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A perfect storm of health issues could be facing children in the UK this winter.

While UK children went fully back to in-person schooling in 2021, after covid-19 lockdowns in 2020, the country is approaching its first winter in years where people of all ages can mix freely, with no restrictions, enforced isolation or official encouragement to work from home.

Covid-19 is usually mild in children. However, waning immunity combined with huddling indoors amid the cold weather means that rates of the infection are set to rise across all age groups.

And covid-19 isn’t the only infection that the UK is set to contend with. Rates of flu and respiratory syncytial virus (RSV) are also expected to soar, with children being both among the worst affected and the biggest drivers of viral transmission.

In addition, , mumps and rubella (MMR) has fallen in England.

The emotional toll of the pandemic on children may also be coming to light, while the UK’s cost-of-living crisis could already be affecting some children’s physical and mental health.

All things considered, children’s health may be a particular concern this winter, but how big an issue could it be?

According to at University College London, both children and adults will have lower immunity to seasonal flu this winter, compared with pre-pandemic immunity levels.

While children rarely become seriously ill with flu, . During the height of the pandemic’s restrictions, flu rates dropped dramatically as lockdowns limited social interaction.

In 2019, the year before the SARS-CoV-2 coronavirus arrived in the UK, . In 2021, when covid-19 restrictions were broadly in place, seven people aged 0 to 19 died from flu.

With covid-19 being more transmissible than flu, social distancing protected against both infections. “[Now,] children are mixing normally again,” says Bedford.

Australia’s winter flu season is usually a good indicator of how flu will play out in the UK, says Bedford. Pre-pandemic, flu cases would start rising in June in Australia. This year, , probably due to lower levels of immunity in the population.

In England, , compared with other age groups, at the end of October. Similarly, in early November. Figures aren’t available for the rest of the UK, and nor are figures for flu-related deaths in children.

at Alder Hey Children’s Hospital in Liverpool, UK, says he has seen an increase in the number of children with flu-related chest infections and pneumonia this autumn, compared with previous years. “We normally come across kids like this now and again, but more often than not these days, we’re referred a child with pneumonia that’s been quite complicated to resolve.”

RSV is another concern, says at Evelina London Children’s Hospital. Although usually mild, the virus is a leading cause of pneumonia in babies and can cause severe chest infections in children, especially among those with underlying health conditions.

“We’re expecting a big RSV wave,” says Absoud. As with flu, any immunity that children built up in pre-pandemic years will have declined amid the prolonged period of restrictions. By 2 years old, most children have usually caught RSV and therefore have some immunity.

According to Absoud, a key issue is that the surges in these seasonal infections will hit the National Health Service (NHS) at the same time, alongside measles, which is also a rising threat due to falling vaccination rates.

From the start of 2021 to September 2022, . This is down slightly from 86.6 per cent the previous year and consistently below the World Health Organization’s target of at least 95 per cent.

Although usually mild, measles can cause serious complications if it spreads to the lungs or brain. It is also . Each person with measles generally infects another 15 people, says Bedford.

Overall, covid-19 is less of a concern for children’s health than flu, RSV and measles, says Absoud. Rates of covid-19-related hospital admissions for children are relatively low throughout the UK. In the week ending 6 November, .

“The risk is not zero, but we’re more worried about flu and RSV,” says Absoud.

The UK’s cost-of-living crisis is also expected to affect children’s health this winter, says Sinha.

The high cost of energy may discourage people from heating their homes, leading to damp, says Sinha. Damp exposure is linked to a higher risk of developing asthma and having asthma attacks.

Cold and damp homes are also more likely to have mould, which can cause fungal infections. “If a child with a compromised immune system is living in a house surrounded by fungal spores, that can lead to chest infections,” says Sinha.

The financial worries that many families are facing may affect some children’s mental health, too.

“Children are hugely affected by the health and well-being and functioning of the adults in their lives,” says Elaine Lockhart at the Royal College of Psychiatrists, UK. “Parents may be struggling with their own mental health or may be stressed about having to work more hours. It becomes a really vicious cycle.”

The mental health impact of the pandemic and its aftermath on children may also be becoming more apparent.

NHS Digital figures show that from July 2021 to July 2022, – an 11 per cent increase on the previous year. While other factors could be at play, many people at least partly blame the pandemic.

Speaking anecdotally, Lockhart says that since the pandemic began, she has seen an increase in the severity of mental health issues that some children are experiencing. Those with less urgent symptoms may therefore have to wait longer for treatment. Conditions such as mild anxiety and mild depression can often be eased relatively quickly if a person is treated early, says Lockhart.

“Child mental health colleagues are completely stretched,” says Absoud.

All the heightened issues that children in the UK may face this winter will probably be exacerbated if they come from a deprived socioeconomic background. These children may live in crowded housing, which could raise their risk of respiratory infections, says Sinha. They may also be more affected by the cost-of-living crisis, both physically and mentally, says Absoud.

“I’ve been in the NHS 22 years,” he says. “Never have I seen social inequalities impact health so visibly on the ground.”