undernutrition or poor nutrition status. 

Also, one in 10 is underweight. Areas where stunting or undernutrition is most prevalent in the country are Kelantan, Terengganu and Pahang. In a 2018 report by Unicef in Malaysia, it was found that stunting among young children is also highly prevalent among the urban poor in Kuala Lumpur. 

This is also without accounting for the rate of obesity among young children in the country, another indicator for poor nutritional status. A 2013 study previously reported that Malaysia is one of the top three countries with a high percentage of obese children between six months and 12 years old.

It is important to note however that nutritional status is related to several factors. One is through food and nutritional intake. Poor nutritional intake on either end of the spectrum can lead to either underweight or obesity among children. 

Another less obvious factor is the environment which serves as vectors for pathogens that cause chronic diarrheal diseases that leads to severe undernutrition in the long run. This can come in the form of inadequate improved sanitation, insufficient handwashing, contaminated drinking water sources as well as seasonal weather hazards like flooding. 

It may be no coincidence that states in Malaysia that experienced severe seasonal floods have the highest prevalence of stunting among young children.

Why is this important you would ask? For that, studies have shown that our immune system is very much associated with our nutritional status. Undernutrition among children, for example, is found to be associated with impaired gut-barrier function, reduced exocrine secretion of protective substances, and low levels of plasma complement. 

More importantly, levels of antibodies, the body’s primary defence against bacteria and viruses, produced after vaccination are found to be significantly lower in severely malnourished children.

Because of a poor immune system, undernourished children are found to be more likely to develop infections and will be less likely to fight the infection successfully. 

In fact, pneumonia is the leading infection-related cause of death among children globally and especially among children with undernutrition. Other than a direct impact on their mortality, undernutrition has been shown to increase the frequency and severity of pneumonia episodes. 

Interestingly too, malnourished children are also more likely to die after successful treatment and being discharged from hospital.

This is all important because it has been widely accepted that at-risk patients can develop pneumonia from a Covid-19 infection, especially when their bodies fail to clear the virus and respond to treatments. Moreover, nutritional status has also been generally accepted as a comorbidity of developing severe Covid-19 symptoms. 

Adults with diabetes, hypertension, cardiovascular diseases as well as obesity are all more likely to develop severe symptoms from the virus such as pneumonia and are more likely to die compared to their healthy counterparts. Nothing in the medical literature has suggested that this does not apply to children with poor nutrition status.

So, what can Malaysia do about this? Globally, international organisations, NGOs, the World Bank and Unicef, are working hard to ensure continued nutritional support to poor families and children. Malaysia can do the same. 

Poor families in Malaysia have taken a severe financial toll during the movement control order (MCO) and this would have severe implications on the nutritional status of their young children. 

Governments at the national and state level should consider increasing and extending current nutritional or supplement intake programmes in addition to the coronavirus food aid programme to ensure that the health of these children are resilient and not develop severe symptoms from the virus if contracted.

There are still many unknowns regarding Covid-19. Researchers and the medical community are learning more about the virus by the day. What we have learned so far is that Covid-19, to an exceptionally low extent, causes severe symptoms and even death among young children. 

However, as I have proposed here, this may be due to a selection problem that we only see studies and reports of Covid-19 in developed and developing countries so far where children are relatively healthier. 

Also, given that evidence in the literature has pointed to poorer immune system and higher susceptibility to developing severe infections among young children with undernutrition, it may be wise to reserve vigilance towards ensuring the health and nutrition of our young children to protect them from Covid-19. 

BILLY HOO is a consultant for World Bank's Water Global Practice. 

The views expressed here are those of the author/contributor and do not necessarily represent the views of Malaysiakini.