This guidance has been developed in partnership with British Association of Perinatal Medicine, British Association for Paediatric Nephrology, British Paediatric Respiratory Society, British Society for Haematology, British Society for Paediatric Gastroenterology, Hepatology and Nutrition and Children's Cancer and Leukaemia Group.
Children who should be advised to 'shield'
Information from national and international data finds that the numbers of children requiring hospital admission as a direct consequence of COVID-19 infection is low, and those needing PICU (paediatric intensive care unit) admission is lower still. It appears children still have infection but in the vast majority it is much milder than that seen in adults. It is also important to recognise that during this current pandemic, children who are unwell remain more likely to be unwell due to a non-COVID-19 condition than to COVID-19 itself; this includes those with the conditions described in this guidance. However, some children may remain more at risk of COVID-19 related disease, and these children should be protected as far as is possible from infection by 'shielding'.
Public Health England's list of conditions for adults and children to which they advise 'shielding' is important. How best to apply this to children and young people in the UK is complex. Although in adults these co-morbidities are associated with an increased mortality risk, the evidence for this among children and young people is very limited.
The guidance presented here is the most current consensus on paediatric patient groups where 'shielding' is recommended. This list will be updated as evidence becomes available from both national data collection and published studies, which will minimise the burden of 'shielding' for those who do not need it.
Some children with the diagnoses listed below will have less severe disease and 'shielding' might be considered unnecessary.
This should be discussed with the clinicians most closely involved in the care of the child and family and the risks balanced. In those situations, social distancing should be strongly adhered to - PHE has guidance on social distancing and isolation advice when living with children.
- Those who have had a recent transplant
- Those children immunocompromised either by treatment or disease
The British Paediatric Neurology Association (BPNA) has advice on COVID-19 and paediatric neurology.
- PIBD (paediatric inflammatory bowel disease) patients with significant co-morbidity (respiratory, cardiac, hypertension or diabetes mellitus) and are on any 'moderate risk' therapy for IBD and / or have moderate to severely active disease (discuss with specialist)
- PIBD patients regardless of comorbidity and who meet one or more of the following criteria:
- Intravenous or oral steroids ≥20mg prednisolone (or >0.5mg/kg)^ or equivalent per day (only while on this dose)
- Commencement of biologic plus immunomodulatory or systemic steroids with previous six weeks
- Moderate to severely active disease not controlled by 'moderate risk' treatments
- Short gut syndrome requiring nutritional support
- Requirement for parenteral nutrition
- Intestinal failure on home parenteral nutrition
- Immune suppression for organ transplant or auto immune hepatitis
The British Society of Paediatric Gastroenterology Hepatology and Nutrition (BSPGHAN) have published guidance on the management of PIBD during the coronavirus pandemic.
- Those on regular blood transfusion with cardiomyopathy from iron overload
- Those who have had their spleen removed or a non-functioning spleen
- Those with sickle cell disease (including HbSS, HbSC, HBS/beta)
- Those on certain anticancer treatments (chemotherapy, immunotherapy including CAR-T, cell therapy, antibody treatments or targeted treatments)
- Those with blood cancer (leukaemia, lymphoma) at any stage of treatment
- Those within 12 months of having an autologous stem cell transplant
- Those within 24 months of a donor stem cell transplant
The Children's Cancer and Leukaemia Group has guidance for children and young people with cancer who are undergoing treatment.
- All those patients undertaking in centre dialysis
- Some patients receiving home dialysis
The British Association for Paediatric Nephrology / Renal Association has detailed coronavirus guidance for children and young people with renal conditions.
- Cystic fibrosis or primary ciliary dyskinesia
- The UK CF Medical Association has a statement on coronavirus
- Chronic lung disease of prematurity with oxygen dependency
- Severe asthma (as defined by NICE)
- Asthma UK has guidance on coronavirus for children with severe asthma.
- Interstitial lung disease
- Life dependent on long term ventilation, either via tracheostomy or by non-invasive ventilation.
- Neuromuscular disease on long term ventilation
- Obliterative bronchiolitis
- Those receiving additional daytime and / or night time oxygen
- Significant lung disease relating to underlying systemic diseases, such as rheumatological disease
- Significant bronchiectasis
- Significant underlying neurodisabilities and lung infection risk, such as those requiring cough assist at home
Communication with children and families
Many families will have been sent NHS letters detailing the need for them to 'shield'. If families have not received these 'shielding' letters but had expected to, they are likely to contact their lead clinician to discuss this. If families have received inappropriate 'shielding' advice, they may also want to discuss this with their clinicians.
Clinicians most closely involved in the care of the child and family can help in 'shielding' decision-making (eg lead clinician within a tertiary centre, local clinician and / or GP). Clinicians can recommend 'shielding' to parents of children, though parents themselves hold the responsibility for the child and family.
Clinicians who identify patients for 'shielding' who are not yet on the Government list will need to apply for the patient to be added to the list. This can be done by following arrangements outlined below as applicable within each of the four UK nations.
It is important to be aware for some children, 'shielding' may pose a risk to the child's physical or mental wellbeing and affect families most in need. Clinicians advising 'shielding' should signpost families to our frequently asked questions below and our resources for parents and carers, which includes how to talk to children and young people about COVID-19 and signposts to mental health / wellbeing resources.
Children who are shielded should still attend hospital for essential treatment as recommended by their clinical teams, following risk assessment. The need for this should be discussed with families and young people in a sensitive and reassuring manner. It is understandable that parents may be apprehensive about attending hospitals even when it is clinically important to do so. The clinical team should do all they can to encourage attendance. If however, non-attendance becomes a clinical concern (despite all attempts at reassurance) and there is a concern for the child, then for the safety of the child, further steps need to be taken. On occasion, non-compliance with treatment recommendations may amount to significant neglect of medical needs and will require discussion with the local safeguarding team, particularly the Named Doctor for Safeguarding Children, and may meet threshold for referral to children’s social care.
- Guidance instructs NHS Medical and Nursing Directors to review patient lists sent by NHS Digital and add patients they deem to be at clinically highest risk, who are not on the Government list (which was created via an algorithm). Each Trust has one named contact who will input daily data into the shielded list.
- These patient lists are submitted to the NHS and put onto the shielded patient list (SPL). These patients are written to with instruction to stay at home and avoid face-to-face contact.
- NHS England has a template letter for clinicians to share with families when indicated to share with families.
- Patients are able to register themselves as having a medical condition that makes them very vulnerable to COVID-19 and needing support. They are instructed to register online and contact their GP or lead clinician if they haven't already been contacted with 'shielding' information.
- On 25 March 2020, GPs were sent a letter requesting them to send a pre-drafted letter to all patients they considered to be at highest risk of COVID-19, according to a given list of diseases and conditions.
- GPs were signposted to guidance to assist them in finding high risk patients in their records.
- The Department of Health wrote to HSC Trusts, asking them to identify patients on red list drugs that may not be recorded in the GP practice's clinical system.
- The CMO has described the approach taken to identify and contact those most at risk of COVID-19 in Scotland (PDF). The most at risk patients have been identified using national data sets.
- Hospitals will be asked to help identify patients that may not be on the central register but may be classified as part of an at risk group.
- Health Boards are establishing teams to coordinate the sharing of information regarding high-risk patient groups.
- NHS Scotland information on shielding is available here.
- All those identified as being at high-risk of COVID-19 received a letter from the CMO regarding 'shielding' by 5 April 2020.
- Information from NHS databases and health records has been utilised to compile a list of very at risk patients.
- On 31 March 2020, GPs were provided with a list of patients who have been sent 'shielding' letters. They were asked to contact any additional high-risk patients to provide the same advice.
- If patients feel that they should be included amongst those who should be 'shielding', they are advised to discuss this with their GP or specialist.
Frequently asked questions on 'shielding'
These FAQs provide advice for clinicians and parents who have been advised to 'shield' children and young people.
What is 'shielding'?
'Shielding' is defined by Public Health England (PHE) as a measure to protect extremely vulnerable people by minimising interaction between those who are extremely vulnerable and others. Those adults and children who are classed as extremely vulnerable or most at risk are strongly recommended to take additional precautions to avoid COVID-19 infection. This includes advice to stay at home at all times. Within their homes, individuals should minimise all non-essential contact with other members of their household.
NHS Scotland has also issued shielding advice and guidance.
What does 'shielding' mean for a child?
Children are different to adults in many ways, but the 'shielding' advice from PHE is the same across all ages.
Children and young people who are 'shielding' must stay at home for 12 weeks (or possibly longer). This means not returning to school if they re-open within this time.
If children receive regular health or social care from any organisation, either through local authority or paid for by the family, care providers should be informed that they are shielding and agree a plan for continuing care at home. Carers and care workers must not enter the home if they have any symptoms of COVID-19.
What does 'shielding' mean for families?
All family members who are currently at home must be encouraged to maintain social distancing advice. This advice from PHE does not specify whether social distancing measures need to be specific for those who are known to be at high risk of being COVID-19 positive.
If the family is able to practice social distancing at home by separating out the family's roles at home, this may allow some family members to continue to work (including within high risk occupancies which may encounter COVID-19, eg front life healthcare). However, they should support the 'shielding' process by following guidance on stringent social distancing when outside the home.
It is important to maintain a normal family life as far as is possible whilst protecting all members of the family. Each family situation will be different and decisions will need to be taken individually. Families with older children should be able to follow advice on social distancing and their decision-making may be easier. Those with younger children will have more difficult decisions and they will need to consider the necessity of following social distancing advice and the needs of other children in the family.
Will hospital and GP appointments continue during the 'shielding' period?
Where possible, healthcare services are making provisions for remote consultations (eg telephone or video consultations). However, some consultations will need to be face-to-face and in these scenarios healthcare providers will follow the latest PHE guidance on correct PPE for safety of both staff and patients.
Is support available for families that are 'shielding'?
Families with children who are within the most at risk or vulnerable group where notification has been completed will have received letters from the NHS and can obtain access to home deliveries. The letter also supports family members who need to discuss the requirements of 'shielding' with their employers.
Latest updates to this page
Updates in this version (12 May):
- Link to NHS Scotland shielding advice and guidance.
- Updated links as appropriate.
Updates in version 27 April:
- Communication with children and families: information added on shielded children attending hospital appointments and safeguarding issues.
Updates in version 20 April:
- Amended renal advice and added coronavirus guidance for children and young people with renal conditions.