On a recent Monday night in the pediatric emergency department, the resident physicians, the nurse practitioners, nurses and I were all sitting around doing various things; some were tending to the needs of the few patients in the ED, some were checking e-mails or catching up on journal articles, some were getting food, others were chatting. It felt more like a typical office setting, not one we’re used to the in the emergency department.

A much more average Monday for me during flu season would have involved constantly running between rooms checking on children and initiating therapies; being interrupted by a very sick child who needs all hands on deck for a resuscitation; keeping an eye on how full the lobby is getting; and simultaneously working with the inpatient admission teams and consultants to keep everyone safe and care plans moving forward. It is a controlled kind of chaos, and one that those of us who chose this kind of work thrive on. There is almost never time for e-mails or chatting, and very rarely any time for eating.

This strangely calm scene is not unique to Seattle, where I practice, as I have been told by many of my colleagues across the country and the world. Even colleagues in New York City, the epicenter of the U.S. pandemic, are reporting the same. As much of the world is now on lockdown or sheltering in place, as schools and playgrounds have been shuttered for weeks, and as people are hesitant to leave their homes due to national pleas to stay at home to mitigate the spread of COVID-19, emergency departments are seeing fewer children coming through our doors.

Our hospital, like many, has been well prepared for a surge in pediatric patients needing high levels of care in isolation, and we’ve put a number of well-planned and orchestrated strategies in place to anticipate that. But just like everywhere else, children in our region are not getting as sick from COVID-19 as our adult population is, though many are presumed to be asymptomatic carriers. What my colleagues across the country have been wondering, however, is, where are all the other patients that used to fill up our EDs?

There are likely many reasons, but the downstream effects of the coronavirus pandemic and social isolation are probably a factor. Viruses are the culprit for much of what we normally see in the pediatric ED: they’re responsible for the seasonal fevers, coughs, croup, ear infections, pink eyes, rashes, vomiting and diarrhea. They’re also behind other, less obvious illnesses as well. Viruses can trigger diabetic keto-acid crises and febrile seizures; they can exacerbate asthma; they can cause children with epilepsy to seize more frequently. Viruses may set off autoimmune conditions; they may cause a telescoping obstruction of the bowels common in children; they can make parotid glands to bloat and boys’ testicles to swell. Viruses have even been linked to appendicitis, to the onset of cancer, to a transient and painful inflammation of children’s joints, to meningitis and to conditions that cause the heart to swell and fail.

These are all conditions that I would have seen over a typical few weeks, but they all seem to have disappeared, practically overnight. With the onset of social distancing some weeks ago and the closure of schools in my area, it appears that all viruses, and not just COVID-19, have been on the decline. And this, it turns out, has been a boon for the health of children overall.

There are other factors at play, I assume, all related to adapting to the new ways in which we now live at home. Primary care and specialist physicians have universally set up easy and reliable telehealth modalities with most of their patients, being able to evaluate and prescribe from their homes. And parents seem much more willing to keep children at home for longer observation times, instead of rushing them into a hospital where they are at risk of being infected with COVID-19. The phrase, “give it a tincture of time,” is something that we say in the medical world in order to talk about waiting to see how a person’s symptoms progress before acting on them. And it appears that, for most healthy kids, whatever minor illness or injury they may have, it is most likely resolving in that tincture.

There are, however, a few very fragile populations of children that we are not yet seeing, that my colleagues and I worry deeply for. We wonder if our “COVID-19 tsunami” as people have analogized, will not actually be from children sick with the disease, but from the consequences that follow.

We are already starting to see reports of the unequal burden of fatalities from COVID-19 as they pertain to race and the social determinants of health. Although racial demographics have not yet been widely released (though there are legitimate calls to do so) in the few areas that we do have such data, we are seeing how black Americans are disproportionately affected by this pandemic. Leaders in the field of health equity have warned of this, pointing to the many studies which have repeatedly proven that black Americans suffer worse health outcomes as a result of long histories of racism, unequal care, and mistrust in failed systems.

Behind each of these fatalities are families dealing with the aftermath, and children who will suffer deeply from the loss of parents and grandparents, from unemployment and income loss, and from the loss of generational childcare. These populations of children, many of whom are already the furthest from health equity, will continue to see cycles of inequity play out over their lives, as determined by the many societal structures that determine their health. We would be wise to pay special attention to these disparities and direct resources toward them.

There is also an unseen population of children who are at significant risk—those who are the victims of physical or sexual abuse, trafficking or neglect. This is, in nonpandemic times, the most difficult population of kids to reach. With the combination of a severe economic downturn, housing and food insecurity, isolation at home, and children no longer having their extended support networks (teachers, friends, neighbors to check on them), we are likely facing historic levels of children who will be abused and neglected.

Although there will be a significant lag time before we can correlate this with numbers, anecdotally, from speaking with colleagues, this is already true. We know, from data following previous natural disasters as well as after the Great Recession of the mid-2000s, that children during crisis times are particularly vulnerable to abuse at the hands of their increasingly stressed caretakers. We have not yet been in a modern-day situation that combines both a global recession as well as an infection-born “natural disaster,” and, as a pediatrician, I fear for what this will mean for the youngest amongst us.

Although the relatively peaceful nature of my recent shifts in the ED feels like it should be a welcome respite, it is an uneasy one. It strikes me that the image of a tsunami is incorrect. We are in a cyclone of unknown proportions, though I fear it is as deep as it is long, and right now, we are sitting in the eye of it, just waiting for it to shift.