LITTLE ROCK, Ark. - It had started on July 1 when she could no longer smell her uncle’s cologne.
Caia Alexx Morris, 13, had been sitting on the couch texting friends, and as other family members joked about the overpowering scent, it hit her that she had no idea what they were talking about. She had no other symptoms at the time. But two days later, she was diagnosed with covid-19 and on a ventilator, and has been in intensive care ever since.
"Thirty-four days," her mother Angela Morris reflected last week while at Caia's bedside at Arkansas Children's Hospital. 816 hours. 48,960 minutes. And counting. "This is a nightmare."
Outside Room No. 5 on the third floor, where Caia lay with a stuffed frog in one hand and a stuffed seal in the other, a crowd of doctors, nurses, respiratory therapists and other specialists buzzed around her and other sick children. The hospital had started the day with 23 covid patients, 10 in intensive care. Five of those were on ventilators and three were on heart-and-lung bypass machines of last resort. It wouldn't be long before more sick kids were on the way.
“You always have times when you cry,” Shonda Grappe, a pediatric intensive care nurse, said a few hours into her shift. “Everyone is feeling this.”
The hyper-contagious delta variant has changed much of what we thought we knew about the coronavirus and children - that kids might get infected, but they were extremely unlikely to become seriously ill. Today, as delta infections mount, some front line doctors suggest children are being hospitalized at higher rates and with more serious illnesses because of the new variant - a still-unproven hypothesis. What is indisputable is that in a swath of low-vaccination states stretching from Florida, South Carolina and Texas, up to Indiana and Missouri, the first large wave of pediatric cases is hitting hard - overwhelming hospitals, dominating political debates over mask and vaccine mandates and throwing school reopening plans into disarray.
Linda Young, a respiratory therapist at the hospital for nearly 37 years, said these latest children with covid appear to be progressing to respiratory distress much faster and in less predictable patterns: “I have never seen anything like this.” Even healthy children are being hospitalized, she said, something she had not seen in previous waves.
Amid the delta-fueled coronavirus surge, the American Academy of Pediatrics reported a nearly sevenfold increase in new child covid infections in one month: In the first week of July, there were 12,000 cases nationwide. By the first week of August, the number had grown to 96,000 - representing about 15% of all new infections.
As of Thursday, 1,785 children with suspected or confirmed covid-19 cases were hospitalized across the country, according to a Washington Post analysis. Florida leads the country in child hospitalizations - with 247 children with covid-19 admitted last week, a rate of 35 new admissions a day.
Doctors at major children's hospitals say nearly all of their patients are unvaccinated. They are either under age 12 and not yet eligible for the coronavirus shots, or teens who put off the vaccine.
While those numbers are still a fraction of adult hospitalizations - and children’s deaths remain rare - they represent the highest rate of new pediatric admissions of any point in the pandemic. And there is growing evidence that even mild or asymptomatic infections in children could lead to long-haul illness, just as in adults.
In a letter this week to acting Food and Drug Administration Commissioner Janet Woodcock, the pediatricians' group urged federal authorities to approve the shots for younger kids as soon as possible: "In our view, the rise of the delta variant changes the risk-benefit analysis."
Combined with a highly unusual spike in the number of children admitted with respiratory syncytial virus (RSV), a flu-like illness that usually strikes in the winter, and parainfluenza viruses - and in some cases, co-infections with covid-19 - many children's hospitals are overwhelmed.
"After many months of zero or few pediatric covid cases, we are seeing infants, children, and teens with covid pouring back into the hospital, more and more each day . . . I worry that we will run out of beds and staff," Heather Haq, a pediatrician for Texas Children's Hospital in Houston, tweeted recently.
Michael Smit, a pediatric infectious-disease expert at Children's Hospital Los Angeles, said he fears things may get even worse over the next few months with vaccines for 5- to 11-year-olds delayed until later in the year.
"We have months more to go," he warned. "We're in a real danger period between now and then."
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Most respiratory viruses like the flu hit the very old and the very young with equal vengeance. SARS-CoV-2 has always been different. There have been about 400 children in the United States who have died from the virus, compared with more than 600,000 adults - and we still haven't figured out exactly why.
The delta variant, which now represents about 97% of U.S. cases, seems almost like another virus than the one that spread from central China last year. Studies suggest it has a shorter incubation period - three to four days, instead of five to six - and that it may result in higher viral loads, which may explain its super transmissibility.
Whether it leads to more severe disease is a matter of intense debate. Doctors and nurses on the front lines report that infected children appear to be sicker than earlier in the pandemic. And several studies, including a report based on data from Scotland, suggested the variant doubles the risk of hospitalization regardless of a patient's age. But the evidence is still mostly anecdotal and some contend co-infections with other viruses, and the larger number of stricken kids may account for what doctors are seeing.
Mark Williams, dean of the College of Public Health at the University of Arkansas for Medical Sciences, said that even the first signs of illness look distinct - "more like a typical cold or pneumonia," than they did a year ago. These include a sore throat, for example, or runny nose, as opposed to a rash or stomach pains which doctors saw more of before.
"The delta variant is acting very, very differently with respect to kids," agreed Rick Barr, chief clinical officer at Arkansas Children's, who said the illness appears to have more of a respiratory impact.
At Barr's hospital last week, the pediatric intensive care unit was a frantic rush of activity. A boy who was admitted the night before had worsened and needed to be intubated. A new patient arrived to take the second-to-last open bed - a school-age girl with signs of MIS-C, the life-threatening inflammatory syndrome that often appears two to six weeks after a covid infection.
"It's exhausting and nonstop," said nurse Brittany Rowell. "These kids are the strongest people I've ever met."
Fortunately, Barr said, most children are recovering after being treated with the anti-viral drug remdesivir, steroids, respiratory support and blood thinners - the same protocols developed through trial and error on adults.
The picture of what's going on with children is muddy in part because the rising number of delta infections has coincided with a surge in other cold-like viruses as vacations, camps and swim teams resumed this summer, said James Versalovic, pathologist in chief at Texas Children's Hospital. He and other doctors said they are seeing more children co-infected with covid-19 and another virus, which may be making their cases worse.
He said about 10 percent of all children who test positive for the coronavirus and seek treatment at the health care system's network of 100 primary and urgent care centers or hospitals are being hospitalized.
"We don't have firm evidence that disease is more severe now than it was a year ago," he said. "But we do know it's different."
As a result of the uncertainty surrounding the delta variant, said Chris Beyrer, an epidemiologist at the Johns Hopkins Bloomberg School of Public Health, "people who have not been immunized, hesitant or reluctant, really now need to do a rethink."
As of July 7, according to the AAP, 6.4 million children had been fully vaccinated, representing 36% of 16- to 17-year-olds and nearly a quarter of 12- to 15-year-olds - with teens having the lowest rates among all eligible age groups.
"Delta has changed a lot of things," Beyrer said. "But what has not changed is that our best protection is immunization."
Outside Caia's window at Arkansas Children's to the north is a majestic view of the state capitol, where on Aug. 5, another child was slumped in his mother's arms.
Orion Bethel, age 10 - two years too young to get a vaccine - had traveled more than two hours from his home in Batesville, Ark., about 95 miles northwest of the state capital, to listen to grown-ups argue about the pandemic. Orion is desperate to join his peers in a real classroom and had signed up to testify about what that would take.
The rising fifth-grader, who is tiny for his age with blond hair with pink streaks, has a pulmonary disease, among other conditions, that requires daily treatment. "I have a lot of health problems," he explained to a reporter, "and I shouldn't go back without masks."
The special legislative hearing - during which about half of the lawmakers and audience members wore face coverings - had been convened at the urging of Arkansas Gov. Asa Hutchinson, R, who had signed into law a ban on mask mandates back in April.
Now, with the delta variant surging and hospitalizations hitting records in his state, Hutchinson called his support of the bill an "error." He was urging lawmakers to create an exception for schools, where millions of children are set to return in person this month.
For hours, emotional parents marched to the stage. One young mother accused lawmakers of being "irresponsible" for stripping layers of protection when children were getting sick in record numbers. But another questioned the evidence for the existence of the coronavirus as "Internet junk science."
Jared Beavers, a pediatrician and parent to two elementary schoolchildren too young for the vaccine, described how hospitals were so besieged that doctors "are triaging as much as we can" - and that is before school starts.
"Going back to school without the protections of a mask . . . I think it could lead to an absolute disaster," he said, adding, "deaths are not the only bad thing that we see in relation to this virus."
That message has been gaining traction in a state where many have flouted mask mandates, denied the pandemic exists and embraced debunked vaccine conspiracy theories. Arkansas has one of the lowest coronavirus vaccination rates in the country for both adults and children, making masking all the more important, according to public health experts and others who testified that day.
But those numbers have inched up in recent weeks as fears of the delta variant have grown. In Arkansas, 19% of children ages 12 to 17 have been fully vaccinated (much lower than the national average), up from 14.9% on July 21, with one-third having gotten at least one dose.
Orion never got the chance to speak that day. Lawmakers abruptly concluded the hearing, voting down the exception for the mask mandate ban. Afterward, he and his mother Kameron, a 39-year-old nurse, wandered the room trying to find anyone who would listen.
Arkansas state Rep. David Hillman, a Republican who represents District 13, smiled and leaned in maskless to hear Orion tell him about his respiratory disorder - he needs a ventilator-like machine to keep him breathing at night - and expressed sympathy when Orion lifted up his shirt to show the feeding tube in his stomach.
But Hillman was unwavering that masks should not be mandated. He said he felt the issue was about personal liberty: "I don't want kids to get sick. But if some kids don't need a mask, we shouldn't make them wear a mask."
Kameron said she was furious at the legislative vote and blamed it on politics. "This is so messed up," she said.
Later, the Little Rock mayor and school officials from several districts said they would institute mask mandates anyway. And that same week, an Arkansas judge temporarily blocked the state from enforcing the ban.
Sarah Wilson of Conway, Ark., got the notification late Sunday, July 18, that a child in her 15-year-old's youth group had tested positive for the coronavirus. By Wednesday, when she returned home from work, she found her usually energetic son, Sawyer, lying flat on his back in bed, instead of playing bass or video games.
“It hurts to move,” he complained. He had only a low-grade fever of 100 degrees and no other symptoms, but the next day, when she took him to the pediatrician, Sawyer’s blood oxygen levels were so low the staff immediately put him in an ambulance to Arkansas Children’s.
One of the first questions the doctors asked was about vaccines. It appeared he was infected just three days after receiving his first shot.
Sarah and her husband Jarrett, essential workers who set up shelters and warming stations for the homeless, had been vaccinated in March. But given that Sawyer wasn't going out much, and that clearance for children's shots had happened so quickly, they hadn't been in a huge hurry for their son. A survey released this week by the Kaiser Family Foundation found that half of American parents had made similar "wait-and-see" decisions for their kids because of concerns about possible side effects, such as the rare heart issue documented in some teens. Many of these same parents were inoculated themselves.
"Maybe the first one did do something to protect him a little. I'm not sure," Sarah said. "The medical staff - they were really wishing he had made it to the second shot."
At the hospital, Sawyer's breathing was touch-and-go - it would be fine for a while and then crash if he moved a certain way or went to sleep - and he was moved to intensive care. Sarah was terrified, and she wrote prayers and scripture passages all over his room.
“When you go through deep waters, I will be with you. When you go through rivers of difficulty, you will not drown. Isaiah 43:2”
"God - guide the hands of those who take care of Sawyer. Amen."
With Sawyer asleep most of the time, Sarah's thoughts drifted. She heard the governor invoke the number of covid patients at the children's hospital during a news conference, and "I remember thinking Sawyer was in that statistic." She recalled one night when the respiratory therapist had to run out of her son's room because "there was a baby crashing next door." She remembered waking up one morning with a start to find the number of children on ventilators had doubled.
Seven days after Sawyer was admitted, doctors told Sarah he was strong enough to go home. She said she knew he was feeling better when "he started shooting video for Instagram, saying, 'Boys, it's time to go home,' and taking pictures of the scars of all his IVs and bruising." Later, though, he turned uncharacteristically quiet.
"Just in asking him simple things like, 'How are you feeling?' he doesn't even want to acknowledge what happened," she explained. "He's not being rebellious. It was the scariest time."
Days later, as Sarah nursed Sawyer back to health at home, she got the news that she, her husband and her 10-year-old son Paxton had all tested positive for the coronavirus. For Jarrett, it felt like a sinus infection. Sarah threw up for days. Paxton had the worst of it with a fever, nausea, headaches and nonstop coughing.
"I worry there's nothing to protect him [since he was ineligible for a vaccine], so "his dad and I are in a scary place right now," Sarah said.
As Arkansas lawmakers debated mask mandates Aug. 5, the Wilson family followed along while quarantined at home and miserably sick. One of the breaking news updates that afternoon was about the state’s third pediatric coronavirus death - an 11-year-old girl from West Memphis near the Tennessee border.
Jordyn Franklin had been counting the days until the start of school. She was not just a good student but a great one, and picked up countless awards for the top grades in math (her favorite subject), science, spelling and numerous other subjects over the years. The rising sixth-grader from West Memphis loved rapper Megan Thee Stallion and singer Queen Naija, and aspired to be a judge one day.
On Friday, July 30, she seemed to have a sinus infection so her mother called the pediatrician’s office, which couldn’t see Jordyn until Monday. She didn’t eat much over the weekend and her family recalled “she wasn’t 100 percent,” but she also didn’t have obvious signs of being very ill.
But as they were getting ready to leave for the doctor's appointment, the 11-year-old slumped over on the couch and said she "felt like she was on fire," her aunt, Kirsten Clark, said. Jordyn's mother called 911, and an ambulance took her to the nearest hospital.
Clark waited outside the emergency room with Jordyn's 10-year-old brother Jaydon. She remembers only snippets of what the doctor told her when he came out to talk to them: "Could not get her stabilized on the ride . . . Ten minutes with no oxygen . . . Coded her three times . . . Did everything we could . . . Going to let the parents spend some last moments with her in there."
Clark said most of her family, including her own teenage son, had not been vaccinated even though they are conscientious mask wearers. She said she expected everyone would get the shots now.
"This is real," she said. "To people who just don't believe it, this is real. Jordyn always wanted to be famous - YouTubing famous, not this way."
On Friday night, one week to the day after Jordyn started feeling ill, family and friends held a vigil in her honor at Jackson-Wonder Elementary School, where she had spent so many happy years. The mayor came, the fire chief, too, and they brought a firetruck. The town released balloons into the air in her favorite color - purple, three of them with her initials.
Jordyn's mother, Caylenn Franklin, wailed into the night. "I did everything I could baby, I'm so sorry baby," she said. "I love you, I miss you."
Caia and her mother, Angela, had known no one who had gotten sick from the coronavirus in their little town of Sidney, Ark., population 179.
For a long time, it seemed as if the pandemic had skipped over them, except that Caia was in virtual school and passed the time drawing Japanese-style manga characters and writing poems. Besides, there were more practical concerns, such as making enough money to get by.
Caia's dad had died from non-Hodgkin's lymphoma when she was 1. That's how Caia and her mother came to be living with Angela's mom, her brother-in-law and his three children. There wasn't a lot of space, Angela says - she and Caia had to share a bed - but she was grateful for the support.
Angela had been working at a chicken farm where she picked eggs. She liked that she could work at her own pace, but at $6 an hour, it wasn't enough for them to have their own place.
In the hospital, Caia's condition deteriorated very quickly. While on the ventilator, she suffered kidney failure and was put on dialysis. At one point, she spiked a 106-degree fever, her blood pressure plummeted and the team treating her had to bring a crash cart.
In the middle of it all, Angela made a decision to get a coronavirus vaccine herself and posted a selfie on Facebook showing her rolled-up sleeve. The reaction was more emotional than she expected. Many strangers praised her bravery. But, she recounted, "all these evil people were saying I deserved to be on the ventilator. Some even called the hospital room."
She does not regret sharing the decision. "I just don't think any parent should be in my situation right now," she said. "I want people to get the vaccine."
On Friday, what seemed like a miracle happened - Caia squeezed Angela's hand. It was followed by coughs, a movement in her eyebrows and other signs she was aware of what was going on around her.
"Angela Morris is feeling blessed," she posted on Facebook.
"It's OK baby," Angela told Caia while holding her hand. "It's going to be OK."
By Sunday, doctors were able to take Caia off the ventilator, and she was finally breathing on her own. It was Day 37.
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The Washington Post’s Jacqueline Dupree, Julie Tate, Magda Jean-Louis, and Michael Williamson contributed to this report. Dupree, Tate and Jean-Louis reported from Washington. Williamson reported from West Memphis, Ark.