This time last year, Claudia Hoyen, a pediatric infectious-disease specialist in Cleveland, remembers staring at an eerily empty hospital as Christmas approached. With many schools shut and activities canceled, most children had been sheltered from the coronavirus. Today, nearly every bed at the children’s hospital where she works is full.

“We are in a difficult situation,” said Hoyen, at University Hospitals Rainbow Babies & Children’s Hospital. “With omicron, we are now having this new surge on top of what was left over from delta.”

Add to that the normal cases of the flu, broken bones, scheduled treatments for children with cancer and other conditions, and the hospital is “in a crisis,” she said.

As the United States enters its third year of the pandemic, forecasters are predicting another ugly winter, but this time, children as well as adults are being affected. Pediatric hospitalizations for COVID are surging in many parts of the country, alongside the arrival of omicron — as of Monday, the dominant strain in the United States — with about 800 new admissions each day for the past three days.

Ohio, Texas, Pennsylvania and New York have been hit particularly hard. As of Thursday, there were 1,987 confirmed or suspected pediatric COVID-19 patients hospitalized nationally, a 31% jump in 10 days, according to a Washington Post analysis. Since the pandemic began, nearly 7.4 million children and adolescents have been infected, with 170,000 more added to that total in the last week alone, according to the American Academy of Pediatrics.

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U.S. doctors interviewed this week said that while they are seeing record positive results from children’s coronavirus tests, the vast majority of cases so far have been mild and look a lot like the common cold.

Indeed, several studies, including a pair published this week from Scotland and England, suggest omicron is sending fewer people overall to the hospital — welcome news. But public health officials have been on high alert about one group, children under 5, who are the last group ineligible for vaccines in the United States. Earlier this month South Africa reported big jumps in hospital admissions for that age group. The accuracy and significance of the South African data is unclear, but on Thursday, the United Kingdom released data showing a bump in admissions for that age group, too. Hospital admissions ending Dec. 19 were at 3.64 per 100,000 for children ages 0 to 4 — three times the rate for those ages 5 to 14.

That trend is not yet evident in the United States. Doctors and officials at eight children’s hospitals in areas of mounting infections said most of their patients are unvaccinated adolescents with underlying health conditions, as has been the case for most of the pandemic, although on any given day, a wide range of ages may be represented.

Still, Aaron Glatt, chief of infectious diseases at Mount Sinai South Nassau, acknowledged colleagues are monitoring a “signal” of a possible increase in hospitalizations of children under age 2: “It’s unknown yet whether the lack of severity that seems to be present in adults will also be true in children,” he said.

Even with less severe disease projected overall as a result of omicron, pediatric specialists said they fear more children may be admitted to hospitals in coming weeks given the sheer number likely to be infected.

Adrienne Randolph, a critical care physician and anesthesiologist at Boston Children’s Hospital who leads a network of researchers studying the coronavirus in children, said that now is the time for parents who had hesitated about getting eligible children vaccinated to schedule the shots.

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“Everybody is getting prepared for the worst at the moment,” she said.

In March 2020, when the first wave of the coronavirus hit the United States, the initial presentation of COVID in children tended to be somewhat distinct — with many reporting a headache, stomach pain, or loss of smell or taste.

With omicron, physicians describe messier symptoms that mimic those of cold and flu. In the United Kingdom, health officials have reported that most children with omicron infections experienced headaches, sore throats, nasal congestion and fever, with those symptoms usually lasting about three days.

In Maryland, pediatrician Aaron Milstone with Johns Hopkins University School of Medicine said emergency visits are extremely high, but few of the children have been sick enough to be admitted to the hospital thus far. He said he has seen more fevers in children with omicron infections than with past variants, and urged parents who have children with “cold” symptoms to assume “it’s omicron until proven otherwise.”

“Parents have to recognize that yes, there is cold and flu and RSV,” Milstone said. “But right now the dominant cause of symptoms that look like cold is probably COVID.”

Outbreaks of respiratory illnesses like the common cold and the flu famously tend to hit the very young and the very old most severely. The elderly tend to have more preexisting medical conditions which make them vulnerable. As for babies and preschoolers, they have fewer defenses to fight foreign invaders, said Patty Manning, chief of staff at Cincinnati Children’s Hospital Medical Center.

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It’s not just about immature immune systems, she said, but also about how the children cough, and manage secretions and body temperature less efficiently than adults, making them more likely to be felled by colds and the flu.

With previous coronavirus variants, there appears to be something protective about that difference in the young. Why that is remains one of the biggest scientific mysteries about the coronavirus even now, two years after the World Health Organization first alerted the world to the new virus.

Most of the U.S. medical centers contacted this week said they are experiencing record volume and positivity rates among children at both their hospitals and outpatient clinics.

In Ohio, where besieged health facilities recently took out a full-page newspaper ad emblazoned with the word “Help,” and the governor deployed nearly 1,200 National Guard members to set up testing sites and help medical personnel, pediatric cases are surging.

Robert McGregor, chief medical officer for Akron Children’s Hospital, said the positivity rate has been so high that “we don’t know the ramifications.” As of Wednesday, the hospital had admitted several kids under 5, including two confirmed cases in infants and two suspected cases in nursery-age children, but most of the other 11 were teens.

“There is a sense that kids progress quicker” to severe illness, he said.

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Nathan Hagstrom, chair of pediatrics at the Lehigh Valley Health Network, which operates hospitals in the Allentown-Bethlehem region of Pennsylvania, said 20% to 30% of coronavirus tests on school-age children and adolescents are coming back positive. He estimated that roughly two-thirds are symptomatic. Hospitalizations of children are double what they were at the previous peak last winter and the highest of the pandemic, but they still represent a small fraction of all those infected, he said.

“The good news is the probability of having serious illness goes down when you are vaccinated across all ages,” he said.

He added that while a large number of children up to age 5 are testing positive, so far “they do not appear to be getting severe illness, or need any interventions or treatment.”

In Houston, hospitalizations among children with COVID have doubled in the past week and over 20% of children at outpatient clinics are testing positive for the virus.

“It’s just crazy,” said Stanley Spinner, chief medical officer/vice president at Texas Children’s Pediatrics and Texas Children’s Urgent Care. “And we are expecting those numbers to go up through the next couple of weeks.”

Spinner said infections are occurring in both vaccinated and unvaccinated children — with most of those who’ve gotten the shots having “much less significant symptoms.”

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He has two grandchildren under 5 and said their parents, one of whom is a cardiac specialist at Texas Children’s, are isolating from anyone who has been out in the community. “If you are not vaccinated, you are a sitting duck and children under 5 are not eligible,” he explained.

In Pittsburgh, Andrew Nowalk, a pediatric infectious-disease doctor at UPMC Children’s Hospital, said he is monitoring news closely from the countries hit with omicron before the United States. While the data out of Denmark and the United Kingdom is reassuring, he said he remains unsettled by the South Africa reports of very young hospitalized children. He said it’s possible South Africa’s data reflects differences in the nutritional status of its children and rates of various diseases there, among other factors, that may not apply in the United States.

“I look at the South African data,” he said, “and I say a lot of prayers.”

As pediatric specialists grapple with omicron, many are also preparing for aftereffects. Those at long-haul COVID clinics at many hospitals — already bursting with patients suffering from lingering symptoms after mild delta infections — anticipate more children in the coming months.

At Rainbow Babies & Children’s Hospital, one looming question has been about the rare post-viral multi-inflammatory syndrome, or MIS-C, associated with COVID that appears in some children four to six weeks after an infection. As of Nov. 30, the latest data available from the Centers for Disease Control and Prevention, there have been 5,973 cases and 52 deaths that meet the MIS-C case definition. Scientists aren’t sure what causes the syndrome but its unpredictability — most of the children are healthy with no underlying conditions — and the suddenness with which it hits have made doctors and parents alike anxious.

One study, published in September in the Journal of Allergy and Clinical Immunology, showed a possible genetic marker that may make a child susceptible to the condition, but it’s by no means the full story since the marker is not present in all patients, said Randolph, the Boston Children’s researcher, who is a co-author.

With Cleveland just seeing the tail end of its delta wave — where the Rainbow Hospital is located — doctors are unsure the extent to which they should expect new MIS-C cases. In many other parts of the country, the dreaded cases did not materialize in the proportions expected after the delta wave. Scientists aren’t sure whether that may be a function of more vaccinations, exposure to previous variants, or delta itself.

However, Hoyen, the pediatric infectious-disease specialist, cautioned that MIS-C has not disappeared: “We had two admissions just this week.”

It’s too soon, she said, to know about omicron.

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