Each generation has to go through an era-defining upheaval. Some of us lived through independence, some through wars, and some through the economic liberalization of the 90s. But, nothing could have prepared us for this. And in turn, it would have been nearly impossible to prepare our children for it. Nevertheless, they find themselves in the middle of a pandemic with death, illness, and misery all around.

The oft-repeated assertion entering the lay con-sciousness has been that children are safe from contracting coronavirus disease 2019 (COVID-19). Whereas a truer statement would be that they are relatively safer from severe forms of COVID-19. They are not immune to it, and the fact that the rate of mortality and severity is lower, does not mean we let our guard down. It also does not mean that we panic about a third wave where children are supposedly at dis-proportionate risk. This pandemic has exhibited a nonlinear, complex nature; all predictions, whether based on complex mathematical model or past experience or even just instinct, have gone for a toss. It would be prudent, therefore, to be cautious against any speculation or prediction unsubstantiated by hard evidence, especially regarding the third wave specifically targeting children. All this can result in is unwarranted mental trauma to children and their caretakers rather than preparing them for whatever lies in store. Usually, it is expected that every fresh wave would be weaker than the previous one, but the strange nature of the virus coupled with human behavior has belied this. The second wave took a heavier toll unlike expected and has given credence to the possibility that the third wave might be even stronger. The number of people infected has been much higher in the second wave; proportionately, the number of children infected has also increased. This remains a possibility even in the third wave but there is no logical reasoning or evidence to believe that the third wave will predominantly or exclusively affect children [1].

An Indian Council of Medical Research survey conducted in December, 2020 and January, 2021 showed that the percentage of infected children in the age group of 10-17 years was around 25%, the same as adults [2]. Almost 90% of infections in children are mild/asymp-tomatic. This indicates that while children are being infected like adults, they are not getting the severe form of the disease. As per data collected in the first two waves, even severe COVID infections in children are less likely to require intensive care unit management.

However, the impact of the pandemic on our children has not been limited to the actual disease, but a gamut of related issues and lifestyle changes forced upon them due to the pandemic. A recent study [3] found that almost one-third of children had developed psychosocial problems, presenting as symptoms of anxiety and depression. The underlying problems for these ranged from the fear of acquiring COVID-19 infection, not being able to attend school, to not being able to meet friends. The thing they missed the most, as well the activity they intended to engage in as soon as the lockdowns were over, was to meet friends [3].

One of the more serious side-effects of the pandemic has been the reduction in child hospital visits. Any pediatrician could attest to parents bringing their children more frequently to their doctors, either for immunization or even in cases of mild illnesses, than they would themselves. These used to provide a vital stopgap in diagnosis and management of chronic illnesses, which would have gone unnoticed, since routine check-ups are almost non-existent in a large part of the country. Now, due to COVID-19, there is an increasing reluctance in bringing children to the hospital. Sure, telemedicine has taken over, where it can, but there is no denying the value of an in-person visit for diagnosis of an underlying disease. Even routine immuni-zation has suffered and can be disastrous in the long-term. The pandemic indirectly might end up aiding the proli-feration of a host of other illnesses. Then there is the economic impact. Already marginalized communities have borne the brunt of it, with no jobs, no income, and savings exhausted. This will invariably have an impact on their child’s nutrition, and in turn, their overall health.

School is an inextricable part of a child’s life, as children spend at least a-quarter of their day in school or traveling to and from it. That is, until the pandemic necessitated stringent lockdowns. And with it, has come a simultaneous need and opportunity for a paradigm shift in education. We also are more cognizant of the possibility that attending school is more important for socialization and associated skills, rather than mere learning. In view of this, and to take better care of our children’s mental health, which has been tested time and again during the pandemic, there is an imminent need to redesign school curricula, as well as performance assessment systems.

A holistic approach to child mental health needs to be adopted by parents and teachers alike, who need to be sensitized into minimizing the stress on every child they are responsible for. Equating excellence in academic learning to self-worth merely serves to inflate an already competitive environment and does not work towards discipline and results. These positive traits need to be self-motivated if they are to sustain for the long term, and the self-motivation can only come from a place of mental calm and security. To build this, screen-time needs to be reduced for children. Yoga, meditation and other forms of exercise need to be taken up. Since we have already seen the psychological issues emanating from the pandemic, an exclusive helpline to combat adolescent suicide, is long overdue.

It is true that the pandemic has wrecked unprecedented misery and chaos everywhere, but it has also exacerbated existing problems like nutritional extremes. On one hand we are battling with nutritional issues such as malnutrition and anemia. The Comprehensive National Nutrition Survey (CNNS) India 2016-18 that included data on 112316 children and adolescents revealed that only 6% of infants are getting minimum acceptable diet, the prevalence of wasting (defined as low weight-for-height, indicating acute malnutrition) and stunting (defined as low height-for-age, indicating long-term malnutrition) in under-five children are 17% and 35%, respectively; and 41% of preschoolers, 24% of school-age children, and 28% of adolescents are anemic [4]. It is highly probable that the problem has worsened during the pandemic, especially amongst children belonging to underprivileged communities, who are struggling to make ends meet. On the other hand, we have urban children living in economically stable households, who are at the other end of the nutritional extreme. In the last decade, options at home for junking have been on the rise, and in the lockdowns, have become ever-more prevalent [5].

Schools need to be reopened to provide a sense of normalcy. However, as an Indian Academy of Pediatrics (IAP) task force recently put forth in its guidelines [6], they should be opened "only when the local epidemiological parameters are favourable, the administration is equipped with adequate infrastructure and health care facilities, and the stakeholders (teachers, students, parents, and support staff) are prepared for the new normal. In the meanwhile, remote learning (media-based and /or otherwise) should reach to the last student to maintain uninterrupted education." School attendance will ensure that children are not leading a sedentary lifestyle, are mingling with peers, and developing a healthy immunogenic arsenal.

The speculation about a third wave which pre-dominantly affects children should not be seen as a reason to panic, but an opportunity to better our pediatric healthcare infrastructure, which has historically been inadequate in normal times, let alone a pandemic. Not just district hospitals, but even many medical colleges in the country do not have intensive care services for children, be it trained specialists or essential equipment. The motto has to be – build in peacetime, so that we are ready for war. Healthcare, especially for children, has to become a priority if we are to handle a pandemic. This does not simply mean buying more ventilators, procuring more equipment or creating more beds. It also means making sure that the workforce responsible for our children is not scanty, starved, or scared.

The writing is on the wall for anyone to read. We can not think short-term and expect long-term gains. Dealing simply with COVID-19 will not erase decades of under-investment in child health. There needs to be a long-term commitment from all private and public stakeholders if we are to be prepared for the next era-defining upheaval.