Hundreds of children in Indonesia are believed to have died from COVID-19, giving the Southeast Asian country one of the world's highest rates of child deaths from the novel coronavirus that experts around the world say poses little danger to the young.
Pediatricians and health officials in the world’s fourth most populous country said the high number of child deaths from a disease that mostly kills the elderly was due to underlying factors, in particular malnutrition, anemia and inadequate child health facilities.
"COVID-19 proves that we have to fight against malnutrition," Achmad Yurianto, a senior health ministry official, told Reuters.
He said Indonesian children were caught in a "devil’s circle", a cycle of malnutrition and anemia that increased their vulnerability to the coronavirus. He compared malnourished children to weak structures that "crumble after an earthquake".
Since Indonesia announced its first coronavirus case in March it has recorded 2,000 deaths, the highest in East Asia outside China.
A total of 715 people under 18 had contracted the coronavirus, while 28 had died, according to a health ministry document dated May 22 and reviewed by Reuters.
It also recorded more than 380 deaths among 7,152 children classified as "patients under monitoring", meaning people with severe coronavirus symptoms for which there is no other explanation but whose tests have not confirmed the infection.
Even the official figure for children who have died of the coronavirus, at 28 as of May 22, would give Indonesia a high rate of child death, at 2.1% of its total.
Different countries use different age brackets in statistics but deaths for those under 24 in the United States are a little over 0.1% of its fatalities.
In Brazil, the number of suspected COVID deaths under age 19 is 1.2%. In the Philippines, deaths of those under 19 are about 2.3% of its coronavirus toll.
Indonesia, a developing country of 270 million, suffers from a "triple burden of malnutrition,” which includes stunting, and anemia among mothers, and obesity, according to the United Nations Children’s Fund.
Nearly one in three Indonesian children under five is stunted, it says.
"The nutrition status impacts children's immunity," said Dr Nastiti Kaswandani, a pediatric pulmonologist in the capital, Jakarta.
"That's important in mitigating COVID infections."
Pediatricians said the ill-equipped healthcare system was also a problem.
"The biggest discrepancy in Indonesia is the availability of pediatric intensive care units," said Shela Putri Sundawa, a pediatric doctor in Jakarta.
The health ministry declined to provide data on care units for children and a senior official said the system had not been overwhelmed.
Equipment shortages are more pronounced outside the capital.
Paediatrician Dominicus Husada said a hospital he worked at on Madura island, in East Java, did not have ventilators for children. An 11-year-old died from the coronavirus there in March.
One father, Iyansyah, whose nine-month old boy died from COVID-19 on Lombok island, told Reuters the hospital did not have care units for children.
"Truthfully, if the hospital I went to had complete facilities, he'd probably have survived,” said Iyansyah.