I recently asked my husband what we would do if we both got severely ill with coronavirus and couldn’t take care of our toddler. Under any other circumstances requiring backup childcare, the answer would be simple: my dad, my son’s grandfather, who lives ten minutes away. Now, Grandpa is emphatically off-limits as a caregiver due to his elevated risk of complications from covid-19. I tried to shrug off this concern—of both of us, neither at high risk, falling critically ill at the same time—as the far-fetched imagining of my worst-case-scenario-ist mind. Then last week brought news stories that put into headlines this parental nightmare.
An article from Slate considered the experiences of parents who mutually fell ill with the novel coronavirus. A woman who came down with covid-19 symptoms alongside her husband told Ruth Graham about her worries: “It makes you contemplate what seemed like a ridiculous reaction five days ago, and then seemed reasonable three days ago, and now is like, ‘Yeah, we should have our wills ready.’” Then, I came across this tragic headline: “4-Year-Old Found Alone With Mom’s Body Hours After She Died From COVID-19.” Clearly, in some extreme and unusual cases, emergency childcare will be necessary for caregivers who fall severely ill amid this pandemic.
Already, this school-shuttering, day-care closing pandemic has for many parents raised a question with no good answers: How do you balance full-time work and full-time childcare? But some parents will face another wrenching question: How do you calculate the best emergency caregiver, psychologically and epidemiologically, under these specific, complex circumstances? The variables are many and no solution is perfect, but experts are now having to consider this difficult dilemma. “This is definitely something in the maternal and child health context that teams are talking about,” said Rachel Thornton, associate professor of pediatrics at the Johns Hopkins University School of Medicine.
For any caregiver seriously concerned about their ability to care for a child because they are currently sick from covid-19, Thornton first recommends a call to your doctor. “It sounds cliche, but we’ve been asking people to please talk to your primary care providers, if you’re so fortunate as to have one,” she said. “It would be worthwhile to connect with your child’s pediatrician, to connect with your internist, to connect with any kind of social service agencies, should people already have those connections, and proactively try to understand what the contingency planning should look like.”
Roshni Mathew, a pediatric infectious disease specialist at Stanford Children’s Health, notes that even in a two-parent household where both caregivers are sick with covid-19, it might be possible to trade off responsibilities, based on the severity of symptoms. Since infections within the same household tend to be staggered and transmission risk is highest in the first few days of illness, she suggested that the parent further along in the course of the illness could take over caregiving during that time. She added that a parent who is “actively sick” can wear a mask to reduce the risk of transmission to the child, especially in the early days of illness.
If an outside caregiver is however absolutely required in these circumstances, Thornton says, “You have to weigh the risk profile of the caregiver and the safety considerations for the child, and the familiarity of that caregiver to that child. Those are personal decisions that people have to make that are responsive to their own contexts.” She adds that children should not be left with a caregiver about whom there is a concern about the abuse of alcohol or other substances.
Of course, part of the evaluation of risk to backup caregivers involves the question of whether the child in question has contracted covid-19. “While it is difficult to avoid transmission within the same household, if a parent is sick and the child is still asymptomatic, then there is a chance they haven’t been infected,” said Mathew. “Shedding of virus in secretions and thus transmission is most likely in the first few days of the illness. As fever resolves and secretions subside, so does the likelihood of transmission. So through good hygiene practices and common-sense measures, like not sharing cups and utensils, eating from the same plates, it can minimize risk of transmission.” Thornton notes that “there’s a spectrum of symptomatology that a child could have, so your child could have really mild symptoms and still potentially be infectious to others.”
Given the greater risk that covid-19 infection poses to older adults, Mathew says that “grandparents are not ideal caregivers in this situation.” She adds that “the risk of severe disease is higher in individuals over 60 and most severe in those over 80.” While younger adults have been hospitalized, “the risk is significantly less for otherwise healthy adults under 60.”
Of course, older family members are often among a child’s most familiar and trusted caretakers, which in these circumstances places emotional comfort against medical risk. Thornton gives the example dilemma of a child who is “much more accustomed to grandma, and grandma knows their routine, but grandma has emphysema or diabetes and they’ve met their aunt a couple times but have never spent the night at her house and her house isn’t baby-proofed.” In such a context, she suggests that “it might be worth really strongly considering a trusted adult who is less familiar to the child but for whom exposure to the child would not present the same level of medical risk.”
Perhaps the next most comfortable option would be to place a child with family friends who are themselves parents. Of course, with more people in the household, that could mean more vectors for transmission. However, Mathew says that as long as the household is made up of people at low risk, meaning they are without heart or lung disease or conditions that compromise their immune system, “they would not generally be at risk for complicated disease course in the event they were to acquire the infection.” Mathew notes that “children, in general, have had far fewer infections compared to adults and the risk for severe disease and mortality is significantly lower in children.”
She underscores that any backup caregiver should take all the recommended protective precautions against covid-19 transmission. That means that, unless that caregiver is at higher risk for a severe case of covid-19, they should take similar measures as those recommended for influenza or another viral respiratory infection, which means “extra diligence on hand hygiene, respiratory etiquette, and keeping regular cleaning practices.” She adds that “surfaces should be cleaned at least once daily in general but spaces like the dining area should be cleaned after each use,” and “hands should be washed when you come in from outside, after using a tissue to clean secretions and of course before eating.” For extra safety, you can change clothing after coming in from outdoors.
For parents who are hospitalized and have no support system—no trustworthy friends, family members, babysitters, or neighbors—the arrangement of care for their child would likely fall to social workers within the healthcare context. “The patient would hopefully be cognizant enough to be able to communicate that [need] either to EMS when they’re picked up by 911 or when they present in a facility,” said Thornton. “People have a lot of concerns about interacting with child welfare agencies depending on what the experience has been like in their given context,” she allowed. There is a long, storied history of race and class disparities in the child welfare system, and emerging evidence points to similar disparities in the devastating impacts of this pandemic. For single parents without support, this could serve as a significant deterrent to seeking medical help. But Thornton generally encouraged parents to not worry that contacting child welfare agencies amid a covid-19 health emergency will lead to “negative scrutiny on the caregiver.”
Thornton emphasizes that “kids are remarkable humans” in their adaptability. Already, they are coping with significant disruption in their daily routines, as schools close and playdates are ruled out. In the case of a severely ill parent who strongly anticipates being unable to provide childcare due to covid-19, she recommends talking with kids about it in an age-appropriate way. “It’s always best to try to prepare children as much as possible,” she said. “Prepare them to wrap their heads around that possibility, if you think it’s something where there is a significant probability of it happening.”