Coronavirus COVID 19

Coronavirus COVID 19 infection 7.7.20 update
 
Q&A on COVID-19:  We began communicating to our Senders Pediatrics community about COVID-19 on 2/28/20 and all of the email updates can be found on our website at www.senderspediatrics.com.  We have heard from many of you that you have greatly appreciated our efforts to curate the many hundreds of weekly articles about COVID 19 in both the medical and popular press and present a nuanced approach that takes into consideration both personal and communal needs.  Early on, we realized the importance of sourcing our material and many of our updates include references to dozens of articles to which interested readers can turn for additional information.  What we have most appreciated are the personal questions that have come via the care@senderspediatrics.com inbox.  These reflect real life issues that need answers if we are to not just survive, but thrive as families, as school parents and as members of society.  As we begin our 5th month of email updates, we have decided to step back from the scientific articles for a week and update our guidance in a Q&A format. These questions and answers will serve as the basis for a COVID FAQ section in our new website set to launch in the next 2 weeks. 

Launching a new website:  Many months in the planning (and delayed somewhat by the COVID-19 outbreak), we are excited to be this close to launching a whole new approach to communication with our patients and their families.  New features of this website include:

  1. A mobile app:  This app will allow you to call or text us directly from your phone as well as access the features of our website in an easy to read mobile format
  2. Hundreds of pages of new educational content:  One of the features of this website is its direct feed from the American Academy of Pediatrics (AAP) on hundreds of clinical and behavioral care topics.  The AAP updates its guidance regularly and this will allow our patients to have access to the latest info on almost everything pediatric.
  3. A section on “Whats going around”:  This is your one stop shopping address for what is happening to kids in the local world of health.  If hand foot and mouth disease or slap cheek disease or poison ivy is becoming a significant issue, we will flag it for you and provide you with guidance on what to do at home. It will allow rapid dissemination of information on a host of fast moving topics in the world of pediatric health care that will complement our current Facebook presence.
  4. A dosing schedule for common medications
  5. A well child care schedule and what we provide at each well child visit
  6. A link to our unique WCC videos geared to children between 3-11 years that provides preparation for what to expect at a well child visit.
  7. A link to our patient portal that will provide you with the ability to download visit notes, labs and other tests.  This portal will go live in early fall. 
  8. Separate websites for our subsidiaries:   Senders Research has had a separate website linked to our own for over 20 years.  Breastfeeding Medicine of Northeast Ohio has had a separate website linked to our own for over 10 years.  This new launch will include separate websites for Behavioral Health and Parenting.  In addition, we are gearing up for the launch of a new Family Weight Management Program later this year and we have developed a website to begin to provide guidance and education on this important new health initiative.

Illness Questions
Q:  What are the symptoms associated with COVID-19?
A:  The CDC does not have an official cluster of symptoms associated with COVID-19 disease, relying heavily on clinical judgement by experienced providers to define “suspected COVID-19 cases”.  Based on our 4 months of experience and a review of the listings by the CDC and Boards of Health from many states (Link to Decision Tree for People with COVID-19 Symptoms in Youth, Student, and Childcare Programs)

We consider symptoms of suspected COVID-19 cases to include:

  1. New onset cough or shortness of breath alone
  2. Otherwise unexplained loss of smell or taste alone
  3. Or 2 of the following: 
    1. Fever of 100.4 or higher
    2. Chills
    3. Muscle pain
    4. Sore throat
    5. GI symptoms (nausea, vomiting or diarrhea). 

A runny nose alone is not currently considered a concern.  There also is no “official” distinction between symptom clusters in younger children and those found in older children.

Q:  What is the difference between “isolation” and “quarantine?”
A:   As we enter a period where the Cuyahoga County Board of Health (BOH) becomes more heavily engaged in our lives by investigating positive cases and doing contact tracing to reduce spread, it is important to understand public health terminology.    

  1. A person who is considered infectious must go into “isolation” for 10 days from the onset of symptoms or from the test date for asymptomatic positives
  2. A close contact of that infectious case must go into “quarantine” for 14 days from the time of that contact to monitor for symptoms

Q:  When can a child return to day care or camp after having suspected COVID-19 symptoms?
A:  We have put together a decision tree in consultation with the BOH to determine “isolation” periods for potentially infectious individuals and “quarantine” periods for their contacts.  According to this tree, a child may return to day care or camp (and eventually school) when: 

  1. They had a NEGATIVE PCR test
    1. AND there has been no fever for 72 hours without acetaminophen (Tylenol) or ibuprofen (Motrin)
    2. AND other symptoms are improving
    3. AND there is another explanation for their illness (strep, GI virus etc)
    4. AND they have not been exposed to someone with a positive PCR test
  2. They had a NEGATIVE PCR test
    1. AND there has been no fever for 72 hours without fever reducers
    2. AND other symptoms are improving
    3. AND there is NO other explanation for their illness
    4. AND they have not been exposed to someone with a positive PCR test
  3. They had a NEGATIVE PCR test
    1. AND there has been no fever for 72 hours without fever reducers
    2. AND other symptoms are improving
    3. AND there is NO other explanation for their illness
    4. BUT they have been have had “close contact” with someone with a positive PCR test – Close contact is defined as being within a confined space with an infectious individual within 6 feet for 15 minutes or more without an N95 mask or a face shield.  The CDC does not consider a cloth mask as adequate protection for the purposes of contact protection.
    5. AND 10 days have elapsed since the onset of symptoms
    6. AND 14 days have elapsed since close contact
  4. They DID NOT HAVE A PCR test (the BOH considers these “probable cases”)
    1. AND there has been no fever for 72 hours without fever reducers
    2. AND other symptoms are improving
    3. BUT they had “close contact” with someone with a positive PCR test
    4. AND 10 days have elapsed since the onset of symptoms
  5. They DID NOT HAVE A PCR test (the BOH considers these likely negative cases)
    1. AND there has been no fever for 72 hours without fever reducers
    2. AND other symptoms are improving
    3. AND they have not had “close contact” with someone with a positive PCR test
  6. They had a POSITIVE PCR test
    1. AND there has been no fever for 72 hours without fever reducers
    2. AND other symptoms are improving
    3. AND 10 days have elapsed since the onset of symptoms

Q:  How long are positive cases expected to be most infectious?
A:  The BOH considers cases to be most infectious from 2 days before symptom onset to 5 days after.  For individuals who have had close daily contact with a symptomatic individual who later has a positive PCR, day zero of quarantine for the contact is counted as day 5 of symptoms for the infectious case
How do I get my child tested for COVID?  Those patients older than 18 years who need or want testing can be tested at local pharmacies but turnaround time for results vary.  For this week, the only options available for our patients under 18 years are the following:   

  1. Symptomatic patients:  Patients whom we see in our Acute Care Clinic and whom we believe have a high possibility of being COVID PCR Positive will be referred to the University Hospitals COVID testing program and be told where to go for testing.  There is no additional visit necessary for this test.  Results are returned in approximately 48 hours
  2. Asymptomatic patients who NEED a test because of camp or school:  Will not need to be seen in our Acute Care Clinic.  We will refer them directly to the University Hospitals COVID testing program and be told where to go for testing.  Results are returned in approximately 48 hours
  3. Asymptomatic patients who WANT a test because of travel to visit a high risk relative:  Unfortunately, we do not currently have a vehicle for testing such patients anywhere in Cleveland at this time.  We will continue to pursue options as we know this is a very important issue for many of our patients.  We hope to have more information next week. 

The ultimate solution is coming this fall which is rapid COVID-19 testing.  We have purchased the Abbott ID Now rapid molecular test for COVID-19 which gives reliable results in 15 minutes.  While this test WILL NOT BE AVAILABLE to us or nationwide until the fall (October or November) it will ultimately allow us to do rapid strep, rapid flu, rapid RSV and rapid COVID.   This will enable children to get back to school assuming they have some of the COVID-19 associated symptoms but do not have a history of exposure to patients with known COVID-19 disease (#1 and 2 above)

Camp Questions
Q:  Is it safe to participate in a day camp? 
A:  The state requirements for day camps are very clear. Click here.  The goal is to allow kids who, in general, are at low risk for developing COVID-19 disease, to have as normal a summer as possible.  We believe it is safe to send your kids to a camp that meets these criteria. 

  1. There must be 1 staff member for every 9 school age children and no more than 9 children in a room
  2. Cloth masks should be worn by all staff personnel.  In outdoor camps, it is not necessary for the children to wear masks.
  3. There must be daily temperature and symptom assessments either at home or in the camp
  4. Children should cohort together meaning that one group of 9 should not mix with the other group of 9
  5. There should be extensive hand washing and sanitizing of toys and equipment

Q:  What about backyard camps?
A:  The same rules apply for backyard camps.  In general, backyard camps are run by high school students and it is important that a parent of such a “camp director” should be responsible to insure that safety rules are maintained.
 
Visiting grandparents questions
Q:  I have a newborn.  Is it okay for the grandparents to see or touch my baby?
A:  Babies are at low risk for COVID-19 disease and are, therefore, at low risk for transmitting the disease to their grandparents.  It is the parents who are the issue.  If the parents of the newborn have been physical distancing and so have the grandparents, it should be fine for the grandparents to become a part of the family’s COVID community.  Seeing and holding the baby under these circumstances should be fine.  Many OBs are recommending that parents quarantine for 14 days after discharge before seeing the grandparents for fear of transmitting any disease that was picked up inadvertently in the hospital.  .  We are concerned about making families overly concerned about picking up COVID-19 disease in the hospital.  Hospital exposures on the post-partum floor are rare.  We have noted a 50% increase in breastfeeding difficulties who are discharged early.  We believe the issue of quarantining should be handled on a case by case basis and we are happy to discuss this further with you when we see your child.
Q:  I have elderly parents without other risk factors or not so elderly parents who are at high risk.  Can I visit them?
A:  This is a much more challenging issue.  We believe these issues are also best handled in a case by case basis.  Please direct your questions to care@senderspediatrics.com.
 
Mask and shield questions
Q:  Why are facial coverings necessary?
A:  Because presymptomatic or asymptomatic spread is not well understood as yet (click here), it is important that even perfectly healthy individuals protect their contacts by wearing a facial covering.  The City of Cleveland has mandated facial coverings in public places.  We recommend that everyone wear a facial covering when entering an indoor space such a store, business, church, synagogue, gym etc. 
Q:  Is there a preferred form of facial covering?
A:  The State of Ohio recommends face coverings.  Unfortunately, there is little data on the mechanism of the protection afforded by either masks or shields in COVID disease. 

  1. Dr Michael Edmond, Chief Medical Officer and Professor of Infectious Diseases at the University of Iowa has written an excellent review piece on the medical benefits of face shields focusing specifically on their 96% protection rating in studies of influenza transmission, their ease of cleaning with hand sanitizer or soap and water, their ability to prevent the user from touching his/her face, their protection against transmission through the eyes and their allowance of visibility of facial expressions and lip movements for communication and speech perception.  Click here.
  2. Moreover, face masks reduce oxygen levels by 13.5% and increase carbon dioxide levels by 17.5% and the long term effects of oxygen deprivation and CO2 increase are unknown.
  3. The Children’s Hospital of Philadelphia suggest using face shields for teachers and students as an alternative to masks and many local school districts have followed suit.  On the other hand, the CDC continues to prefer face masks. 
  4. Because COVID-19 is spread primarily by droplets and face shields protect both the wearer and the person with whom he/she is speaking while most face masks protect the other person but not the wearer (unless it is an N95 mask), we support the gradual shift from face masks to face shields.  See the 6.24.20 update for more information on this subject. 

Q:  Do we need to wear face masks or face shields outdoors?
A:  It is not necessary to wear a mask or a shield outdoors.  However, it is recommended that masks or shields be worn indoors.  We have made exceptions for what we call COVID communities which include more extended families or small numbers of families who agree to reduce outside exposures and who therefore become essentially part of the nuclear family.  
 
Travel Questions 
Q:  Where is it safe to travel internationally this summer?
A:  Many countries are still not allowing Americans in.  The EU has a travel ban on visitors from the US.  The Canadian border is closed except for family members but requires a strictly enforced 14 day quarantine before visiting relatives.  Hefty fines and potential jail time are in store for violators.  The United Kingdom is less restrictive on entry but also has a strictly enforced 14 day quarantine period.  For a country by country guide including restrictions, testing requirements and in some cases, hefty “health” down payments, click here.
Q:  What about domestic travel?
A:  Because of increases in COVID 19 activity in a number of locales (some because of testing and some because of increased activity), it is important to check with local health authorities before planning a trip.  A neat tool to check on outbreaks is COVID-19 Watcher which culls data from multiple sources and reports on a county, city and state level.  Click here.  In most cases, a 14 day quarantine means checking into a hotel, a private home or an AirBNB for 14 days before travelling. 

  1. Hawaii:  Requires a 14 day quarantine period for all out-of-state visitors
  2. Florida:  Visitors from NY, NJ and CT are subject to a 14 day quarantine
  3. New York, New Jersey and Conn:  Visitors from AL,AR,AZ,CA,FL,GA,IA,ID,LA,MS,NC,NV,SC, TN,TX,UT are subject to a 14 day quarantine
  4. Alaska and Maine:  Proof a negative COVID PCR test can bypass the quarantine
  5. Vermont:  Proof of a negative COVID PCR test need only 7 days of quarantine
  6. Massachusetts:  Exempts visitors from RI,CT,VT,ME,NH,NY, NJ from any quarantine

Q:  What about road trips?  Do any states have COVID 19 checkpoints?
A:   The AAA has produced a nice guide for roadside restrictions.  Click here.

  1. Florida:  Has a checkpoint on Interstate 95 just south of the Georgia border where it screens visitors from NY,NJ, CT and requires a 14 day quarantine
  2. New Mexico:  Has a checkpoint on US 64 leading in and out of Taos Pueblo, NM which is closed indefinitely to non residents

Q:  Are hotels safe?
A:  Many hotels never closed as they were deemed essential businesses but housed only COVID-19 workers.  Now most are open for leisure travelers.  The larger chains including Hilton (click here) and Marriott have overhauled their standard housekeeping practices (click here) and these operating procedures have become standard across the industry
Q:  What should you do when you arrive at a hotel? 
A:  The CDC recommends sanitizing all high touch surfaces including tables, doorknobs, light switches, counters, desks, remote control devices, phones, toilets and sink faucets.  It is not necessary to bring your own towels and sheets
Q:  How can you keep safe along the way?
A:  At gas stations, wear gloves to pump the gas or use hand sanitizer immediately afterwards.  Public restrooms at gas stations are likely to be the safest according to the AAA.  Use hand sanitizer after touching surfaces and cover the toilet seat with toilet paper or with disposable toilet seat covers.  Purchase food from restaurants that have workers in masks.  Dispose of containers and sanitize your hands before eating. 
Q:  What about airplane travel?
A:   Airplane travel has become safer

  1. The problem with air travel is not the airplane air.  Virtually all domestic flights are equipped with HEPA filters similar to those in hospital operating rooms that block more than 99% of particles.  Cabin air is circulated from ceiling to floor and refreshed every 2-3 minutes.  Between flights, airplane cabins are scrubbed down carefully.  It is always advisable to bring sanitizer or wipes to wipe down the tray, the side rails and the seatbelt clasps. 
  2. Airports have become cleaner as well.  Hand sanitizers are all over and many airports have made kiosk screens, bathroom faucets/soap dispensers and restaurant menus hands free
  3. Airport security lines may take longer.  TSA officers wear masks and gloves.  TSA has granted an exception to the rules on liquid for hand sanitizer allowing up to 12 ounce bottles instead of the usual 3.4 ounce limit.  Be on notice that if you have a prohibited item or forgot to take your laptop off, you may have to go through the line again so that the TSA agent doesn’t have to rifle through your belongings
  4. Masks are necessary for all flights with no exceptions so bring as many as you need.  Many airlines will allow face shields on the flight but not on line to get on the plane.  United, American, Delta and JetBlue have said that passengers who refuse to wear a mask after frequent requests by flight attendants could be barred from booking future flights
  5. Physical distancing on the plane itself is very airline dependent:  For airline by airline information, click here
  6. Expect a travel credit not a refund if you cancel:  The terms differ airline by airline

Q:  What about rental cars?
A:  All national brands do extra cleaning.  Sanitize the wheel and any parts of the dashboard that you expect to use to be extra careful. 
Q:  When will it be safe to book a cruise?
A:  While most cruise lines have temporarily suspended voyages worldwide until September 15, 2020, we believe that it will not be safe to travel on a cruise until a vaccine is readily available for everyone (including children) which is not likely to occur until late 2021. 
 
Mental health questions
Q:  How can one reduce anxiety and effectively parent during the COVID 19 pandemic?
A:  We have offered many suggestions over the past 4 months.  We review here some of the best recommendations.

  1. Engage in activities that enhance the relaxing chemicals of serotonin, oxytocin, dopamine and endorphins.  Here is a new resource for getting your share of these 4 critical relaxing chemicals https://www.bananatreelog.com/worksheets (How to Get You Daily DOSE of Happiness Infographic)                                                     
  2. Find ways to breathe more effectively
    1. Extend breaths and increase nose breathing from Breath:  The New Science of a Lost Art by James Nestor.  Click here.
    2. Shape breathing:  Here is a great resource for teaching the concept of shape breathing to children. Click here.
  3. Engage in progressive muscle relaxation:  Here is a great script for helping children go through the exercise of progressive muscle relaxation and here is a helpful YouTube cartoon video that teaches kids the importance of this exercise and a visual “how to”.
  4. Indulge the clinginess:  Click here.
  5. Exercise your prefrontal cortex:  Our prefrontal cortex is responsible for calming down the fight or flight reaction controlled by our limbic system.  Here is an excellent resource for exercising your prefrontal cortex. Click here.
  6. Be kind to yourself:  Click here.
  7. Get enough sleep:  These excellent scientific reviews shows the value of getting adequate sleep (defined as 7-8 hours of sleep for the average adult, 10-11 hours for a 10 year old, 9-10 for a 12 year old, and 8-10 for a 14 year old.) Read more here and here
  8. Look to move from survival to acceptance to growth and meaning:  
    1. Understand the 3 stages of dealing with a pandemic.  Click here.
    2. Look to find meaning in all the stress.  Click here
  9. Follow Play Therapist Gary Landreth’s 6 rules of thumb:  Click here.

A child’s “meltdown” is usually less about a messy ice cream cone than it is about overwhelming feelings that are being expressed with “out-of-control” behavior.  Children carry an image of how they think the world should work. When another person or situation fails to meet this expectation, children become easily upset because a situation is not unfolding the way they thought it should. Their immaturity and limited life experience makes it more difficult for them to manage life’s disappointments.

Providing support to a child in the midst of an emotional outburst is challenging for most parents. Children’s upsets and misbehaviors often trigger adults to respond with anger and irritation – energy that fails to teach children self-regulation skills. Because children learn more from what their parents do than from what they say, adult composure is a prerequisite skill for children’s self-regulation. Parents who are aware of their own thoughts and feelings can maintain a sense of calm and well-being, even when their children are upset. Adult composure teaches children how to navigate unpleasant feelings and provides them with a healthy model to emulate.

Attending to a child’s upset can be likened to a firefighter trying to put out a fire. If the firefighter brings gasoline to the scene, the fire can grow out of control. If the firefighter uses water, the fire can be extinguished. Children’s emotional outbursts work in a similar manner. If parents respond to their children’s upset with anger, the situation usually worsens. Conversely, when parents respond to children’s upsets with composure, they inhibit the upset from getting bigger and also model the state they want their child to attain.  Adult composure is self-control in action and requires “pressing pause” in order to respond rather than react to a given situation. The suggestions below help to support adult composure:

  • Become self-aware
    • Take ownership of your feelings by acknowledging your upset intellectually without reacting to it emotionally
  • Become consciously aware of your thoughts and feelings
    • Thoughts create feelings – when you change your thoughts you change your experience
  • Identify  triggers that provoke strong reactions
    • Create a plan of response in anticipation of being triggered – do a dress rehearsal when your brain is calm and relaxed so you can more easily access your plan during a challenging situation
  • See your child as struggling to handle something difficult, rather than label him/her as mean, lazy, or manipulative
    • The way you choose to perceive a situation will dictate your level of upset or composure
  • Resist catastrophizing
    • Do not allow temporary chaos to become life-defining moments
  • Avoid blaming others
    • When you place someone in charge of your emotions you give your power away by placing that person in charge of you
  • De-personalize your child’s behavior
    • Think of your child’s behavior as happening in front of you, instead of to you
  • Use positive self-talk
    • “I can handle this – this is not about me!”
  • Implement stress reduction activities and regular self-care
    • Think of deep breathing exercises as your portable stress reduction system

Parent Coaching & Class Options for You: 

1. We are continuing to offer free 10 minute phone-based, one topic coaching sessions per patient family with parent coach, Joan Morgenstern.  This is ideal for families struggling with a particular COVID-19 related problem that lends itself to gentle guidance. 

2. For more complicated parenting problems:  25 minute or 50 minute one-on-one individual coaching sessions via Zoom.  (Reduced fee to support families during the pandemic.)

3. Potty Mastery Class:  Joan’s popular class geared to parents of 20-30 month olds is now available online via Zoom with the next class scheduled for Tuesday, July 14th from 6:30-8:00pm. This class is designed to help parents turn lemons into lemonade and achieve Potty Mastery while sheltering at home. (Fee: $25 for one parent/$40 for two)

All coaching services and classes can be scheduled by calling the office (216-291-9210). The fee will be charged at the time of the scheduling. 

Print your for My COVID-19 Memories – Journal Entry #6 – click here.

Coronavirus COVID 19 infection 6.30.20 update

More on PCR testing for COVID-19:  The most challenging aspect of dealing with a pandemic is to constantly evolve as the disease evolves.  Almost every day, we are forced to improvise.

  1. Our testing program for our patients with symptoms suggestive of COVID-19 disease as well as for our asymptomatic patients who need testing to enable them to go to camp or school was forced to quickly evolve just yesterday.  We had developed a relationship with Quest Diagnostics to provide test results within 3 days.  But when the governor required all personnel at nursing home and state developmental centers to be tested beginning today, our symptomatic and asymptomatic patients were bumped to the bottom of the barrel increasing testing time to 5-8 days which is clearly not helpful to anyone. 
  2. Fortunately, we were able to coordinate with another system to provide PCR testing results with a more reasonable turnaround time.  We are working out the details this week and hope to have an organized plan to present to you in next week’s email update.  Please bear with us.  No other primary care practice is providing this service but we believe that having a robust testing program is crucial to helping parents navigate the nuances of sports, visits to relatives and participation in camps.  While facts on the ground change almost daily we are willing to accept a few hiccups to move forward on a testing program and will communicate with you as best as possible as things change.
  3. Remember, for symptomatic patients, most insurance plans are likely to cover all fees.  For asymptomatic patients, there will continue to be a $50 fee for coordinating and counseling. 

    The new normal:  Almost every day, we hear of a local business establishment, restaurant or sporting league that has to confront COVID-19 positives in one of their employees, patrons or family members.  Much of the information that is being disseminated has not been cleared with the Cuyahoga County Board of Health (BOH) leading to miscommunications, increased fear and wasted resources.  In the event that you hear from someone in a position of authority in any establishment that you or your child must be tested for COVID-19, we ask that you send an email to care@senderspedatrics.com and let us help you sort things out.  This past weekend, our answering service fielded over 50 calls from worried parents after being notified that they and their children needed emergency testing after a parent of a Little League player had tested positive for COVID-19.  No exposure should ever require an immediate test and most exposures never require any testing.  Give us the time to investigate the situation and allow us to serve as your conduit to the BOH to come up with the correct plan to deal with the problem.  We are in touch with public health officials at the BOH almost daily (and on weekends as well) and if we don’t know the answer, we can get it for you from the public health officials who know the most about containment of the virus.  The goal will always be to keep people safe while we try to keep things as normal as we can for our children.

    Our COVID-19 vaccine trial will be beginning in the next 2 weeks:  We are honored to be the only site in Cleveland conducting a clinical trial of this formulation of an mRNA vaccine.  mRNA vaccines are an entirely new category of vaccines designed to turn on each individual person’s genetic code to produce immune protection against the spike protein of the COVID molecule or its place of attachment.  Because it is not a foreign protein being injected into the body, it is hoped that side effects will be much lower than with other vaccines.   In the over 200 clinical trials in which we have participated to date, we have never seen things move so efficiently.  While “fast” often translates to “mistakes”, the A team that has been put together by this sponsor to move this vaccine from the drawing board to reality while keeping safety paramount is truly inspirational.  We will be enrolling patients from 18-45 years (note that we have increased the age range to 45 years) for this placebo controlled (50% get the real vaccine and 50% get sugar water) trial.  We are focusing our efforts on getting ready to enroll and if you have reached out to us and not heard back, rest assured that we will be getting back to you in the next two weeks to provide you with more details and ascertain your interest in participating.  For more information about this trial, contact us at study@senderspediatrics.com.  Again, to enable us to provide great customer service, PLEASE DO NOT CONTACT OUR OFFICE FOR INFORMATION ABOUT THIS STUDY.  We will contact everyone who contacts us.  Thank you in advance.  

    Getting kids back to school:  The American Academy of Pediatrics has recently provided guidelines for how this coming school year might look.  We are quoting sections in their entirety to insure that the tone comes across clearly without editorializing.  For more information especially with regards to specific guidelines for different age groups, click here.  We are aware that all school districts are in the process of finalizing their plans which will likely incorporate many of the suggestions below.  We encourage parents to be part of the process to ensure that their children get the best education possible in the safest possible way. 

  1. The goals: 
    1. The AAP strongly advocates that all policy considerations for the coming school year should start with a goal of having students physically present in school. (AAP emphasis) The importance of in-person learning is well-documented, and there is already evidence of the negative impacts on children because of school closures in the spring of 2020. 
    2. Lengthy time away from school and associated interruption of supportive services often results in social isolation, making it difficult for schools to identify and address important learning deficits as well as child and adolescent physical or sexual abuse, substance use, depression, and suicidal ideation. This, in turn, places children and adolescents at considerable risk of morbidity and, in some cases, mortality.
    3. Beyond the educational impact and social impact of school closures, there has been substantial impact on food security and physical activity for children and families.
  2. Role of children in transmission of COVID disease:
    1. Policy makers must also consider the mounting evidence regarding COVID-19 in children and adolescents, including the role they may play in transmission of the infection. SARS-CoV-2 appears to behave differently in children and adolescents than other common respiratory viruses, such as influenza, on which much of the current guidance regarding school closures is based.
    2. Although children and adolescents play a major role in amplifying influenza outbreaks, to date, this does not appear to be the case with SARS-CoV-2. Although many questions remain, the preponderance of evidence indicates that children and adolescents are less likely to be symptomatic and less likely to have severe disease resulting from SARS-CoV-2 infection.
    3. In addition, children may be less likely to become infected and to spread infection. Policies to mitigate the spread of COVID-19 within schools must be balanced with the known harms to children, adolescents, families, and the community by keeping children at home.
  3. Mitigating but not eliminating risk:
    1. Finally, policy makers should acknowledge that COVID -19 policies are intended to mitigate, not eliminate, risk. No single action or set of actions will completely eliminate the risk of SARS-CoV-2 transmission, but implementation of several coordinated interventions can greatly reduce that risk
  4. Physical distancing:
    1. Physical distancing, sometimes referred to as social distancing, is simply the act of keeping people separated with the goal of limiting spread of contagion between individuals. It is fundamental to lowering the risk of spread of SARS-CoV-2, as the primary mode of transmission is through respiratory droplets by persons in close proximity.
    2. There is a conflict between optimal academic and social/emotional learning in schools and strict adherence to current physical distancing guidelines. For example, the Centers for Disease Control and Prevention (CDC) recommends that schools “space seating/desks at least 6 feet apart when feasible.”
    3. In many school settings, 6 feet between students is not feasible without limiting the number of students. Evidence suggests that spacing as close as 3 feet may approach the benefits of 6 feet of space, particularly if students are wearing face coverings and are asymptomatic.
    4. Schools should weigh the benefits of strict adherence to a 6 feet spacing rule between students with the potential downside if remote learning is the only alternative. Strict adherence to a specific size of student groups (e.g, 10 per classroom, 15 per classroom, etc) should be discouraged in favor of other risk mitigation strategies.
    5. Given what is known about transmission dynamics, adults and adult staff within schools should attempt to maintain a distance of 6 feet from other persons as much as possible, particularly around other adult staff.
    6. For all of the below settings, physical distancing by and among adults is strongly recommended, and meetings and curriculum planning should take place virtually if possible. In addition, other strategies to increase adult-adult physical distance in time and space should be implemented, such as staggered drop-offs and pickups, and drop-offs and pickups outside when weather allows.
    7. Parents should, in general, be discouraged from entering the school building.
    8. Physical barriers, such as plexiglass, should be considered in reception areas and employee workspaces where the environment does not accommodate physical distancing, and congregating in shared spaces, such as staff lounge areas, should be discouraged.
  5. Physical Distancing in Specific Enclosed Spaces
    1. Bussing:
      1. Encourage alternative modes of transportation for students who have other options.
      2. Ideally, for students riding the bus, symptom screening would be performed prior to being dropped off at the bus. Having bus drivers or monitors perform these screenings is problematic, as they may face a situation in which a student screens positive yet the parent has left, and the driver would be faced with leaving the student alone or allowing the student on the bus.
      3. Assigned seating; if possible, assign seats by cohort (same students sit together each day).
      4. Tape marks showing students where to sit.
      5. When a 6-foot distance cannot be maintained between students, face coverings should be worn.
      6. Drivers should be a minimum of 6 feet from students; driver must wear face covering; consider physical barrier for driver (e.g, plexiglass)
      7. Minimize number of people on the bus at one time within reason.
      8. Adults who do not need to be on the bus should not be on the bus.
      9. Have windows open if weather allows.
    2. Hallways
      1. Consider creating one-way hallways to reduce close contact.
      2. Place physical guides, such as tape, on floors or sidewalks to create one-way routes.
      3. Where feasible, keep students in the classroom and rotate teachers instead.
      4. Stagger class periods by cohorts for movement between classrooms if students must move between classrooms to limit the number of students in the hallway when changing classrooms.
      5. Assign lockers by cohort or eliminate lockers altogether
    3. Playgrounds
      1. Enforcing physical distancing in an outside playground is difficult and may not be the most effective method of risk mitigation.
      2. Emphasis should be placed on cohorting students and limiting the size of groups participating in playground time.
      3. Outdoor transmission of virus is known to be much lower than indoor transmission
    4. Meals/Cafeteria
      1. School meals play an important part in addressing food security for children and adolescents. Decisions about how to serve meals must take into account the fact that in many communities there may be more students eligible for free and reduced meals than prior to the pandemic.
      2. Consider having students cohorted, potentially in their classrooms, especially if students remain in their classroom throughout the day.
      3. Create separate lunch periods to minimize the number of students in the cafeteria at one time.
      4. Utilize additional spaces for lunch/break times.
      5. Utilize outdoor spaces when possible.
      6. Create an environment that is as safe as possible from exposure to food allergens.
      7. Wash hands or use hand sanitizer before and after eating.
  6. Behavioral Health/Emotional Support for Children and Adolescents
    1. Schools should anticipate and be prepared to address a wide range of mental health needs of children and staff when schools reopen. Preparation for infection control is vital and admittedly complex during an evolving pandemic. But the emotional impact of the pandemic, financial/employment concerns, social isolation, and growing concerns about systemic racial inequity — coupled with prolonged limited access to critical school-based mental health services and the support and assistance of school professionals — demands careful attention and planning as well. Schools should be prepared to adopt an approach for mental health support
    2. Schools should consider providing training to classroom teachers and other educators on how to talk to and support children during and after the COVID-19 pandemic. Students requiring mental health support should be referred to school mental health professionals.
    3. Suicide is the second leading cause of death among adolescents or youth 10 to 24 years of age in the United States. In the event distance learning is needed, schools should develop mechanisms to evaluate youth remotely if concerns are voiced by educators or family members and should be establishing policies, including referral mechanisms for students believed to be in need of in-person evaluation, even before schools reopen.
    4. School mental health professionals should be involved in shaping messages to students and families about the response to the pandemic. Fear-based messages widely used to encourage strict physical distancing may cause problems when schools reopen, because the risk of exposure to COVID-19 may be mitigated but not eliminated.
    5. When schools do reopen, plans should already be in place for outreach to students who do not return, given the high likelihood of separation anxiety and agoraphobia in students.
    6. Students may have difficulty with the social and emotional aspects of transitioning back into the school setting, especially given the unfamiliarity with the changed school environment and experience.
    7. Special considerations are warranted for students with pre-existing anxiety, depression, and other mental health conditions; children with a prior history of trauma or loss; and students in early education who may be particularly sensitive to disruptions in routine and caregivers.
    8. Students facing other challenges, such as poverty, food insecurity, and homelessness, and those subjected to ongoing racial inequities may benefit from additional support and assistance.
    9. Schools need to incorporate academic accommodations and supports for all students who may still be having difficulty concentrating or learning new information because of stress associated with the pandemic.
    10. It is important that schools do not anticipate or attempt to catch up for lost academic time through accelerating curriculum delivery at a time when students and educators may find it difficult to even return to baseline rates. These expectations should be communicated to educators, students, and family members so that school does not become a source of further distress.

Thinking out of the box on UVC lighting: The biggest challenge we face as we open schools, businesses, restaurants and religious institutions is how to reduce viral spread indoors.  While universal adoption of increased handwashing, disinfection of surfaces and physical distancing can help, these methods may not decrease COVID-19 transmission in small indoor spaces such as bathrooms, classrooms, public transport vehicles and smaller offices.  This will become a much greater issue a few months from now when we are all forced indoors by inclement weather (remember we do live in Northeast Ohio).  While we have discussed this previously, a new article expands on the potential possibilities for UVC treatment to inactivate viruses such as COVID-19 that are emitted in indoor environments and become airborne or are deposited on surfaces. Click here

  1. Many of you are aware that when we installed a new HVAC system in our building, it came equipped with UVC light treatment of our air that circulates 12x per minute.  We feel fortunate that in addition to facial coverings, this state of the art system provides an additional layer of protection to all of our patients. 
  2. A few comments on why UVC is so valuable.  Most people are aware of UVA and UVB, the two most commonly known forms of ultraviolet light spectra because we have been protecting against them for many decades in the various sunscreen products that have lined our shelves and our swim bags. 
  3. What is less known is that UVC light has been used for sterilization of air and surfaces for over a century.  It works because the spectrum of light lies just at the edge of the UV/water transparency window where water in virus contained droplets is transparent enough to allow UVC light into the droplet and allow for inactivation of the virus.  
  4. A study of the MERS animal coronavirus showed almost 100% inactivation of animal coronaviruses with a 5-10 minute exposure.  The problem is that UVC can produce eye damage and is carcinogenic when exposed to human skin for any length of time.  The solution is to place UVC light sources in places where there is no direct exposure to human eyes or skin. 
  5. We are reporting on these options in an effort to spur decision makers to think of quick implementation strategies to help protect us over the next 2 years when COVID-19 is still likely to be a significant part of our lives.  
  6. The study estimates that an investment of a few billion dollars worldwide could help protect upwards of a billion office workers, students and businesses.   
  7. In addition, UVC disinfection could be the long term solution to getting children back to school and permanently reduce transmission of all disease (think strep, RSV, croup, influenza etc).  The challenge will be to figure out ways to use UVC treatment options in a safe and secure manner.  The devil will be in the details. 
  8. Suggested implementation options:
    1. Hiding UVC elements in duct work or in HVAC systems and using fans to circulate potentially contaminated air through those elements (which is what we have in our building)
    2. Placing UVC units in bathrooms, elevators and office pantries which have a high turnover of people but which are used only intermittently and having them cycle on when there is no one in the room to guarantee a virus free environment when the new user enters.  The same approach could be used in public transportation with periodic cycles at the end of a route when everyone has disembarked
    3. Frequently touched surfaces such as elevator buttons, handles and handrails could have a hidden UVC source aimed at them so that they are constantly disinfected

Nanotechnology to help reduce the spread of COVID-19:  Nanomaterials are single structures that are smaller than 100 nanometers in any dimension.  They have increasingly been used in healthcare applications such as sanitizers, wound dressing, antimicrobial drugs, vaccine development and drug delivery.  Click here. Nanomaterials have been shown to inactivate both RNA and DNA viruses which make them particularly useful in prevention and treatment of COVID-19 and influenza, both of which are RNA viruses.  We are bringing you this information because it is likely that you will be hearing more about the uses of nanomaterials in the future.  The potential is huge for help in managing this pandemic.  Some useful applications include:

  1. Personal protective equipment (PPE):  Fibers embedded with metallic nanoparticles such as copper and silver can prevent viral spread.
  2. Surface coatings:  Nanomaterials can be embedded in paint or coating for medical instruments, gloves, doorknobs and handrails.
  3. Sanitizers:  Disinfectants with silver salts are already available as silver is safe for sanitizing purposes.
  4. Air filters:  Embedding nanoparticles in air filters can potentially disinfect the air while filtering it at the same time.
  5. Preventing secondary infections:  Many COVID 19 patients suffer from invasion by bacteria made possible by the inflammatory effects of the COVID-19 virus.  These so-called bacterial biofilms can be destroyed by nanoparticles.

Pre-participation guidance during the COVID-19 pandemic:  The resumption of sports and exercise will ultimately bring athletes in closer proximity to one another than the recommended 6 foot physical distancing, potentially increasing one’s risk of infection.  There is some evidence that high-intensity exercise may increase aerosolization and droplet dispersal in mildly symptomatic individuals.  Click here.  While children and young adults are generally considered at lower risk of contracting COVID-19 disease and suffering more serious complications, which is one of the reasons that the Ohio High School Athletic Association (OHSAA) is sanctioning school sports programs, Ohio High School Athletic Association there are certain categories of athletes who might be at higher risk.  A recent article looked at how to identify such participants.  Click here.

  1. Diabetics:  Diabetics have a 4x greater risk of severe complications from COVID-19, click here and should be probably be counseled to delay sports return until sports reintegration is deemed safe
  2. Severe asthmatics:  Asthma affects up to 8.4% of the population from 0-17 years but the CDC maintains that those with mild, well-controlled asthma are not at risk for poor outcomes.  Patients with exercise induced asthma are also not at higher risk for developing complications from COVID-19.  Patients with severe asthma who are well controlled can participate but if they experience asthma complications, should be counseled to drop out of sports participation until they are in better control.
  3. Sickle cell disease and beta thalassemia:  The CDC considers these two diseases as higher risk for developing complications of COVID-19.  Sickle cell trait is not a risk factor.  However, patients with sickle cell trait who do develop the disease should be monitored closely to ensure that they maintain adequate hydration.
  4. Hypertension:  This condition is not considered an independent risk factor for COVID-19.  However, patients with uncontrolled hypertension should be restricted from sports participation until they are controlled.   
  5. Obesity:  Younger patients with BMIs >30 and especially >35, particularly those with a higher percentage of body fat are at much higher risk of complications from COVID-19 and also should be counseled to take a wait and see attitude before engaging in close-in sports activities.  Click here.

Virtual Summer Institute featuring in-house therapist Laurel Greene Kaiser: 

  1. Join the Bellefaire Social Advocates for Youth (SAY) program  and Laurel Greene Kaiser, LISW-S for an energizing and interactive online workshop for teens on building your own resilience
  2. Resilience is the foundation for personal success, it is what helps us navigate and bounce back from any challenge in our life, whether that challenge is big or small. This workshop will help you get to know yourself better and how your strengths can help you navigate any fear, stressor, difficulty, or set back.
  3. This workshop will give you the opportunity to not only find out how resilient you are now, but ways you can increase your own resilience no matter where you’re starting from. Come to just listen or share, sharing will be optional. 

Register @  https://www.eventbrite.com/e/109834736654

Parenting Tips & Takeaways

“I scream, you scream, we all scream for ice cream!” With summer in full swing, what better time to cool off and enjoy some delicious ice cream. Did you know that July 1st is National Creative Ice Cream Day? As the name suggests, this special holiday is an opportunity to ditch conventional flavors, like chocolate, vanilla and strawberry, for something completely different. It’s also an opportunity to appreciate many favorite delicious ice cream flavors while innovating and adding new creations to the list.
“COOL” facts about ice cream:

  • One single serve ice cream cone can be finished within 50 licks
  • United States is the world’s largest producer of ice cream
  • 90% of American households eat ice cream
  • The first ice cream cone was created during the 1904 World’s Fair in St. Louis
  • 12 gallons of milk can produce 1 gallon of ice cream
  • Chocolate chip cookie dough ice cream made its debut in 1991
  • California is the country’s top ice cream producer
  • Chocolate ice cream came before vanilla ice cream
  • There’s a Hawaiian fruit, the inga feuillei, that tastes exactly like vanilla ice cream, but the locals call it ice cream bean.

Consider these different ways to celebrate National Ice Cream Day:

  • Purchase a flavor of ice cream you’ve never tried before
  • Purchase an assortment of different ice cream flavors and create your own unique flavor
  • Patronize one of our amazing Cleveland ice cream shops
  • Participate in Senders Pediatrics National Ice Cream Day Challenge described below:

Here’s the scoop… At Senders Pediatrics we believe that anything that has to do with ice cream is worth celebrating. Therefore, in honor of National Creative Ice Cream Day, we hope you will use your imagination and create your own unique ice cream flavor. Then, complete the entry form found here so you can be entered into our raffle to win a $20 gift card to Mitchell’s Ice Cream. Four winners will be selected – so don’t let this “sweet” opportunity pass you by.

Parent Coaching & Class Options for You: 

1. We are continuing to offer free 10 minute phone-based, one topic coaching sessions per patient family with parent coach, Joan Morgenstern.  This is ideal for families struggling with a particular COVID-19 related problem that lends itself to gentle guidance. 

2. For more complicated parenting problems:  25 minute or 50 minute one-on-one individual coaching sessions via Zoom.  (Reduced fee to support families during the pandemic.)

3. Potty Mastery Class:  Joan’s popular class geared to parents of 20-30 month olds is now available online via Zoom with the next class scheduled for Tuesday, July 14th from 6:30-8:00pm. This class is designed to help parents turn lemons into lemonade and achieve Potty Mastery while sheltering at home. (Fee: $25 for one parent/$40 for two)

All coaching services and classes can be scheduled by calling the office (216-291-9210). The fee will be charged at the time of the scheduling. 

Click here for My COVID-19 Memories – Journal Entry #5

Coronavirus COVID 19 infection 6.24.20 update

COVID 19 vaccine research is coming to Senders Pediatrics in the month of July:  We have been site selected to conduct late phase 2 and phase 3 trials on one of the exciting new vaccines being developed to protect against COVID 19.  The trial will be conducted in patients 18-85 years but we will be enrolling subjects only from ages 18-40 years which includes our patients, their family members and other interested parties.  If you have an interest in hearing more about this vaccine opportunity, please send an email to study@senderspediatrics.com.  We will be contacting you with more details over the next two weeks for potential enrollment in mid-July.  PLEASE DO NOT CALL THE OFFICE.  Although we recognize there may be great interest, details are still being finalized and our Patient Service Representatives do not have additional information to share. It is critical that we ensure that are phones are available for scheduling and advice calls.  

We continue week 2 of PCR testing for the following situations:

  1. Symptomatic patients who are seen in our Acute Care Clinic – these patients are not scheduled for testing, but are scheduled for their illness; the provider will evaluate each patient and determine whether testing is appropriate
  2. Asymptomatic patients interested in attending camps and schools that require testing prior to entry.  A reminder to not leave for camp or school until the results are known just in case the test turns up as asymptomatic positive
  3. Patients and their parents who are interested in visiting grandparents or relatives who are immunocompromised
  4. Patients and their parents who have been exposed to someone who tested positive within the past 14 days if the health department will not be doing contact testing

For all asymptomatic testing, there is a fee of $50 for the service and there may be an additional fee of up to $99 dollar charged by Quest for the lab test.  For symptomatic patients, these fees are likely to be a covered insurance benefit.  For asymptomatic patients, the fees are not likely to be covered. 

Drug overdose deaths are up significantly since the onset of the COVID 19 pandemic:  Nationwide, during the months of March, April and May, fatal drug overdoses are up 11.4% and nonfatal drug overdoses are up 18.6% over the similar period in 2019.  ODMAP report  The data is sobering and reflects the need to identify teenagers and young adults at risk, to connect with them, to reduce their isolation and loneliness and to provide them with services.  If you have such an at-risk child or young adult or you personally are looking for help, please use us as your go-to resource to help.

How is COVID 19 spread – by droplets or by aerosols

  1. Droplets versus aerosol (droplet nuclei) spread:   (Warning:  This discussion contains graphic descriptions of the spread of disease.  If such a description will prevent you from living in the world, skip this section please!) Infected people spread viral particles whenever they talk, breathe, cough or sneeze.  These viral particles are covered by globs of mucus, saliva and water.  Bigger globs fall faster and splash down as droplets.  Smaller globs termed ‘droplet nuclei’ (which are thought to be < 5 microns) evaporate faster in the form of aerosols, linger in the air and drift further away than droplets. (The reason for the 5 micron cutoff is that is the size of a viral particle that has the potential to reach the most minute lung cells called alveoli.)  While one might posit that aerosol spread may pose a greater risk for the spread of viral disease (because of the potential to linger in the air for a longer time), studies of viruses known to spread by aerosol find that not to be true because of dilution and inactivation of viruses that linger for extended periods of time in the air.  Click here.
  2. Much is known about the droplet versus aerosol spread of other respiratory infections including influenza, measles and TB.  Click here.  Not as much is known for sure about COVID 19.    
  3. The WHO approach:  Early on, the World Health Organization (WHO) took the position that COVID 19 is spread only by droplets and not by aerosols. Click here. This droplet theory has been the source for the 6 foot physical distancing rule that has been in place since March. 
  4. Evidence for aerosol or droplet nuclei spread:  However, since that time there has been a lot of research on the potential spread of COVID 19 by aerosols or droplet nuclei. 
    1. There is some evidence that some larger droplets can evaporate into droplet nuclei before hitting the ground and become aerosolized.  Click here.
    2. There is also research that suggest that while most particles between 5-100 microns fall to the ground or to surfaces, some can remain aerosolized depending on clearance by the ventilation system.  Click here.
    3. British researchers recently used computer simulations to approximate the number of droplets < 100 microns produced by typical coughs and speaking events.  On average each cough and speaking event produces the same number of droplets.  A symptomatic patient (4 coughs and 10 speaking events/hour) produces an average of 16.9 droplets < 100 microns/hr or 676 per 40 hour work week.  An asymptomatic patient (10 speaking events/hour) produces 8.3 droplets/hr or 332 per 40 hour work week. Click here
    4. But these lab simulated studies do not take into account environmental factors such as temperature, humidity (and in our office, the presence of UVC treatment of the air).  Click here
    5. So while studies of computer simulations of disease spread suggest potential for COVID 19 spread by aerosols or droplet nuclei, the predominant method of spread is still thought to be large droplet spread.  That explains the continued focus on physical distancing and hand washing protocols. 

A review of face masks

  1. Masking has reduced disease spread:  An analysis of the rates of COVID 19 infection in the US found that the mandated use of masks issued by 15 states and the District of Columbia in April and May was associated with a modest decline of 1% in the number of cases in the first week after implementation and 2% after 3 weeks.  Click here.  This study did not distinguish between the types of masks worn.
  2. How effective are different kinds of masks:  In a 2008 study that looked at test volunteers and an artificial test head, outward mask protection (protecting the environment from the mask wearer) and inward mask protection (protecting the wearer from the environment) were evaluated.  Surgical masks provided 2x the protection of homemade masks while N95 masks provided 50x the protection of homemade masks and 25x the protection of surgical masks.  The protection was 80% less for children.  Click here.
  3. Improvements in masking technology:  Mask technology has improved significantly over the past decade.  In a study that we have reviewed previously, click here, researchers at the University of Illinois found that the blocking efficiency of an 85% polyester/15% nylon used dishcloth gave the same 95% protection as an N95 mask but was twice as breathable.
  4. Some of the best homemade masks:  Researchers at the University of Chicago found that a mask made from a 600 thread per inch (TPI) sheet and one that carried an electrostatic charge such as silk and chiffon (90% polyester and 10% Spandex) blocked large size droplets at a rate of 99.2% and small size droplet nuclei at a rate of 97% which is equivalent to or better than a properly fitted N95 mask.  The problem is that a single hole or leak around the fabric could reduce filtration by 50% or more.  Click here.
  5. How to reduce air leakage from a mask:  Pulling an 8-10 inch tube of nylon cut from a queen size nylon stocking over a standard surgical mask onto the neck converted that mask effectively into an N95 mask.  Click here.
  6. How to clean a cloth mask:  The CDC has some great recommendations and diagrams to effectively clean your mask.  Click here.
  7. Potential buildup of carbon dioxide from a mask: In 2015, Singapore researchers found that N95 masks can reduce oxygen intake 13.8% and increase carbon dioxide consumption by 17.7%.  This can cause dizziness and lightheadedness and worn long enough can potentially damage cause damage to the lungs.  Click here.  The study was done to look specifically at the implications for pregnant health care workers.  However, given that the masking restrictions in our world are likely to last a year or more, there may be some long term issues for people with underlying respiratory issues who are masking regularly.  This is not an invitation to unmask.  However, it may make the shift to a shield more palatable for some including for older school-aged children. (see below).

A review of face shields 

  1. Protection from face shields:  At a distance of 18 inches from a coughing simulator, face shields were shown to reduce viral exposure by 96% in a 2014 influenza study. Given that the mode of spread of influenza is similar to that of COVID 19, it is likely to be similarly protective.  Click here.
  2. Eye protection from face shields:  In a meta-analysis (which combines data from multiple studies to analyze common effects) of 172 studies in healthcare and non-healthcare settings adding eye protection (which is achieved with a face shield) to face masks reduced infection by 78%.  Click here.
  3. Advantages of face shields:  Face shields help wearers to avoid touching their faces, allow for easier communication (because you can see the entire face) and are more easily cleaned with soap and water or hand sanitizer and are reusable. Click here.  They also are not associated with oxygen deprivation or carbon dioxide increases.
  4. Face shields aid people who depend on lip reading.  They allow facial expressions and lip movements to remain visible while serving as an obvious reminder to maintain physical distancing.  Click here.
  5. Face shield protection against aerosolization:  While face shields are only 68% effective in protecting against droplet nuclei or aerosolization in studies using cough simulators, in the real world, in patients wearing shields, viral collection between 5-30 minutes after a cough was only increased by 10% suggesting that most respiratory infections occur immediately after a cough or speaking episode.  Click here.
  6. Community use of face shields:  Dr Michael Edmond, Chief Quality Officer at University of Iowa Hospitals says, “For general life, I just wear a shield”.  While the CDC has not yet commented on face shields, he believes that with wide usage, it is a better option for community containment.  Click here.
  7. Face shields may help in return to school programs:  Recently, the Children’s Hospital of Philadelphia released its recommendations for returning to school.  Click here.  Included in their extensive review is the suggestion that teachers wear face shields.  We strongly endorse this position for teachers.  And for students, while they are certainly not perfect, and have not yet officially been endorsed by the CDC, face shields provide children from lower school on up, the ability to breathe, the ability to see their friends, a real lack of facial touching and a constant reminder to reduce physical interactions.  Couple that with ease of cleaning once a day and this may be one of the ways to facilitate the learning process for our children.
  8. Some highly rated face shields: 
    1. https://www.amazon.com/Shield-Protective-Protect-Adjustable-Comfort/dp/B0869HP2QB
    2. https://www.amazon.com/Transparent-Breathable-Windproof-Dustproof-Protective/dp/B086WFYC1B (currently unavailable but wait a day or two)
    3. https://www.amazon.com/All-Round-Protection-Lightweight-Transparent-Adjustable/dp/B0865JGRFH
    4. Don’t forget that there is a clear film on each face shield that should be removed before usage.

Summer is officially here.  Although most of us will not be enjoying the summer we planned for six months ago, the warmer months ahead can be filled with different, unanticipated pleasures.

We have been adjusting to the loss of the lifestyle we had before COVID 19.  But imagine approaching these changes from a place of curiosity. Curiosity allows us to embrace unfamiliar circumstances with a sense of interest and intrigue, and is a part of us from infancy through adulthood.  Also imagine feeling peaceful with life the way it is. When we are at peace, we are engaged with life while feeling relaxed, calm and safe.  Sometimes things turn out better than expected, especially when we don’t allow our expectations to get in the way of reality.  Expectations are beliefs centered on the future and result in pre-determined outcomes. When our expectations don’t match our reality we can become stressed, angered or disappointed.

Replacing fixed expectations with an open mindset enables us to remain curious to new possibilities. When what is happening is not what you expected, an open mindset can help you find positives in what you have.

Many of us have heard the saying “attitude is everything.” Attitude is an all-encompassing term that defines one’s outlook and approach to life and includes one’s inner thoughts and outward expression. The remarkable thing is that we each choose our attitude; it does not choose us.  It’s born from free choice and it’s always within our control. As we approach the days ahead, keep in mind the following:

  1. Attitude is a choice – choose yours wisely
  2. Expectations won’t always get met –  stay flexible
  3. Positivity makes a difference – be open-minded
  4. Things will  look different – remain curious
  5. Acceptance is key – allow rather than resist

As the summer unfolds, stay present, playful and positive – who knows what hidden treasures may await you! Attached you’ll find the story, “Who Knows? The Farmer’s Son: Fortune or Misfortune?” This story illustrates that the nature of any event, “good” or “bad,’ is only relative to the changing circumstances and conditions surrounding it.

Read story here.

Click here for My COVID-19 Memories – Journal Entry #4

Coronavirus COVID 19 infection 6.16.20 update

The value of creating a COVID community: 

  1. In his address at his son’s high-school graduation, former Supreme Court justice, Antonin Scalia warned his audience to ignore the platitudes commonly spouted at commencement addresses that “we live in unprecedented times.”  The statement is dangerous he said because it leads us to conclude that the past has no wisdom to offer us as we face our current challenging situations. 
  2. In the past few months, we too, have been told that we live in unprecedented times.  But students of infectious disease know that many previous pandemics (including the many medieval plagues and the 1918 Spanish flu) killed far more people with far more devastation to society and the economy.  Our goal should not be one of despair but of hope. 
  3. Modern commentator, Meir Soloveitchik writes there are a lot of lessons that can be learned from previous world experiences with pandemics.  One of the most helpful ones comes from Sir Isaac Newton.  It is a well-known fact that Newton discovered the rules of calculus while in quarantine from the plague.  But what is less well known is that he also discovered a radical new conceptualization of gravity.  A student described this aha moment in the following manner:  “In the year he retired again from Cambridge on account of the plague….and whilst he was musing in a garden, it came into his thought that the same power of gravity (which made an apple fall from the tree to the ground) was not limited to a certain distance from the earth but must extend much farther than was usually thought.  Why not as high as the Moon…and if so, that must influence her motion and perhaps retain her in her orbit.” 
  4. Says Soloveitchik, in quarantine, Newton conceived of a gravitational bond that could span heaven and earth.  Our job during this quarantine is to identify a spiritual bond that binds us to others and that creates a unique community of individuals all pulling together toward a common goal. 
  5. This is particularly hard in our modern American society where we are never alone but we are often so very lonely.  Just think about the Starbucks experience.  In his book, From the Ground Up, longtime CEO, Howard Schultz notes that focus groups hired by the company found that people go to Starbucks stores because of the social feeling.  They like the espirit de corps of being in a place where you never feel alone.  And yet, “fewer than 10% of the people they (the focus groups) observed in the stores at any given time actually talked to anyone”.  Most people waited silently in line and interacted only with the barista. 
  6. People today have more “friends” but are experiencing loneliness like never before (see below).  The solution is to create a covenantal community, a community of like-minded individuals bound by common goals and aspirations, one that pulls together especially when times are tough. 
  7. We are trying hard to create that special type of community here at Senders Pediatrics by collecting a group of individuals dedicated to nourishing you both physically and medically as well as emotionally and spiritually.  It is a hard slog especially since there are so many forces in our larger society that seem intent on tearing us apart as a community by emphasizing our differences.  Newton was right.  There is a gravitational pull that transcends us as individuals and successful communities understand that pull.  We don’t always get it right but we always keep on trying.  So remember, in the days, weeks and months ahead, there will be times when you may be alone in quarantine but our goal is that you should never feel lonely.   

More scientific data on why children continue to be less affected by COVID 19:  Despite local reporting to the contrary, children continue to have a significant lower incidence of COVID 19 disease than adults. The increased availability of acute PCR testing will likely also increase the total number of positives in children just as it has in adults but the percentage of positives in children overall has remained remarkably stable over the past few months at 5-6%.  In past updates, we have described  many medical explanations for this phenomenon focusing primarily on differences in the immune status of children.  This week, Turkish critical care physicians provide additional physiological differences to account for the lower illness rate and improved recovery in children. Click here.

  1. It is thought that COVID-19 attacks the body by attaching to the angiotensin converting enzyme type 2 (ACE2) receptor on a particular type of lung cell called Type 2 alveoli.  Infants have only 3 million alveoli while adults have over 500 million. Fewer type 2 alveoli may predispose children to less immune damage from COVID 19.
  2. Ina addition, because they have fewer alveoli, alveolar ventilation is greater per alveolus in children than in adults which may lead to increased clearance of COVID virus.
  3. The ventilation of alveoli is facilitates by bypass pathways called Pores of Kohn which functions as a type of collateral ventilation.  This serves as an EZ pass lane for the spread of disease.  Infants and young children have none of these collateral ventilation pathways.

Our PCR testing program for acute disease (active infection) begins today:  While there are many labs and pharmacies that are enabling acute testing for COVID 19, most involve self-swabbing and poor reporting and none are testing patients under the age of 18.  As your Patient Centered Medical Home, we have searched for a way to insure accurate testing and reporting for patients with acute illness that should be tested in our Acute Care Clinic, for patients who need testing to enable them to participate in camps and schools, and for patients who are concerned due to exposure or desire to visit a vulnerable family member.  We are excited to be able to partner with Quest, a national lab, to provide PCR testing for both groups beginning today.  A few details:

  1. Patients with acute illness suspicious for COVID 19 :  We will continue to see these patients in our Acute Care Clinic, swab as necessary and treat as appropriate.  Results will come back to us within 1-3 days.  Patients who test positive will need to quarantine at home for 10 days and the Cuyahoga County Board of Health will connect with the family to do contact tracing to identify individuals with whom the affected patient has been in contact in the previous 48 hours.  These visits will continue to be submitted to insurance companies for reimbursement.
  2. Patients who need PCR testing for camp or school:  We will also see these patients in our Acute Care Clinic but because they are well, we will only do the swab and send it to Quest for PCR testing.  Results will also come back within 1-3 days and will be reported to the Board of Health. Positives will be treated as in #1 above.  There is a $50 fee for processing these specimens and providing guidance as necessary and Quest will bill for up to $99 for the test itself.  This service is not reimbursed by any insurance company. 

Why we need to protect and connect with our elderly? 

  1. As the COVID 19 pandemic has evolved, it has become increasingly evident that the group at greatest risk are the elderly.  A majority of the over 115,000 Americans who have died have been over 65 years and very early in the pandemic, as it became clear that children had mild or no disease and their parents also had mild or no disease, the focus turned to isolation and protection of the elderly age group.   All of our shelter in place rules, the wearing of masks and the physical distancing have been designed to help protect our elderly from community contacts and caregivers who might be harboring the disease and might accidentally spread it to them.  There is almost universal agreement about the purpose for protecting our vulnerable elderly population.
  2. There are abundant religious and moral explanations that have been offered over the centuries for the special place that the elderly hold in almost all societies.  However, a special issue of the Philosophical Transaction of the Royal Society entitled Life History and Learning is devoted to looking at some of the purely practical implications of supporting and maintaining a vibrant elderly population.  Specifically it seeks the answer to two simple questions.  How did we evolve as a species to be so vulnerable for such long percentage of our lives?  And why do strong, able humans in the prime of life spend so much of their time caring for those who are no longer as productive?  After studying more than 20,000 interactions across 40 different societies, the answers they uncovered may help us find our way forward in the evolving response to COVID 19.  
  3. Says Alison Gopnik, editor of the special issue, “Humans have always been “extractive foragers”, using complicated techniques like hunting and fishing that let us find extra calories in almost any environment.  Our big brains make this possible but we need culture and teaching to allow us to develop complex skills over many generations.”  Older people have a special place in that process.  Why? Because it is hard to practice a skill and teach it to someone else at the same time, the best evolutionary strategy for developing many complex skills is to have the elderly teach the young.  In their extensive studies across many cultures, there was a consistent pattern of prime of life performers concentrating on being productive while their parents taught their children.  According to this approach, there is a very evolutionary sound reason to protect our vulnerable parents and children at either end of life.  It allows all humans to flourish. 
  4. Concludes Ms. Gopnick, “Perhaps after the pandemic, we will appreciate better the profound connection between brilliant, fragile young learners and wise, vulnerable old teachers and bring the grandchildren and grandparents back together again.” 
  5. I have watched this process in vivid color over the past few weeks.  As my elderly father almost died of loneliness, it was his grandchildren who brought him back to life by showing up and giving him a reason to live.  “I now know that I need to keep going to be able to teach my grandchildren and great grandchildren” he said just the other day.  We are obligated to protect our elderly relatives and friends from accidental exposure but we have to figure out ways to connect them in person with their children and grandchildren.  Life is too fragile and they cannot wait a year or more for a vaccine.  Let’s take advantage of the nice weather to plan visits where we physically distance while socially interact.  It will take some creativity and we are happy to help you figure out your specific details.  But if the report cited above is correct, the success of our society hangs on our ability to navigate this issue with safety and sensitivity.   

Factors associated with depression, anxiety and PTSD in young adults during the COVID 19 pandemic:  As there is almost no data on the effect of a pandemic on the mental health of so- called millennials (18-30 year olds), the CARES (COVID 19 Adult Resilience Experience Study) was launched to track the health and well-being of this age group in the US across multiple time points in 2020-21. Click here.

  1. This prospective study reports on the first wave of data collection on 898 subjects from April 13 to May 19, 2020, during the period of most shelter in place requirements and prior to the lifting of any restrictions. 
  2. The initial study group came from New England but later waves will include data from the Midwest, South and West. 
  3. Respondents completed a 30 minute online survey that looked at COVID 19 related experiences, risk and resilience and physical and mental health outcomes.  81% were female/19% were male, 60% were white/40% were minorities, 61% were students and 81% made less than $50,000.
  4. 43.3% of study respondents had clinically elevated levels of depression, 45.4 elevated levels of anxiety and 31.8% elevated levels of PTSD. 
  5. 61.5% had high levels of loneliness, 28% with low resilience and 25.9% with significant distress tolerance (the ability to manage and tolerate emotional distress). 
  6. High loneliness and high distress tolerance were strongly correlated with high levels of depression, anxiety and PTSD. 
  7. Emotional support from family but not from friends was associated with lower levels of depression, anxiety and PTSD perhaps because friends may be perceived as having less capacity to validate another’s emotional experiences while they are having those same experiences themselves.
  8. This is the first prospective study to look at the mental health of our millennial population and the results are not reassuring.  The take home lessons seem to be the following:
    1. Millennials are a vulnerable group and their mental health needs need to be appreciated
    2. Family matters.  Friends are helpful but family makes a bigger difference.  So even if you have not been close to your college and beyond age child, now is the time to repair relationships and provide support.  They need it
    3. Keep us in the loop.  We can help by acknowledging and putting a label on the problem. 
    4. Building resilience and distress tolerance appear to be critical in reducing levels of anxiety, depression and PTSD.  This is often difficult to achieve independently so let us help by providing referrals to mental health professionals equipped to handle these problems.
  9. This is also the first report on the validity of using a COVID 19 worry scale that consists of the following 6 items measured from 1-5 (with 1 meaning not worried at all and 5 meaning very worried):  having enough groceries during lockdowns and distancing protocols, obtaining a COVID 19 test if I get sick, getting treated for COVID 19 if I contract it, keeping in touch with loved ones during distancing protocols, maintaining employment during the subsequent economic downturn and having enough money to pay for rent and buy basic necessities.  A score above 24 indicated high worry.  10.1% scored above 24 in this first wave study.  Take the test yourself to see where you stand and use it as a basis for comparison as time goes on.  For info about another COVID 19 anxiety scale developed in India, click here.

And finally, the effect of parental anxiety on childhood anxiety: 

  1. Demographic data on generalized anxiety disorder, anxiety in children, coping mechanisms and overall health was collected on 2200 self-selected volunteers in the United Arab Emirates.  Click here.
  2. Participants were predominately female (82.8%) and in the 25-44 age range (61.7).  50% had a bachelors degree and 61.3% were employed.  71.8% reported anxiety and 38% reported that it was of moderate to severe nature.  The highest percentage who reported anxiety in their children (26.7%) were parents who were also teachers compared to parents alone (14.6%) and teachers alone (4.7%).  Not surprisingly, there was a significantly increased percentage of parents of children in middle or upper school who reported emotional problems in their children.  Almost all parents reported having made changes in their behavior since the onset of the COVID 19 infection but there were significantly increased anxiety scores in parents who reported “always” practicing hygienic behaviors.  Parents who reported that they had “severe worry” were 7x more likely to report emotional problems in their children.
  3. The message to us from this well-crafted study seem to be the following:
    1. Telling people not to worry doesn’t ever work!  The more effective solution is better anxiety screening for parents and children so that we can make earlier referrals to mental health professionals
    2. Higher risk perception was associated with higher anxiety levels.  It is incumbent upon health professionals to provide effective data to reduce risk perception.
    3. Since there was a higher incidence of anxiety (51.3%) in parents who openly discussed all aspects of the COVID pandemic with their children compared to those who did not (33.3%), it might behoove us as a society to be less graphic in discussing our COVID concerns with our children
    4. Teachers who are parents seem to be at higher risk for anxiety disorders.  It may be helpful for health care providers to specifically target this vulnerable population to help reduce anxiety for them, their children and their students. 

Children’s Happiness
Parents are responsible for providing children with food, shelter, clothing, and love. But they are not responsible for their children’s happiness. In my role as a Parent Coach, I work with many parents who assume this role, too. It’s time to put that responsibility where it belongs – in the hands of children. Allowing children to own their own happiness is often easier said than done, because:

It takes a lot of parental practice and self-restraint

  • Parents are biologically wired to protect their children
  • It’s difficult for parents to see their children being uncomfortable, unhappy or in distress
  • Children’s unhappiness can trigger similar feelings in their parents

It requires a new understanding

  • All emotions, even the unpleasant ones, are important for children to experience
  • Ordinary unhappiness is simply a fact of life
  •  “Unhappy” feelings belong to those experiencing it!

It involves dispelling myths that …

  • Parents are responsible for their children’s happiness
  • Children’s ordinary unhappiness leads to depression or other emotional disorders
  • Children’s disappointments turn into traumatic life experiences

It calls for a new set of beliefs

  • Children are responsible for their own happiness
  • Children’s ordinary unhappiness is a normal and necessary part of life
  • Children develop strength from overcoming difficulties – not by avoiding them

Even though parents are not responsible for their children’s happiness, helping children become more aware of their feelings better equips them to handle emotionally difficult situations.  The following tips can assist parents in this process:

  • Use daily opportunities to discuss situations that trigger different emotions
  • Avoid dismissing, diminishing or denying children’s emotions, even when their emotional response seems unwarranted to you
  • Don’t exercise punitive measures when a child displays “messy” emotions; instead, recognize that your child is struggling to handle a difficult situation
  • Help your child learn to label his/her emotions with words
  • Listen with empathy and validate your child’s feelings
  • Help your child notice and label the different gradations in their feelings; use the feeling thermometers provided here as a reference.

Allowing children to accept responsibility for their happiness prepares them to handle the inevitable disappointments they will face and better understand that daily distresses are a manageable part of life.

Click here for My COVID-19 Memories – Journal Entry #3

Coronavirus COVID 19 infection 6.9.20 update

Spread of the disease:  Over the past 2 weeks, the number of new cases statewide has dropped from nearly 600 per day to 440 and the number of deaths from 49 per day to 32.  Locally, the number of cases has dropped from 85 to 65 while the number of deaths has remained stable at 6.  Ohio ranks 34/41 in the number of cases/10,000 people and 18/41 in the number of deaths/10,000 people (note that 9 states had insufficient reporting and could not be included in rankings as a result).  While there is no data on whether lack of physical distancing during the widespread protests in wake of the George Floyd murder will lead to a surge in cases, we continue to be cautiously optimistic about “opening up”.

PCR testing for COVID 19 disease:  Many of you have asked about PCR testing for the presence of acute disease.  Some out of state camps are requiring negative PCR testing before they will allow a camper to participate in camp activities and we are excited to announce a relationship with a national lab that will allow us to swab you or your child and provide you with results in 1-3 days.  Beginning Monday, June 15, 2020, we will be able to test the following groups:

  1. Our own symptomatic patients seen in our Acute Care Clinic who we suspect may be COVID 19 positive. 
  2. Asymptomatic patients who need PCR testing to ensure that they are negative prior to participation in camp or school or family trips 
  3. If we are not overwhelmed, we will be willing to expand this service to test the asymptomatic parents of our patients who may need PCR testing for work or for trips.

The caveat is that no test is 100% sensitive (no false negatives) and 100% specific (no false positives).  That said, we have partnered with this laboratory because their test has been demonstrated to be close to 100% sensitive which is valuable in determining if you currently have the disease.  There is likely a fee associated with this service.  

Asymptomatic carriage and transmissibility:  As the world “opens up” and the number of symptomatic patients drops, there will naturally be a public health shift to understanding the role of asymptomatic carriers in the continued transmission of the disease.  WHO official, Maria Van Kerkhove was quoted yesterday as saying that asymptomatic transmission was rare and walked that statement back today adding more confusion to an already confusing subject.   An excellent recent review paper from Harvard University looks more critically at this issue.  Click here

  1. The median incubation period (period from exposure to development of symptoms) continues to be 5 days with 99% developing symptoms by 14 days (this explains the 14 day quarantine that has been used since the beginning)
  2. The peak transmissibility is from 2 days before to 2 days after in symptomatic individuals but the median transmissibility in asymptomatic individuals is 9.5 days (with a maximum of 21 days)
  3. Most people infected by asymptomatic individuals will be asymptomatic but some will be symptomatic  (these percentages are unknown at this time)
  4. In unique populations of confined individuals (such as the Diamond Princess cruise line and the US Navy aircraft carrier, Theodore Roosevelt), the percentage of asymptomatic individuals ranged from 17.9% to 60% but in those situations there was ongoing and constant exposure which has not been shown to be present in non-confined situations
  5. In children where symptomatic disease is rare, asymptomatic disease is rarer.  In one Chinese study, the percentages ranged from 4.4%-5.7%
  6. The current national focus has been on identifying patients with symptomatic disease.  As we shift to being able to test for asymptomatic disease, it is likely that the numbers of asymptomatic patients will rise and we will better understand which asymptomatic patients are more likely to transmit disease and which contacts are more likely to develop symptomatic disease.  Despite daily comments about this matter in the media, this information is unknown at this time
  7. In discussions with public health officials, the focus at this point (which will be our focus) will continue to be on the contacts of symptomatic patients.  While our ability to use PCR testing has now improved significantly, this ability will ramp up slowly over the next few weeks.  Remember, a negative PCR test just means you do not have disease right now and do not have asymptomatic disease.  It doesn’t mean you are protected.  Right now in Cleveland, public health officials still believe that the vast majority of people are PCR negative and antibody negative.

What about backyard camps:  Despite the state’s willingness to allow up to 9 children per camp setting, the requirements require physical distancing that is not likely to be possible in the average backyard camp.  Click here.  It is for this reason that we have been recommending going slow on backyard camps, starting initially with 5 children and expanding to 10-12 by July 1 only if there is no significant increase in cases. 

Supporting individuals with intellectual and developmental disability during the COVID 19 outbreak:  In a study of over 11,000 adults with intellectual and developmental disability (IDD) living in 2400 community homes, data from February to the end of April showed that by using a comprehensive prevention and suppression strategy, involving quarantine of individuals with signs and symptoms of acute infection, the total number of positive cases was 1.3% with 15 hospitalizations and 3 deaths.  Click here. These data differ markedly from the experience in nursing homes across the country where the incidence of positive cases and deaths were significantly higher.  The take home message is that with appropriate education, symptom screening of employees, limited visitors, strict quarantine and compulsive cleaning, even high risk groups can be protected from the ravages of COVID 19.  This study has significance for effective infection control in institutions caring for IDD adults as well as senior citizens.   

A gene mutation has been discovered that is associated with the Kawasaki like illness in children with COVID 19:  This Kawasaki like illness (now called MIS-C or Multisystem inflammatory Syndrome in Children in Coronavirus Disease) which is associated with low blood pressure, multi-organ involvement and elevated inflammatory markers is a rare complication of COVID 19 in children.  Researchers at the University of Pittsburgh have found that the a mutation in the SARS-Co-2 virus that causes COVID 19 disease enhances the binding of a molecule to T cell immune receptors that is similar to a molecule called a superantigen that causes the very similar toxic shock syndrome (TSS) in women.  This superantigen-like molecule appears to be responsible to both the MIS-C disease and the severe reaction that some adults have to COVID 19.  This may help explain why MIS-C is so rare (the mutation has been found primarily in Italian cases) and help guide us towards therapy (IV immunoglobulin works for TSS by binding and neutralizing this superantigen and appears to be helpful in MIS-C disease as well).  Click here

The use of metered dose inhalers (MDIs) in the COVID 19 era: 

  1. Almost 2 months ago, we realized the safety hazards associated with aerosol machines for treating asthmatics with albuterol or inhaled steroids. 
  2. While aerosol spread of COVID 19 is not thought to be a significant cause of spread, because of their 10-15 minute duration of the aerosol, aerosol machines have the potential for increasing spread of the disease. 
  3. At the beginning of the pandemic, we switched exclusively to the use of MDI spacers (where the medicine is inserted into the end of the spacer and the child breathes in multiple times.  This is repeated for the total number of puffs ordered.  It comes with a mask for younger children and without a mask for older children). 
  4. In addition to protecting against the spread of COVID 19, MDIs are associated with up to an 80% decrease in the deposition of medicine in the upper airway (where it does no good) and the generation of smaller particles that better penetrate the lung.  In the regular 3 month follow up for our patients with asthma, we are encouraging parents of children over 2 years (and some even under 2 years) to make the switch. 
  5. Now that generic albuterol has been approved by the FDA, the cost has dropped from $80 to $25 using GoodRx  (click here) and the cost for an MDI is $40 at our office so there is little downside and tremendous upside to making the switch from aerosols to MDIs. 
  6. A note about GoodRx:  Remember that GoodRx is a low cost pharmacy option which gives you the best prices at local pharmacies.  Download the app that can be used at any pharmacy and you will potentially save hundreds of dollars a year on your prescription medications. You will need to verify if these costs can be applied towards your deductible with your insurance plan.

Novel role of plastic wrap in protecting against COVID 19:  Keyboards and elevator buttons are difficult to disinfect from COVID 19 droplet transmission because of their uneven surfaces.   The Chinese authors of this correspondence describe their experience of using plastic wrap to cover keyboards and elevator buttons.  They note that it does not impact on usability and can be changed daily.  While masks and shields can certainly prevent one type of droplet transmission, this simple and inexpensive suggestion is worth considering as another form of protection.  Click here

The impact of quarantine on sleep quality and BMI: 

  1. Italian researchers did telephone assessments of sleep quality, physical exercise and working modality at the beginning of the quarantine and 40 days later. 
  2. Not surprisingly, they found worsening sleep quality, reduced physical exercise and increased BMI which was exacerbated in those participating in Smart Working Activities (defined more by project completion than hourly work).  Click here
  3. The authors found that participants in Smart Working Activities (an Italian term created by a 2017 law to improve work/life balance) were more likely to be smart device over-users, more likely to be consumers of processed foods and sugary drinks, more likely to be eating within a few hours of bedtime all associated with poor sleep quality and less likely to be consumers of fresh fruits and vegetables, Vitamins C and D and beta carotene all associated with good sleep quality. 
  4. While we don’t call it Smart Working Activities in the US, those of us who have found ourselves working remotely at home, teaching our children at the same time and not doing much exercise likely experienced the same effects. 
  5. The message is relevant for all of us in trying to cope during the ongoing pandemic world.  At dinner, we should be aiming to increase our consumption of foods which contain or promote the synthesis of relaxing and sleep inducing chemicals (serotonin and melatonin) such as almonds, bananas, cherries, and oats.  In addition, like some of us are doing for our children, we should be setting a limit to our own use of screens prior to bedtime, we should be reducing our carb intake within 3 hours of bedtime and we should be making sure to have 30-40 minutes of daily exercise. Click here.

Tips for a safe road trip this summer:  We have long been an advocate of “getting away” and enjoying nature.  As Richard Louv, author of the book, The Last Child in the Woods (about what he calls Nature Deficit Disorder which looks remarkably like Attention Deficit Disorder), The Nature Principle (about why adults need to find ways to better connect with nature) and most recently, Vitamin N (which gives 500 practical tips on how to better connect with nature) notes, the benefits of connecting with nature are huge especially in reducing deleterious health outcomes like hypertension, anxiety and depression and improving positive outcomes such as better sleep patterns and  living a more mindful existence.  So we strongly recommend that you get away if you can.  Here is how to do it safely in the middle of the COVID 19 pandemic.  Click here

  1. Pay attention to the COVID 19 conditions at your destination:  Look at COVID 19 Watcher which culls data from multiple sources and is able to be evaluated by state, by county and by city.  Click here.
  2. Some cities and states have special rules about who may enter:  As of June 6, Maine and New Mexico and all of Canada still require 14 days of quarantine for out of state visitors before you can go to your destination.  Check with state and local health departments for up to date information about your specific trip plans.   Click here
  3. Bring extra supplies:  AAA reminds travelers to bring health insurance cards as well as face coverings, gloves, disinfecting wipes and cleaning supplies
  4. Pumping gas:  At gas stations either wear gloves and dispose of them immediately or use hand sanitizer immediately afterwards.  There is no preference
  5. What about hotels, Airbnb or motels?  Call before you make reservations.  Travelocity.com and other online sites highlight health and hygiene measures in all hotels booked on that site
  6. What should be done when you arrive at a hotel?  The CDC recommends sanitizing all high touch surfaces which include tables, doorknobs, light switches, counters, desks, phones, remote control devices, toilets and sink faucets.  All reputable chains do this already but an extra level of precaution is not unreasonable.
  7. What about towels and sheets?  We do not feel it is necessary to bring your own towels or sheets
  8. What about public restrooms?  Because gas stations are essential businesses, they have the longest experience in keeping things safe.  Sanitize door handles and pick a bathroom that is likely to have a toilet cover seat cover or bring your own.  Click here.
  9. How about food along the way?  It is best to order from a restaurant that offers contactless, curbside pickup.  Bring aluminum foil or plates on which to put the food and dispose of the container.  Sanitize your hands before eating. 
  10. What about rental cars? As mentioned last week, all national brands do extra cleaning.  Sanitize the wheel and any parts of the dashboard just to be extra careful.  

Responsibilities – Why They Matter
Parents have several responsibilities including keeping their children safe and helping them grow and become independent. As Hodding Carter noted, “There are two lasting bequests we can give our children, one is roots and the other is wings.”

While it comes naturally for parents to keep their children out of harm’s way, promoting their independence can be a daunting task.  We can encourage independence, self-reliance and self-esteem in children by involving them in household responsibilities. Too often these actions are described as chores and perceived as boring tasks. It’s more helpful to view them as contributions that enhance the well-being and functioning of the household. Family contributions reflect a shared responsibility that shifts the focus from “control” to “cooperation.”

Involving children in assuming household responsibilities:

  • Increases family togetherness
  • Helps children acquire new skills and gain new masteries that promote self-esteem
  • Enables children to experience first-hand what it means to be a family “producer” instead of a family “consumer”
  • Helps children learn from an early age that real work is fun and rewarding
  • Nurtures children’s natural desire to feel useful and helpful

Tasks should always be developmentally appropriate and adapted to a child’s interests and abilities. The following suggestions can serve as a helpful guideline.

  • Notice what behaviors children are imitating, especially those related to adult tasks.
  • Involve children in deciding what contributions they would like to make; greater input typically equates to greater buy-in!
  • Help children learn how to do a given task before they attempt to do it on their own.
  • For younger children, divide larger jobs into more manageable parts. For example, when sorting laundry, first have your child pick out all of the socks and then introduce the idea of finding matching pairs
  • Encourage and reinforce children’s efforts. While their standard may not be the same as an adult’s, resist redoing a task a child has already completed.
  • Avoid describing adult tasks as boring and mundane; children learn more from our example then from our direct instruction.
  • Acknowledge children’s accomplishments and be very specific about the value it serves. For example, “Setting the table allowed us all to sit down and eat as soon as dinner was ready; that was helpful!
  • Avoid using rewards to motivate compliance by “buying” children’s cooperation. Instead, acknowledge children’s efforts that result in positive outcomes.  The goal is to help children become intrinsically motivated to assume responsibility and experience the pleasure associated with making an important contribution.
  • Avoid using household tasks as punishment, which teaches children that contributing to the welfare of the family is unpleasant.

Children want to be part of the adult world just as much as they want adults to share their world. If children are encouraged to contribute their efforts to appropriate tasks at home, the lives of both parents and children become enriched. This summer is the ideal time to teach children to assume new responsibilities that benefit the entire family.

Click here for  My COVID 19 Memories – Journal Entry #2

National Donut Day, recently celebrated on June 5th was created by the Salvation Army in 1938 to honor the women who served donuts to soldiers in World War I. We are acknowledging this holiday by encouraging kids to perform an act of kindness for a friend, neighbor, family member or stranger. Once we receive your completed registration form (due by June 17), you will be entered into a raffle.  Four (4) winners will each receive a $20 gift card to Dunkin Donuts. Click here for your DO GOOD entry form!

 
Parenting Tips & Takeaways 6.4.20 update – ttp://mailchi.mp/a501224d1412/parentingtips7
 
Did you know that tomorrow, June 5th, is National Donut Day? National Donut Day was created by the Salvation Army in 1938 to honor the women who served donuts to soldiers in World War I. We are acknowledging this holiday by encouraging kids to perform an act of kindness for a friend, neighbor, family member or stranger. Once we receive your completed registration form you will be entered into a raffle – 4 winners will each receive a $20 gift card to Dunkin Donuts. Click here for your DO GOOD entry form!

Help Children Document the 2020 Pandemic
 

Studying history includes understanding the people, societies, events and problems of a given period. We often envision wars, lost empires, royal weddings, and moon landings. But we are also making history each and every day. Our children are a part of a living history that will be talked about for generations to come.  Due to the novel coronavirus, our children are experiencing months of virtual home schooling, shelter in place orders, and canceled activities, including sporting events, concerts, recreational venues and summer camps. What better time to encourage children to become storytellers and document their unique experiences of living through the pandemic by creating a tangible, personal resource they can share with future generations. One day their own children might ask them, “What was it like during the pandemic?  What did you do? How did you feel?”

To assist with these efforts, each week we will be including a journal sheet for children to complete. It will provide a concrete tool to help them record what life was like before the coronavirus and during the summer of 2020. As they record their thoughts and reflections about this important historical event, it can also help them process different changes and experiences they are coping with. It’s a perfect way to remind our children that they are living out history and that their story matters! Click here for this week’s journal entry.

 

Calling all parents of young children to join an informative virtual panel discussion, Thriving in Survival Mode this Wednesday at 8pm. Hear from our Parent Coach Joan Morgenstern and other experts as they provide practical tips for creating balance, structure, coping with changing relationships, and building resiliency and responsibility in children. Register @ https://www.eventbrite.com/e/thriving-in-survival-mode-registration-106946578094?aff=websiteevent

 
Coronavirus COVID 19 infection 6.1.20 update
 
COVID 19 and children:  COVID 19 seems to affect children with a lower incidence (2.4%), lower level of seriousness (0.2% critical) and lower rate of infectivity (R factor or number of people infected by one positive case < 2.0 which is preferred) than it does adults.  The 2003 SARS epidemic which also involved an animal coronavirus followed a similar pattern with a low incidence (2.7%), a favorable clinical outcome and a low rate of infectivity (only 1 published case of pediatric transmission).  Click here. Why?  Yet another article has appeared looking at potential explanations for these phenomena in children.  Click here.

  1. Lymphocyte function is not impaired in childhood cases.  In adults with severe COVID 19 infection, 63% had reduced lymphocytes (a type of infection fighting white blood cell) but those lymphocytes that were present especially T lymphocytes were overactivated leading to more serious immune damage.  Children with COVID 19 and SARS have normal lymphocytes, especially T lymphocytes.  This may be related to the persistence of the thymus gland, the site of T lymphocyte development which reaches its peak size between 6-13 years.
  2. Children have more mixed infections.  Up to 30% of viral infections are dual infections with viruses such as RSV, human coronavirus (not COVID 19), influenza and adenovirus.  And the rate of virus-bacteria infections also is up to 31% (strep pneumonia, the most common cause of pneumonia in children is often present with RSV).  There is experimental evidence that when there is a dual infection, the immune system is revved up to accelerate virus clearance before there is the opportunity for excessive damage.  Click here
  3. Children receive many vaccines.  Vaccines now protect children against more than a dozen bacterial and viral infections which once again, put the body in a state of high immune clearance and low immune response.  Adjuvants or chemicals that potentiate the immune response (which have drawn the ire of anti-vaccine proponents) may actually promote the body’s non-specific and cellular immune function and produce more effective immune fitness. Click here.
  4. Children have had more recent infections:  Past infections cause the production of a chemical called IFN which activates cells called macrophages to give a temporarily enhanced innate immune status against other infections.  This so called trained immunity produces memory cells that can prevent outside infections such as COVID 19.  This concept of trained immunity may explain the reduced number of COVID 19 cases in countries that vaccinate children against tuberculosis by using a vaccine called BCG.   In some countries, there is talk about the potential benefit of using BCG to potentiate the immune system of high risk groups to prevent COVID 19 infections. 
  5. Children have better immune fitness:  Immune fitness is the balance between killing the infection and tolerating it.  Because children have other so-called covert or undiagnosed illnesses, their immune system is forced to adapt.  Covert infections serve like a vaccine to give low level exposure and allow the immune system to clear infections before they take over the body. This appears to be true of infants and newborns because they have had the passive transfer of antibodies from the placenta or from breastmilk. 

These data are important to remember as we begin to open things up for children (please see 5.11.20 update for more information on this topic).  We have received many questions about the wisdom of opening camps and schools and the more we read studies that actually examine the immune responses in children, the more it appears reasonable that children will continue to have minimal infection rates and that those children who do become infected are likely to be the exceptions that prove the rule.  The challenge may therefore be one of protecting high risk individuals such as elderly teachers and grandparents rather than low-risk children.  

So what should re-opening look like at the beginning of June?  Over the past 2 weeks, the number of new cases of COVID 19 in Cuyahoga County has remained stable in the low 70s and the number of deaths has actually dropped.  Statewide, the number of new cases has dropped by about 15% and the number of deaths has dropped by 30%.  This suggests that the increase in exposure has not caused a spike in the number of cases or deaths and that the cautious steps taken have been reasonable.  Click here.

A few suggestions for the next few weeks:

  1. Increase your COVID community – We have suggested slowly adding more friends to your children’s lives.  Initially, this will include more kids playing outdoors together without masks but when coming indoors, to wear masks (This is similar to the state’s recommendation that in Little League, when playing on the field, masks do not need to be worn but when on the bench, masks should be worn.)  Because of the data shown above, start with children as they are at the lowest risk and if the trends continue, expand to include small groups of adults
  2. Be cautious around grandparents and other high risk populations – If your children have elderly grandparents be careful about exposures.  If your kids are playing with lots of other children, even if the kids are at low risk for contracting or transmitting COVID 19 disease, for now, they probably should still not be having indoor activities with their grandparents over 65.
  3. Backyard camps:  These have been wonderful proving grounds for entrepreneurial and nurturing teens and young adults.  This year, backyard camp leaders need to follow the state’s guidelines and have an option for what to do for a rainy day.  We believe that having 3-4 kids with some adult supervision will be fine for June.  If current trends continue, this will likely expand as we head into July.
  4. Think about school:  Remember, most schools are looking at reopening in the fall in some fashion.  For children who have been trained to be fearful of going out, we cannot go from staying at home all summer to going to school all day in the fall.  That is why we have continued to emphasize the importance of taking baby steps so that your children read your own body language and realize that playing with others is going to be okay, that they are going to be safe.   

Relapse, reinfections and re-positives: 

  1. RT-PCR or Reverse Transcriptase Polymerase Chain Reaction is the so-called nasal swab test for acute infection with COVID 19.  It essentially breaks apart intact COVID 19 cells, isolates the RNA genetic material and causes the RNA to bind with a DNA tracer.  These DNA tracers are amplified or enhanced in the test process and then measured.  When they reach a threshold value, the test is called positive. 
  2. There have been a number of patients who have tested positive in RT-PCR tests, gotten better, tested negative and then tested positive again.  Does that mean they got reinfected?  A recent article from the Korean CDC looked at 285 of these re-positives.  Click here. 48% had symptoms and 52% had no symptoms.  23/285 were tested for antibodies and 96% of those 23 had antibodies, in 108/285, there was actual testing for intact viral particles and 0% had intact viral particles and 790 close contacts of these 285 patients were tested and 0% tested positive.  What this suggests is that people who recover clinically from COVID 19 are likely truly recovered.  When their RT-PCR tests positive after symptoms have resolved, the test is just picking up broken down RNA viral particles that cannot reinfect that person and cannot spread the disease to others.  This is an important piece of information as we try to better understand the nature of COVID 19 disease

Summer activities in our COVID 19 world:  Our newest in-house therapist, Laurel Greene Kaiser LISW, has put together an annotated list of summer activities that are grouped by age group.  Let us know which ones you really like and if you have additional suggestions, tell us about them and we will include them in the next version of this listing.  Click here for the summer activity list.

How safe is it to travel by plane?  

  1. The issue:
    1. The advantages of plane travel are that customers face forward and not towards each other, seat backs provide a barrier and there is limited movement of passengers once they are seated.  HEPA filters on airplanes capture 99.9% of viral particles and air is replaced rapidly as well as often as every 90 seconds. 
    2. But COVID 19 is spread by direct infection by particles, not by aerosolization (air transmission) and while air is refreshed, it only takes a droplet or two from a cough or sneeze to end up in your personal space and if you are not protected by a mask or a shield, it can end up in your mouth or nose
    3. The greatest danger is that you are in a metal box for a period of time with people whom you don’t know so the shorter the trip, the safer.  The distance of greatest infectivity comes from the rows within 5 rows of your own
  2. How to protect yourself on a plane:
    1. Inanimate objects are not much of a concern because of the time lapse between flights.  You can be extra careful by bringing your own sanitizing wipes and cleaning the tray table, the audio and TV knobs and the touch screen TV as well as the sidewalls (if you have a window seat).
    2. Wear a mask or a shield for the duration.  Given how difficult it is to wear an N95 mask for a long trip, try using a shield instead (see the 5.25.20 update)
    3. It is generally safe to use the lavatory as long as you avoid passengers in line.  Gel your hands after touching anything in the lavatory. 
    4. Use sanitizing gel often and avoid eating on the plane
    5. Avoid leisure travel until we know more about the transmission on planes.  Travelling by car to most places is preferred.  Just find out the local quarantine rules in the place to which you are travelling. 

For more info about the policies of each airline, click here.  
 
What about the rental car you need at the other end of your plane trip?

  1. Thomas Russo, Chief of the Division of ID at the University of Buffalo says rental cars are generally safe especially if you wipe down the steering wheel and any part of the dashboard you might be touching like the radio or the AC.  Your greatest risk is giving a ride to someone you do not know in that car since COVID 19 is spread from people, not inanimate objects. 
  2. Rental car companies are already cleaning your car more carefully including the following areas as a matter of routine:  the key and key fob, center console, cupholders and compartments, seat surfaces and pockets, areas between the seat and console and seat and doorjambs, the dashboard, instrument panels, steering wheel and column, accessory panel, door interiors and pockets, all interior and exterior door handles, mirrors, and other high-touch areas. The company also has measures in place to immediately isolate and quarantine any vehicle if needed. Click here.

Why we are waiting to use our IGM/IGG antibody test: 

  1. What antibodies are being tested?  As we have previously discussed, antibody testing can be helpful in determining a previous COVID 19 infection.  IGM antibodies typically rise in the first few weeks and then fall off.  IGG antibodies typically rise after a few weeks and remain elevated. 
  2. COVID 19 antibody patterns:  But according to personal communication from researchers at Harvard, the rise of COVID 19 antibodies do not fit a standard pattern.  In some patients, there is the traditional IGM first, IGG later pattern.  In some, IGG comes first and IGM comes later.  In some, IGM and IGG are both negative but IGA, a third type of antibody is positive.  Moreover, no one knows how long these antibodies persist.  Click here
  3. What is an ELISA test?  The gold standard for measuring antibodies is called an ELISA test which stands for enzyme linked immunosorbent assay.  Click here. In this test the COVID 19 antigen (or infectious particle) is stuck onto a plastic surface, a blood sample from the affected patient is added and any antibodies to COVID 19 will bind to the antigen.  Then a second antibody with a marker is added and it binds to the antibody that was present in the blood causing a color change.  ELISA tests are typically 100% specific, meaning there are no false positives (if the test is positive, you really have the disease) and >98% sensitive meaning there are few false negatives (if the test is negative, you really don’t have the disease).  In this disease, we are much more interested in having zero or close to zero false positives because we want you to know if you have really had the disease.  Many companies and universities have developed ELISA testing.  The problem is that this is not a rapid test.  It takes over 24 hours. 
  4. What are rapid antibody tests?  Rapid antibody tests are examples of lateral flow immunoassays where the sample of blood flows from one end to the other end and like the ELISA test produces a colored reaction if the viral particle is present. The most common example of such a test is a home pregnancy test.  There are now over 100 COVID 19 antibody tests and the FDA is being very careful to see which ones are close to 100% specific and at least 95% sensitive.  Click here.
  5. Senders Pediatrics and antibody testing:  We are waiting for guidance from the FDA to see if the rapid antibody test that we have purchased is sufficiently sensitive and specific to use in large scale studies of patients.  As we have noted before, we are keeping a list of patients and their families who believe they may have had the disease and will hopefully be able to test this group if/when we get clearance.
  6. How long does protection last?  Ultimately long term studies will have to be done to show if these antibody tests can be relied upon to predict long term immunity.   

How long does the loss of smell (dysosmia) last in COVID 19 disease:  In large scale studies from China, dysosmia was identified in 5.1% of patients.  https://jamanetwork.com/journals/jamaneurology/article-abstract/2764549.  In a recent study of 145 patients with dysosmia, it was found that this symptom can last up to 95 days or longer (median 62 days) and that 11% of patients had persistence of this symptom for at least 25 days.  This symptom is twice as common in females as in males, more common in patients over 40 years and more common in smokers and patients with a history of seasonal allergies.  Persistence of dysosmia alone is not an indicator of persistence of the disease.  Click here.  

The healing power of breathing: 

  1. COVID 19 has made us crazy about coughs and sneezes and chest tightness.  Our anxiety about the signs of this disease have made us into a planet of breath-obsessed people.
  2. But says James Nestor, author of the new book, Breath: The New Science of a Lost Art, the silver lining to all this COVID talk may be a new found awareness of the healing power of breathing. 
  3. It is not only THAT we breathe that is important.  It is HOW we breathe.  “Breathing properly can allow us to live longer and healthier lives.  Breathing poorly can exacerbate and sometimes cause a laundry list of chronic diseases including asthma, anxiety, ADHD and hypertension.”
  4. Pulmonologists (breathing doctors) say the majority of us breathe inadequately.  Some of it has to do with our skull.  Our mouths and sinuses have shrunken and humans are now the only species whose teeth don’t fit in our mouth (ask any of our children who have seen an orthodontist).  As we age, bones in our chest collapse inward, we lose up to 12% of our lung capacity by age 50 and it gets worse after that. 
  5. In the 1980s, researchers with the Framingham Study in Massachusetts in evaluating 5200 subjects over a 70 year period (one of the longest studies ever attempted) found that the greatest predictor of life span was not genetics, diet or daily exercise but rather lung span.  Larger lungs allow us to get in more air with fewer breaths and save us from wear and tear.  So what can we do?
    1. Extend our breaths:  Try inhaling gently through your nose to a count of 5 and then exhale.  This reduces the number of breaths per minute, protects our lungs from irritation and infection and boosts circulation to the brain and body.  Just a few minutes of inhaling and exhaling at this pace can drop blood pressure by 10-15 points
    2. Breathe through your nose:  Up to 50% of us are chronic mouth breathers.  Mouth breathing saps our body of moisture, irritates our lungs and causes damage to the soft tissue in the back of our palate.  It also increases sleep apnea, increases blood pressure and causes increased respiratory infections.  Nose breathing allows us to absorb up to 18% more oxygen than breathing through our mouths.  It reduces cavities and probably improves sexual performance. 

This is a crazy but simple solution to a lot of diseases we see as we age.  Teach your kids to extend their breaths and to breathe through their noses and you may be doing more for them than many of the medicines we pour into them for allergies, asthma and pneumonia. 

Thanks for all your comments.  If you have any specific questions about COVID related issues, please let us know at care@senderspediatrics.com.

 

Parenting Tips & Takeaways 5.29.20 update – http://mailchi.mp/3bf1d5c8388a/parentingtips6

Most families will be experiencing a disruption to their summer plans, due to the novel coronavirus. But happy memories, such as bike rides in the neighborhood, catching fire flies at night, and making mud pies while digging in the dirt, can lead to a fulfilling summer 2020. These are activities today’s youngsters don’t always seek out when more exciting options are readily available, but they present wonderful opportunities for children to interact with the world around them while learning how to use their own resourcefulness for engagement.

Nostalgic summer activities can be found here.

As the school year comes to an end, we want to help families find new meaning and pleasurable moments in the months ahead. So, we created a summer calendar that includes different activities that engage children and encourage them to spread kindness at the same time.  As a bonus, any child who participates in one of these summer activities and submits a completed entry form will be entered into a raffle and will become eligible to win a prize. Stay tuned for our first event, which we will promote in next week’s newsletter.

Our summer calendar is attached below and can be found here.

Additionally, this calendar also highlights several fun and unusual summer holidays. Since holidays can feel like a fun change from the ordinary, this is a perfect time to make these unusual and lesser known holidays more visible as we look for any excuse to celebrate!

Find a complete listing of unusual holidays click here.

Download your free copy of When School Comes To An EndThis book was designed as an interactive tool to assist young children, ages 2-5, in documenting aspects of their school experience before COVID-19. More than just a keepsake, this book provides an opportunity for children to recall, record and remember different aspects of school, all which will assist them in bringing closure to the academic year.

Click here to download the book.

Coronavirus COVID-19 infection 5.25.20 update

What does the school year look like? On May 19, 2020, the CDC released its guidelines for reopening schools in the fall.  Click here for full details.  Included in the document are the following recommendations:

  1. Promoting behaviors that reduce spread
    1. Staying home when appropriate.  This includes having an active illness or recent close contact with someone with documented COVID-19.  Recent is not yet defined.
    2. Hand hygiene and respiratory etiquette.  This includes hand washing for 20 seconds or the use of hand sanitizer.  Used tissues should be thrown in the trash, not left in a pocket.
    3. Cloth face coverings (see below for discussion about face shields as an alternative)
    4. Adequate supplies of soap, hand sanitizer, paper towels, tissues, disinfectant wipes and no-touch trash cans
  2. Maintaining Healthy Environments
    1. Cleaning and disinfection:  playground equipment, door handles, sink handles and drinking fountains should be cleaned at least once daily.  School buses should be disinfected in between trips.
    2. Shared objects:  Each child should have his/her own supplies and equipment.  Electronic devices, toys, books and other games should not be shared.
    3. Ventilation.  There should be circulation of as much outside air as possible unless it poses a safety risk by opening doors or windows.
    4. Modified layouts.  Desks should be 6 feet apart when feasible (CDC language) and should not face one another.  Seating on buses should create distance between children.
    5. Physical barriers.  As in other businesses, partitions should be placed at reception desks.  Tape guides should be placed to remind children to have physical separation.
    6. Communal spaces.  Communal shared spaces such as dining halls or playgrounds should be closed or used in a staggered fashion.
    7. Food service.  Children should bring their own meals or be served plated meals in their classrooms.  Disposable food service items such as utensils and dishes should be used.  Buffets should be eliminated and prepackaged boxes and bags should be used instead.
  3. Maintaining Healthy Operations
    1. Protection for staff and children at higher risk.  Higher risk individuals should be offered telework or tele-education options.
    2. Gatherings, visitors and field trips.  Virtual group events and virtual field trips should be encouraged.  Non-essential visitors and volunteers should be limited.
    3. Identify small groups and keep them together.  Try to keep the same group of children and staff together, especially in young children.
    4. Stagger scheduling.  Ensure that adequate physical distancing can occur at all times.
    5. Communicate effectively.  Develop communication procedures in the event a staff member or student is diagnosed with COVID-19.
    6. Develop back up staffing and leave plans for teachers.
    7. Conduct daily temperature checks of students and teachers.
  4. Preparing for illness
    1. Isolate and transport staff members and students who are ill.
    2. Develop a cleaning and disinfection policy for exposures. 

The state is working on developing an implementation plan that incorporates the CDC recommendations and school districts and private and parochial schools are in the process of forming committees of school and community stakeholders to prepare for the 2020-21 school year. 

  1. Because most schools are not sufficiently spacious to maintain the 6 foot distancing that is being recommended, it looks like many will be looking at ways to split up classes such that there is a combination of in-school and at-home programming.  One of the popular approaches appears to be 2 days in-school, 2 days at-home and one day for special programming.  How sports programs can be implemented remains to be seen.
  2. Any combination of in-school and at-home programming will likely be very challenging for working parents who have weathered the at-home online experience for the past few months often with significant impact on both their child’s education and their own job performance. 
  3. Our suggestion is that parents already look to develop COVID-19 Communities of 3 families so that one parent is responsible for the online learning and supervision of the children in that group only one of the 3 online days and will be able to function at work or at home the other 2 online days (for a total of 4 days per week).  It is likely that maintaining that small type of COVID-19 Community will be sanctioned even if there is a phase 2 outbreak at some point during the school year.  Alternatively, hiring an individual to provide online learning supervision for 3 families may allow all 3 sets of parents to function at work or at home with less individual financial burden.  More options are likely to surface as the details of school opening are released. 

Using face shields as an alternative to face masks to protect against COVID-19:  As society is beginning to open up for churches, synagogues and other social events where there may be prolonged exposure to lots of people and the need to breathe more easily, the idea of physical distancing continues to be the most important way of reducing passage of the disease.  While the 5.18.20 update discussed how to make face masks more effective, face shields offer a number of useful advantages over masks. 

  1. The Infectious Disease Society of America has long included society use of PPE such as masks and face shields in its recommendations for easing restrictions.  Click here to review. 
  2. As more data about transmission becomes known, it continues to look as if COVID-19 is transmitted by droplets and not airborne aerosolization.  This means that face shields which enables easier communication (especially for lip readers), can be easily cleaned with household disinfectants, protect the eyes, nose and mouth and reduce the potential of spread by preventing the wearer from touching his face may be a good alternative option. Click here.
  3. Face shields have been shown to reduce viral exposure from influenza (which is spread in a similar fashion) by 96% when worn by a simulated health care worker within 18 inches of a cough and have been shown to be equal to physical distancing of 6 feet.  Remember, that even vaccines are not 100% protective.  Click here
  4. While there is some controversy about whether face shields can replace face masks entirely (click here), there is increasing evidence that they can.  Click here.  State guidelines use the words “face coverings” which include both masks and shields. 
  5. We are not yet endorsing face shields as an office policy but with the strong scientific background, the drop in the cost, the relative availability and the comfort advantages, it would not be surprising to hear more about face shields in the next few weeks.
  6. For optimal protection, a face shield should extend below the chin, reach to the ears and have no exposed gap between the forehead and the shield (usually achieved by using a foam cushion).
  7. Consumer Labs (by subscription only) reviewed some of the available face shields and gave an adequate and top pick rating to the Homasen brand, adequate to Petocase brand, not adequate to Ringkle brand all of which are sold on Amazon and adequate to Safeprotec which is told directly to the consumer.  There are many other brands on the market.  If choosing a shield, please choose one with the criteria established above. 

Why are kids so clingy now?  Many parents are asking us about excessive clinginess and how we can be spending so many hours with them and they still seem to need more.  Kids of all ages are chatting more with their parents, holding hands more, climbing into bed with their parents more and looking for more attention.  To understand why this is happening, we must first appreciate the meaning of healthy secure attachment.

  1. What is attachment?  Attachment researcher, Alan Stroufe says that attachment is the deep abiding confidence a child has in the availability and responsiveness of his/her caregiver. 
  2. The definition of secure attachment:  Researcher Mary Ainsworth defined secure attachment as children who play and explore freely from the secure base of their mother’s presence (the initial research was done in the 1950s when mothers were the primary caregivers.  It has since been shown to be true of any primary caregiver).  When the mother leaves, the baby can become distressed but when the mother returns, the baby expresses her joy, sometimes from a distance and sometimes asking to be picked up depending on personality type.  Mothers who fall into this pattern are responsive, warm, loving and emotionally available and their children grow up confident in their mothers’ ability to handle feelings.  Babies feel free to express their positive and negative feelings openly and don’t develop negative defenses against the unpleasant feelings. 
  3. Even in infants, secure attachment only occurs about 30% of the time.  What is more important, however, is that child’s trust that his/her caregiver will respond and meet his/her needs and that when mismatches occur, that caregiver will right the boat and repair the interaction.   https://psycnet.apa.org/record/1987-15272-001

So what’s with all the clinginess and what can we do about it?  Psychologist Steven Meyers notes, “Clinginess is an instinctual response to perceived threat and anxiety.  In evolutionary terms, offspring of all species are more likely to survive if they stay close to their parents for protection when danger is imminent. Children have this encoded in their biology and it can be triggered by the stresses and uncertainties of a global pandemic.”  Click here to read more. 

Clinginess doesn’t mean you did anything wrong as a parent because it occurs even in the presence of secure attachment.  It is an attempt to cope with anxiety.  These are some of the tips that experts recommend to help with the extra clinginess.

  1. Figure out the root cause of the anxiety.  Is it fear of contracting the disease? Is it fear of losing a parent or grandparent?  Is it loss of the ability to go to school or play with friends?
  2. Understand regression.  Older children may regress and act in ways not common for their age.  Says Meyers, “this regression is a threat-based response to increase perceived safety, receive comfort and reduce anxiety.”  So think about how you can provide a safe environment, offer comfort and reduce anxiety for that specific child.
  3. Keep routines as much as possible.  This is one of the hardest things.  We are working harder than ever, homeschooling at the same time and trying to get food on the table and laundry into the machines.  But routines are all about giving kids that sense of security that they need to thrive.  It can be a relaxed schedule but it should be predictable.  And if it is routinized, it will be easier to go back to school in the fall after 6 months of mommy and daddy time.
  4. Include stretches of uninterrupted kid/parent time.  Giving undivided attention for even short periods fills them up emotionally so they are less likely to be clingier the rest of the time.
  5. Indulge the clinginess:  Attachment expert Stroufe says that assuming the requests aren’t insane, if its stress that is making them clingy, “far and away the best thing to do is let them be clingy. They will cling as much as they need and then they’ll want to get back to exploring and playing.”  If you respect that there is a real reason for your child to be feeling this way, the answer is parent sensitivity, not threatening a time out if he/she doesn’t let go of your leg. Click here.
  6. Try to model calmness and confidence.  Never before has the adage, “fake it till you make it” been so important.  That doesn’t mean you shouldn’t be real with your feelings.  But be mindful of how much fear and anxiety is coming from you, how much you may be inadvertently modeling or maintaining anxiety and how important it is that you convey that message that you will never put them in an unsafe position.
  7. Make sure you are not promoting clinginess:  Sometimes neediness comes when parents give children the sense that they can’t do things on their own.  Children need help and guidance but allow them to try things on their own and work through the inevitable frustrations. 
  8. Remember, you are all they have now.  Concludes Dr. Meyers, “many children have become clingy towards their parents because they have fewer avenues to socialize with others.” Introvert or extrovert, human beings are programmed for connection and interaction.  That is why it should always be “physical distancing and social interaction”.  And that is why the antidote to clinginess will ultimately be figuring out better ways for responsible and safe social interaction.   

What we know about asthma and COVID-19 in children:  A recent Letter to the Editor in the European Journal of Allergy and Immunology reviewed data from Southern Italy.  Click here.  The population in South Lombardy and Liguria is 2,315,000, the pediatric population is 14.5% (335,675) of which 30% (100,702) have allergies and 11.6% (38,938) have asthma.  12,055 of the total population (0.5%) were diagnosed with COVID-19 and only 40 were children.  2/40 (5%) had allergies and 1/40 (2.5%) had asthma.  This study continues to show a low incidence of COVID-19 in children and while the total numbers were low, the incidence in patients with allergies and asthma was lower than would have been predicted by the incidence of those diseases in the general population.  The authors hypothesized that the presence of eosinophils, a type of immune cell present in abundance in patients with allergies and asthma may be protective against viral infection noting that low eosinophil counts have been described in patients with COVID-19.  Whether that theory proves correct is unclear.  But what is clear from this and other such studies (click here) is that initial concerns about asthmatics being at higher risk for COVID-19 disease appear to be overblown.  While all children are at low risk for developing COVID-19, a well-controlled asthmatic child appears to be at no greater risk (and possibly a lower risk).

Please bring books and toys to your child’s appointment:  In order to ensure the health of our patients who are seen in our main office, one of the first things we did was remove all the books and toys.  Sadly, especially for families in which two children are being seen, it has become increasingly difficult for families to adequately distract their younger children.  Please remember to bring a couple of toys and books to your appointment so that you do not have to rely on more electronic devices to enable you to engage with us in a meaningful discussion.

Parenting Tips & Takeaways 5.22.20 update – http://mailchi.mp/433bd818a736/parentingtips5

What Do You Do books by Joan Morgenstern:  While we have reduced our COVID-19 updates to once a week, we continue to also provide you with helpful parenting tips from Joan Morgenstern, our Parent Coach on a weekly basis.  Click here for a copy of Joan’s newest book:  What Do You Do….When School Comes to an End.  It is another in what will ultimately be a series of What Do You Do books for your 3-5 year old.  All our updates can be found on our website, www.senderspediatrics.com.  Stay tuned for a brand new web design coming mid-June with hundreds more articles and a mobile app for ease of scheduling, communicating with us and texting us. 

And finally, have a meaningful Memorial Day:  Some thoughtful poetry from children on the meaning of Memorial Day which are especially poignant in a world trying to figure out how to coexist with a pandemic.  Take a moment today to celebrate our military heroes who gave their lives so that we can spend the day with our families, a bit more isolated but ever so grateful for life.  Click here for Memorial Day poems. 

As many schools prepare to end the academic year, children will be experiencing a new type of closure that may pose different challenges. This year they will need to process the end of school amidst feelings they experienced when the Shelter in Place order took effect.
 
When School Comes To An End is a book designed as an interactive tool to assist young children, ages 2-5, in documenting aspects of their school experience before COVID-19. More than just a keepsake, this book provides an opportunity for children to recall, record and remember different aspects of school, all which will assist them in bringing closure to the academic year.

Click here to download your free copy.

Did you know that May 24th is National Scavenger Hunt Day? Elsa Maxwell (1883 –1963), an American gossip columnist, author, songwriter, screenwriter, radio personality and professional hostess admired for her renowned parties, is credited with the introducing the scavenger hunt as a party game.

A scavenger hunt is a game in which individuals or teams try to collect or photograph items on a list, without buying them, within an allotted time. Each listed item is worth a certain number of points (at the discretion of the organizer) and the team or individual that has accrued the most points by the end of the game is the winner. A scavenger hunt list can be eclectic or theme based and can be easily customized to appeal to a child’s interests and abilities.  

Scavenger hunts are often confused with treasure hunts. Although the two games share some similarities, they are not the same. Scavenger hunts are straightforward and involve finding different items on a list.  Treasure hunts usually consist of several clues, one leading to the next, until a “treasure” is found.

This weekend, in honor of National Scavenger Hunt Day, consider adding a scavenger hunt to your family’s agenda. Tell your children, this is just what the doctor ordered! If you’re not interested in creating your own list, we’ve attached three types of scavenger hunts for your family to enjoy.

Click here to download your free copies.

Coronavirus COVID 19 infection 5.18.20 update

Responsible ReStartOhio:  Over the past two weeks, the number of COVID cases in the state of Ohio and locally, in Cuyahoga County has remained stable even with a greater degree of movement and the reopening of many businesses. Click here. More kid-related sectors are opening up shortly with some sports leagues, gyms and pools reopening on 5/26, childcare and day camps reopening on 5/31.  For a full listing of the new requirements click here.

We have received many questions about this reopening process and share some of the Q&As below.  As we have shared multiple times in the past, in determining how to reopen, data should be the key.  If the studies about temperature turn out to be correct, the number of cases will continue to stabilize and the decision to move forward will have been the correct one.  And if we see a significant rise in cases, we will need to slow things down again.  One caveat to consider:  if there is a grandparent over 65 in your home or someone with cancer, uncontrolled diabetes or significant heart disease, it will be important to wait until there is a drop in cases before increasing exposure to these more vulnerable groups in any of the venues mentioned below. 

Q:  My child is in a day care.  Is it safe for me to send him/her?
A:  According to the CDC and the state (click here), the following rules should be followed:  Use “curbside” drop-off and pick-up when possible. • Have a dedicated staff person escort your child into and out of their child care facility each day. • Wash children’s hands upon arrival and before departure. • Have adults wear masks. • Limit mixing of classrooms. • Sanitize toys after each use and remove toys that cannot be sanitized. • Stagger the use of communal spaces, such as playgrounds and lunchrooms, until they can be sanitized. 

But it is not all up to the daycare.  Parents have a real role in ensuring that a “day care COVID community” can be created by doing the following:  • Child care providers are limited in the number of children they can serve. If you can stay home with your child, please do so. This will help keep limited child care spots available for families that have no other child care options. • Children run fevers for many reasons, such as teething or colds. If your child is running a fever of 100 degrees or more, do not take them to child care. Your child should stay home for at least 24 hours after their fever subsides. • Watch for symptoms of COVID-19, such as sore throat, cough, fever, headache, runny nose, and difficulty breathing. If your child is exhibiting any of these symptoms, contact your pediatrician and keep your child home from child care.

Despite some of the reports of Kawasaki like illnesses in children, the data supports the fact that children are at very low risk for COVID 19 as well as this likely post viral manifestation. Click here.  As a result, we support the positions of the CDC and the state to open up day cares under the appropriately designed recommendations.

Q:  What about Little League?  I have heard that children will need to wear masks.  Is it safe for them to play sports in the heat wearing a mask?
A:  The good news is that the current recommendations do not recommend masking while in the field of play which we support because we are worried more about heat stroke than COVID spread in these age groups.  In addition, when outdoors, the risk of spread is low. 

As we describe below, a good fabric mask will allow effective breathing when on the bench.  Water bottles will be used instead of water coolers.  Spectators will need to wear masks.  While the state recommendations (click here) continue to use the words social distancing, we would like to emphasize that the goal is physical distancing.  Baseball is a social sport and while high-5s will be eliminated for this (and probably next) season, the goal is for our children to learn about sportsmanship in a COVID safe environment.  

Q:  My kid is getting shaggy?  Is it okay to go to get a haircut? 
A:  Yes, the current recommendations (click here) ensure that hair stylists and barbers wear masks and clean in between clients.  Clearly, it is impossible for 6 feet barriers to be maintained when getting a haircut.  However, one should support a salon where there are fewer clients at any one time and at least 6 feet of barrier maintained. 

Q:  What about day camps?
A:  Many day camps have already made the decision to close because it is too hard to keep kids separate.  If the spread of the disease continues to remain flat, however, the state may find it easier to lessen some of the requirements so we are cautiously optimistic that mid-June through August will look a little more promising.  Backyard camps run by teenagers must have limited participation and have adult supervision to ensure that the recommended best practices (click here) noted below can be achieved. 

Current state best practices include:  day camp workers should wear a cloth face covering, unless it is unsafe for them to do so. *Day camp providers should cancel all field trips, excursions, and large-group events such as parties. • Day camp providers should, to the extent possible, prevent groups from mixing. • Teachers should remain with their group throughout the day. • Support staff should only serve one group of children and should not “float” from room to room. *Day camp providers should stagger the use of any communal space, such as playgrounds, lunchrooms, and bathrooms.

Providers should sanitize communal spaces between each group of children. • When temporary dividers are used, day camp providers should ensure that groups do not mix. • Providers should use different entrance/exits for each group of students. • Providers should use separate sinks for each group of kids. • To the extent possible, providers should use different bathrooms for each group. • Day camp providers should sanitize toys after each use and remove toys that cannot be sanitized. • Day camp providers should wear gloves while serving food. • Day camps that operate exclusively outdoors should consider total camp capacity based upon best social distancing practices between groups and upon inclement weather circumstance.  

In case of weather emergencies, campers and staff should be moved to a secure area maintaining safe social distancing when possible. If safe social distancing practices are not possible during such period, masks or cloth facial coverings should be used. • Day camps should stagger employee break times to prevent employees from congregating in break areas or common areas and to accommodate cleaning procedures.

Q:  When can my child play with other children?
A:  With day cares and day camps opening up in the next two weeks, it is logical for parents to be asking when their children can play with other children.  Our approach is to recommend that you expand the circle slowly, by one family a week for now.  Start with supervised outdoor playdates for now and we will update our recommendations on a weekly basis.  Remember, if there is a grandparent over 65 in your home or someone with cancer, uncontrolled diabetes or significant heart disease, you should wait until we have more information before increasing exposure.

Q:  When can my child see his/her grandparents?
A:  It depends on the age and health of the grandparents.  If the grandparents are under 65 and in good health, we think it is reasonable to allow expansion of the COVID circle.  Holding a baby is not likely to be a problem for such a grandparent since babies have, by and large, not been vectors for the spread of disease.  If the grandparents are older or in poor health, we should be holding off until we have more data. 

On antibody testing:  While we have access to antibody testing and we expected to begin larger scale testing in early May, we are waiting on guidance from the FDA before using this test.  We are not being cagey.  We simply have to follow federal guidelines.  We will provide updates as we hear them.  

How to make a safe, breathable home mask:  Researchers at the University of Illinois looked at how to make face coverings made by home fabrics as effective against the spread of COVID particles as many commercial medical masks. Click here

  1. The authors studied 10 different common fabrics from 100% cotton to 100% polyester, from shirts, T shirts, quilt cloths, dishcloths and bed sheets. 
  2. They found that all worked great even when used as a single layer.  For example, a 1 layer T-shirt fabric blocked 43% of droplets but when used in 2 and 3 layers, improved to 98.6% and 99.98% respectively which is comparable to an N95 medical mask but with considerably greater breathability. 
  3. Breathability is critical for a mask because if it has low breathability, air will flow out the sides and will give you a false sense of protection.
  4. Home fabric masks are hydrophilic (water soaking) compared to hydrophobic (water preventing) medical masks.  This is not a problem because these masks soak and hold the droplets.
  5. In another study, adding a layer of nylon stocking under the mask improved efficiency by 15-50% and because it is nylon, added an electrostatic charge that prevents air leakage.  Click here.

Hopeful information about T cell protection against COVID 19:  There are two major types of immune warriors in the body.  Most of what we hear about in the media has focused on B cells.  B cells produce antibodies and that is how most vaccines function in protecting us against disease.  T cells thwart infections in two different ways.  Helper T cells spur B cells and other immune modulators into action and killer T cells target and destroy infected cells.  Two new studies have shown that even in patients never infected with animal derived COVID 19, have T cell defenses that protect against COVID 19.

La Jolla Institute of Immunology researchers found COVID 19 specific T helper cells in up to 100% of patients recovering from COVID 19 and in 40-60% of unexposed individuals. Click here.  German researchers found a similar number of COVID specific T helper cells in 38% of uninfected individuals.  Click here

Both sets of researchers hypothesized that these T helper cells were likely triggered by past infection with one of the 4 human coronaviruses that cause colds.

The three take home messages from these studies are:

  1. They start to define the role of T cells in COVID 19 infection:  They suggest that T cells have a role in protecting against COVID 19 infection rather than in provoking the immune system overreaction.
  2. They give us hope for the efficacy of vaccines:  For many of the vaccines being evaluated, to produce the antibodies that we need for protection, there must be good helper T cell responses.  These studies suggest that such responses exist.
  3. They help us understand COVID 19 disease in children:  They help explain why most children have been spared some of the significant complications of COVID 19.  And those who have not been so spared, may either not have had exposure to these human coronaviruses or have minor T cell defects that would ordinarily not have been discovered.  Further studies of infected children are likely to focus on these immune defenses.

Why have we lost our ability to focus and how we can get it back?  Google searches for “how to focus” are up by 300% since the onset of the pandemic.  We are all desperately reading, viewing webinars and spending money on apps and motivational videos to find ways to change our workflows and then beating ourselves up for our inability to be successful.  Yale Neuroscientist Amy Arnsten says from a brain research perspective, the problem is actually quite simple.  We are not able to access our prefrontal cortex which carries out our higher order abilities which include:

  1. Higher reasoning/abstract thought:  “The incidence is low in my age group and my parents are low risk”
  2. Working memory/ability to focus:  “I am particularly good at focusing and if I blot everything out, I will go back to my natural position.”
  3. Inhibiting inappropriate impulses:  “Listening to the media only makes me more anxious so I will stop listening to TV personalities and do no social media activities during the day.”
  4. Planning and organization:  “I have always been great at planning out my day”
  5. Flexible decision making:  “I have a plan for the day but if my kids need my help while I am working from home, I will simply take a break and get back to my plan for the day”
  6. Empathy:  “I know there are people in my office who are more anxious than I or more fearless than I.  I won’t get into a tussle with them.  I will simply wish them well.”
  7. Patience and hope:  “No matter how long this takes, my family and I can withstand the stress.  We will not remain in limbo forever.”
  8. Insight and judgment:  “I have always been able to steer my family through challenges”

Unfortunately, with uncontrollable stress, high levels of arousal chemicals rapidly shut off our prefrontal cortex and allows us only to operate with our primitive brain which makes us distracted, forgetful, disorganized, less thoughtful and more reactive, emotional, irritable, impatient, rigid in our thinking and more vulnerable to scams. https://www.youtube.com/watch?v=TsQUeNuvIDY (but mute the annoying background sound)

According to Dr Arnsten, the COVID 19 pandemic is unusual because:

  1. It is invisible and global:  We worry that the person in front of us is asymptomatically spreading it to us.  And we can’t even go on a vacation to escape it.
  2. We have no individual control:  If we are worried about strep, we go to the doctor and find out if we have it.  Here, we can’t find out if we have it or have had it and there is no vaccine yet so we cannot even protect ourselves.  We are desperately dependent on other forces.
  3. We are forced to go against our normal habits to protect ourselves:  Social interaction is our normal response to stress.  With this disease, everyone is talking about social isolation and we fundamentally know that social isolation is bad for us.

So what should we do? 

  1. Understand the molecular mechanisms of stress.  We need to realize that an inability to focus under stressful conditions is how we are wired to preserve our species.  It is nature, not us. Click here.  
  2. Be kind to ourselves:  Says Dr Arnsten, when you start blaming yourself, you actually reduce your prefrontal cortex control even further. So take a minute to give yourself a break.  Click here.
  3. Avoid exhaustion:  Many people have turned to expensive apps to limit their time on social media or are using techniques like the Pomodoro method (25 minutes of work, 5 minutes break) which 6 months ago they thought were silly.  Unfortunately, forcing yourself into smaller and smaller boxes, leads to burnout.  Exhaustion coupled with stress actually causes your prefrontal cortex to atrophy or shrink on MRI.
  4. Exercise our prefrontal cortex:  The good news is that we can actually grow our prefrontal cortex in some bite size ways.  Click here. While #5 and #9 are things that innately attract me, #8 and #10 may be the best ways to deal with this pandemic over the long haul.  Let us know how these exercises help you by sending your comments to care@senderspediatrics.com

Further thoughts on natural substances to keep your immune system healthy and prevent the serious complications of COVID 19: Pulmonologist and Critical Care physician, Roger Seheult puts out a YouTube video on COVID 19 multiple times a week with downloads of some of his posts as high as 1.1 million viewers.  He makes COVID sound simple if that is at all possible. Update 59 is must listening for all our patients.   https://www.youtube.com/watch?v=NM2A2xNLWR4.  He describes his own personal regimen and provides the scientific background for each:

  1. Vitamin C:  He encourages eating fresh fruits and vegetables on a daily basis.  This provides the most bioavailable form of vitamin C.  If you are not able to get vitamin C the natural way, there is limited risk to taking a supplement of 1 gram daily. 
  2. Vitamin D:  Vitamin D ingestion has been shown to prevent respiratory illnesses.  For people with severe deficiency, only 4 people would have to take supplements to prevent one respiratory illness which is an amazing statistic.  Given the amount of vitamin D deficiency we see each day, we recommend 5000 units once a week for children under 10, 10,000 units once a week for teens from 10-20 and 15,000 units once a week for all adults over 20.
  3. Quercetin:  Is an antioxidant and anti-inflammatory with antiviral effects against both RNA viruses (influenza and coronavirus) and DNA viruses (herpes). Click here.  It has been shown to prevent entry of influenza A into the cell. https://www.mdpi.com/1999-4915/8/1/6  While long term studies have not been done, there appear to be few side effects.  Click here. The dose is 1 gram twice daily for adults.  It seems reasonable to use 500 mg twice daily in patients over 10 years.  
  4. N-Acetyl Cysteine or NAC:  In a 6 month controlled study of 262 primarily elderly subjects, those who received 600 mg NAC twice daily had fewer flu like episodes and days of confinement. Click here.  The recommended dose for adults is 600 mg twice daily.  Once again, the dose 10 years and above should be 300 mg twice daily.

And finally, ways to enhance social connectivity in 3-6 year olds:  We have spent a lot of time talking about helping teenagers physically isolate and socially integrate.  But it is harder to make that happen in young children.  We asked Parent Coach Joan Morgenstern and In-house therapist, Dr Sharon Bursky for their thoughts:

From Joan: 

  1. Validate feelings of loss:  Help your child make sense of the feelings around ‘missing.’ Most parents gloss over these feeling for fear of provoking more upset.  It rarely does; in fact, talking about the ‘missing’ helps young children make sense of their emotions which promotes greater understanding and ultimately a better ability to accept them.
  2. Look for Joan’s new book, What Do You Do … When School Comes to an End, which you will receive this week for a tool to help children make sense of the loss associated with the abrupt closure of school combined with the soon-to-be end of the school year. The goal is to help children recall, record and remember  – in essence, to help concretize this experience so they are better able to emotionally move from missing to remembering.
  3. Encourage service activities:  Encourage children to do a demonstrative act of service on behalf of their teachers/classmates. For example, create hand-made cards, jewelry, personalized messages, anything that requires their active participation and engages their senses, hence, nothing technologically oriented. This helps children create ‘meaning’ out of loss, which Kessler added as the 6th stage of grief.
  4. Expand the circle – Slowly expand your social circle and include one or two families of similar age into your COVID community. 

From Sharon:

  1. Charades- Great game that can be played with children (mostly 4 yrs +) from a safe distance. Another version of this game can be picture charades with a dry erase/chalk board or side walk chalk and a driveway. Have children stand on opposite sides of driveway (6 ft away or more) to play this game
  2. Guess who- This is a great game for kids 4+ to play from a distance as you each have your own board which can be disinfected easily. 
  3. Nature walks- There are some fantastic and free outdoor scavenger hunt sheets online. This can be done with friends from a distance at a local park with a trail. Rules are suggested (no touching, keeping safe distance). This would be appropriate for ages 3+  
  4. Obstacle Course on driveway- this is a great way to engage socially from a safe distance, combine exercise, and large motor development. Suitable for ages 3+

There is a lot of information here this week.  If you have specific questions about a personal situation, let us know at care@senderspediatrics.com.

Parenting Tips & Takeaways 5.14.20 updatehttp://mailchi.mp/40c236d58e60/parentingtips4

FEELINGS:
The world has been thrust into the unknown, which is causing many different emotions to surface for children and adults. Frustration, anger, loneliness, and fear are just a few of the many feelings people are struggling to handle. With additional stress and pressure, tempers are more likely to run short. So, it’s important to remember that feelings are neither good nor bad; they are simply pleasant or unpleasant to experience. And all feelings, including the “messy” ones, are a big part of who we are.

As we make space to honor our feelings, it’s important to do the same with those of our children. If their feelings are repeatedly invalidated, they might stop trusting themselves. Frustrated children who begin to cry can become confused by a parent (or other significant adult) who tells them they’re okay and that there’s nothing to cry about. Over time, confused children question whether they should trust themselves or the adults they look up to.

Many parents unknowingly, and with loving intentions, instinctively dismiss, diminish, or invalidate their children’s emotional turmoil with the following responses: “You’re fine,” “Get over it,” or “Don’t be so dramatic.” Children’s feelings are real to them, even when they appear trivial or unwarranted to their parents. It’s important to give children latitude and permission to express unpleasant feelings and reserve the use of limits for behavior that is unsafe.

We all have an innate need to feel heard and understood. When parents use statements of support, like those listed below, which validate children’s emotional upsets, children learn that accepting and understanding their emotions is part of everyday living and learning.

  • Thank you for letting me know how you feel.
  • Your feelings are important to me.
  • I appreciate your willingness to share your feelings with me.
  • I see this is hard for you and I’m here to help.
  • Is there something I can say or do that would be comforting.
  • I care and I’m available if you need or want me.
  • I love who you are, and I appreciate that you feel so deeply.

Coronavirus COVID 19 infection 5.11.20 update

Challenges for higher education:  Former Nebraska Governor and President of New York’s New School, Bob Kerrey, joined Harvard physics professor Eric Mazur, to produce an insightful challenge to universities.  “Higher-education leaders should seize this period of upheaval as an opportunity to focus on learning, shift to student-centered instruction, and look for new opportunities the online setup affords. The move to virtual classrooms is a chance for institutions at every level to make learning more effective—off campus or on. It is an opportunity to refocus on student outcomes, on the development of universal skills that will enable graduates to respond to the next crisis, to create resilience and adapt to unfamiliar territory, and to help lead society forward.  To remain relevant in the post-Covid world, universities must be able to demonstrate real progress toward better teaching methods with clear outcomes, driven by the science of learning.” Click here

We believe that the same challenge exists for K-12 educational enterprise as well as for parenting approaches and workplace opportunities.  We know it has affected our thinking about the future of pediatric care.  Futurist Daniel Burrus writes in his book Flash Foresight, that successful people are able to see the invisible and do the impossible.  This past year, the reality of life in a COVID 19 world, forced us all to do the best we could under trying circumstances.  But now it is time to see the invisible and do the impossible.  As Kerrey and Mazur suggest, let’s use this COVID pandemic as an opportunity to learn and to grow.  Let’s assume this COVID cloud may not lift for another two years and that this is the new normal.  In the educational world, let’s learn how we can equip our students with the mind-sets and skill sets they’ll need to succeed in an uncertain future.  Let’s use that same expansive approach to figure out better parenting options and better ways of conducting what we do at work.  If you have come up with out of the box ways of dealing with your life’s challenges let us know.  We expect to use these updates to share some of these innovative approaches as motivations to us all to figure out how to create a better society.

Hyperinflammatory Shock in Children with COVID 19:  Over the past two weeks, there have been a number of reports of children with a Kawasaki like illness associated with COVID 19. Click here. Kawasaki disease is a well described unusual condition in children (we see about 5-9 cases a year in our practice) that is associated with high fever for 5 or more days, a peeling rash, red eyes without discharge, swollen hands and/or feet and enlarged lymph nodes.  A small percentage of children with Kawasaki Disease go on to a shock like condition (called Kawasaki Shock Syndrome or KSS) where there is a deep drop in blood pressure and multi organ failure.  In England, New York City and scattered other places around the country, there have been clusters of cases of KSS like disease, some associated with COVID 19 disease.  Harvard pediatrician and Director of the Kawasaki Program at Boston Childrens Hospital had this to say, “It’s still very rare, but there’s been a wave of cases. Physicians and scientists are working hard to understanding the mechanisms at play, and why only some children are so severely affected.”   COVID 19 disease in children continues to be mild (see below) but as with every disease, there are more severe manifestations about which we need to be vigilant. 

More data on COVID disease in children and lack of spread to adults:  Early on, Iceland did extensive screening of its population.  In one study, 0.8% of the adult population was positive while no cases were reported in children under 10 years. Click here.  In the municipality of Vo, Italy, 86% of the population (about 2500) were tested with a 2.6% prevalence rate and again, no children with disease under 10 years.  Click here.  In a case study in the French Alps, a child did not transmit it to over 100 contacts and in a cluster study in New South Wales, Australia, there was no transmission in a school of 735 children and 128 adult staffers when exposed to 18 index cases for an extensive period. There were no cases of children affecting teachers.  Click here.

In light of the above, UK researchers Munro and Faust conclude, “The media highlight of a possible rare new Kawasaki-like vasculitis that may or may not be due to SARS-CoV2 does not change the fact that severe COVID-19 is as rare as many other serious infection syndromes in children that do not cause schools to be closed. Individualized risk assessment and decision-making by clinicians should occur for those considered at exceptional risk (such as in immediately after bone marrow transplant) or where there are other older family members at significant risk.” Click here.  While we have to be cautious about extrapolating information from individual reports describing small numbers of children, if the trends hold up in larger studies in the United States, data like these can be helpful in informing decisions about school reopening plans. 

Theories about why COVID 19 has a milder course in children: Duke researchers review the literature about COVID 19 disease in children and offer the following theories about the generally more benign nature of this disease in children. Click here.

  1. The lack of severe comorbidities in children:  High blood pressure, diabetes, severe obesity  (BMI >35 in one study and >40 in another, click here) chronic pulmonary disease and cardiovascular disease are independent risk factors for severe COVID 19 disease.  The fact that children have fewer of these comorbidities may predispose them less to severe disease. 
  2. COVID uses the ACE2 receptor to activate the immune system and produce the cytokine cascade.  Children have fewer ACE2 receptors in their lung tissue.
  3. Outside of COVID disease, children have a lower incidence of a condition called ARDS or adult respiratory distress syndrome which is the presentation of severe cases of COVID disease.  One of the chemicals associated with ARDS is called nuclear factor kappa light chain enhancer of B cells and this is present in much lower levels in children.
  4. Children with COVID disease produce less of an inflammatory molecule called IL 6 which may predispose them to less inflammation.

How long does COVID 19 immunity last and its implications for vaccination:  The same Duke researchers reviewed data on the persistence of immunity in the first SARS epidemic (COVID 19 is technically called SARS 2).  In adults, six years after the initial infection, there was a lack of B cell (antibody) immunity in almost all cases and a lack of in T cell immunity (cellular immunity) in 40% of cases.  This suggests that immunity may wane with COVID 19 as well.   It will therefore be critical to measure B and T cell immunity in children over time.  Children may be protected at young ages for any of the above reasons or for a completely different reason.  But, if, as these researchers suspect, COVID immunity is also more long lasting in children, it will be important to understand why and to use that knowledge to develop the ideal vaccination and booster plans for this disease. 

Steps we are taking to keep you and your children safe:  The health and safety of our patients and employees continue to be our top priority and we have taken extraordinary steps to ensure a clean and illness free environment in our main clinic.

  1. At the beginning of this crisis, we installed a unique UVC air treatment system that cycles 12 times a minute to eliminate any potential airborne contaminants.  
  2. We have an extensive cleaning program in place for all of our rooms
  3. For over a month and for the foreseeable future, all patients with illness symptoms have been seen in our isolated Acute Care Clinic and prior to that, we were completing car visits for ill patients. This clinic has a separate entrance and exit where providers are wearing full personal protective equipment.  
  4. We call each patient the day before their appointment to screen for any illness symptoms and are also screening everyone in the foyer before entering the main lobby.
  5. We are rooming very quickly to avoid waits in the lobby and per the governor’s recommendations, have reduced the number of individuals in the building at any time.
  6. We have installed glass guards at the checkout areas to prevent potential spread in areas that cannot be separated by a 6 foot barrier

We continue to support the state’s mask policy and you’ll see our team members wearing masks but as with the state’s policy, we recognize that not every patient or parent can or will wear a mask and forcing masking on some individuals may be counterproductive. Since the ultimate purpose of masks is to avoid spread when in close contact with others, we have set up our office environment to make sure families are able to maintain the appropriate 6 feet of physical distancing from each other. We continue to trust our patients to determine if they are able to mask while practicing physical distancing and the vast majority do. We appreciate that there are arguments and emotions on both sides of this issue but again, as with the state’s policy, we are asking our community to work together for the common good.
 
Please continue to let us know if you have any specific questions about your COVID related condition and send them to care@senderspediatrics.com.     

Coronavirus COVID 19 infection 5.9.20 update

A path towards opening up schools in the fall:  The American Academy of Pediatrics (AAP) has put together a position paper describing a path towards opening schools in the fall.  Click here to review the details. 

 The 6 caveats include:

  1. Local and national spread of COVID 19
  2. The availability of point of care testing that can help determine infections in real time and the ability to do community surveillance and contact tracing (tracing those with positive tests)
  3. Implementation of a measures to limit the spread of COVID 19 within the schools including:
    1. Sanitizing procedures
    2. Screening, monitoring ad testing for illness amongst staff and students
    3. Use of masks
    4. Limiting student interactions (having teachers move between classrooms rather than students
  4. Data about the spread of disease amongst children and adolescents.  Right now it appears to be low
  5. The possibility of intermittent closure of schools if there are outbreaks (similar to influenza)
  6. A phased approach that looks at any potential spread of disease prior to full reopening

The position paper makes the following points:

  1. Distance learning this year could not come close to replicating in-person learning
  2. There is likely a widening divide between those who can learn effectively with distance learning and those who cannot
  3. It is also not feasible to catch kids up on all lost academic progress
  4. Millions of children who rely on school based meals have been impacted.  It will continue to be the responsibility of schools to figure out how to maintain this nutritional program throughout the next year
  5. Students with disabilities are being impacted more than most with the loss of OT/PT and speech therapies and mental health
  6. It is likely that sporting events, practices and conditioning sessions will be limited in many locations
  7. There will continue to be both students, parents, teachers and support personnel who are so distressed by the anxiety of contracting COVID disease that they will not be able to participate in in-school activities.  Schools will need to incorporate academic accommodations and supports for such individuals
  8. Schools will need to be attuned to the broader social and family stressors that may affect a student’s ability to attend school or be ready to learn
  9. Isolation measures and protocols for sick children and staff will need to be developed
  10. Schools will need to anticipate continued restrictions on physical distancing and group size

Our thoughts include the following:

  1. It is imperative that schools and school districts develop multiple scenarios for the way school will look for the entire 2020-21 school year or parts of it given the unknown about if or when a resurgence of cases will occur.
  2. Schools will have to develop more robust ways of educating both in-school, at home and in a blended learning environment
  3. Schools will need to model community building behavior where the needs of all members of the school community are taken into consideration and compromise positions are developed that can appeal to the greatest percentage of individuals.  For those for whom anxiety continues to be overwhelming, alternative options for learning must be developed that provide a quality educational experience in a home environment without stigmatization.  
  4. The child care needs of parents will have to be an important consideration.  Any program that attempts to have 2 or 3 day in-school programs will need to address how working parents can function in that environment
  5. Effective means of providing testing and feedback to students and parents will need to be established
  6. Schools should look at creative solutions to the school schedule which include shorter semesters with fewer classes, an earlier start to the year, dismissing high school students at the same time as elementary and middle school students to allow for more child care opportunities, a truncated program if and when school is disrupted and an extended school year to accommodate any disruption.  None are ideal but all should be on the table
  7. All stakeholders will need to buy into whatever program is developed including parents, students, teachers, educational supervisors, health, special education and physical education providers and administrative and custodial personnel.

Target lockdowns appear to be optimal:  Boston researchers look at the number of COVID related fatalities which have reached 1.83% of the US adult population and the lockdowns which have cost about 24.3% of one year’s GDP.  While in the first go around, there was little knowledge about what could work, their sophisticated modeling approach can help us look at what we can do better if and when there is the next wave.  The looked at multiple scenarios for targeted lockdowns to evaluate whether avoiding a one size fits all approach in the management of COVID disease.  Reports such as this can help inform our politicians on appropriate steps to maximize safety and minimize financial impact. 
https://www.nber.org/papers/w27102?mod=article_inline

  1. Increasing physical distance between the oldest group and the rest of the population by reducing visits to older relatives or segregate the times when different demographic groups can go to grocery stores and pharmacies can reduce mortality by 67%
  2. Effectively identifying and isolating infected individuals can reduce mortality by 50% when that probability is 0.4 and by 80% when that probability is 0.6 and reduce the impact on GDP by 50% when the probability is 0.4 and by 95% when the probability is 0.6
  3. The added advantage of full closure is small 

5 amazing ways to reduce anxiety:   In honor of Children’s Mental Health Awareness Day on May 7, we asked Dr Sharon Bursky, one of our in-house therapists to prepare the following coping skills to manage anxiety:

  1. Grounding technique using your 5 senses:
  •  Look around for 5 things you can see and say them out loud. An example would be, “I see a tree, picnic table, coffee mug, sun shining, and the walking path.”
  • Pay attention to your body and identify 4 sensations you feel and name these feelings out loud. An example, “I feel my heart beating, the shoes on my feet, the cold necklace around my neck, the warmth of my breathe.”
  • Use the sense of hearing to identify 3 sounds. This can be hearing the birds chirping, the sound of traffic, your stomach rumbling.
  • If you are able to, identify two things you are able to smell. If you are unable to smell anything in your current location, it is okay to move to the kitchen or go outside. If you are still unable to find smells in your location, you can identify your two favorite smells and close your eyes to attempt to smell them in your mind.
  • Identify one thing you can taste and name it out loud. This can be the mint you had after lunch, the toothpaste from brushing your teeth, or the last thing you ate. If you are unable to taste something, you can again close your eyes and think of a favorite taste to imagine what this would be like.
  1. Breathing- deep breathing is one of the quickest and easiest ways to reduce the physiological symptoms of anxiety, which then provides an opportunity to work through some of the cognitions that accompany the physical response. The tricky part about breathing is that if we teach kids to use it only in a crisis or a time of very high anxiety, the likelihood it will be used is low. I suggest teaching kids (and adults!) deep breathing when things are going well, integrating this coping skill in daily life such as 3 times a day (morning, noon, and night). When coping skills are used regularly, this increases the likelihood a child will use this skill at times of stress and worry.
    1. 3x3x3 Breathing technique- Breathe in through nose for 3 seconds; hold breathe for 3 seconds, exhale through mouth for 3 seconds. Do this 3 x in a row for it to be most effective (hence the name: 3x3x3).
    2. I suggest using bubbles or a windmill to teach young kids how to do this exercise to keep them more engaged and work on technique.
    3. Tell kids to imagine that they breathe in all the way from their belly and distinguish between short chest breathing and deep belly breathing. We do this together a few times so they can feel the difference.
    4. Instruct kids to exhale through their mouth by pushing all of the air out, and if they are struggling, we “roar” our breath out, like a lion.
    5. Shape breathing – here is a great resource for shape breathing to teach kids deep breathing skills
  1. Progressive muscle relaxation – anxiety can cause the constant tensing of muscles. This exercise helps child learn to distinguish between the feelings of a tensed muscle and a completely relaxed muscle. This in turn teaches children to learn how to prompt this relaxed state at the first sign of the muscle tension that may accompany anxiety. This technique is especially helpful in providing a better awareness to mind-body connection and that we often hold our feelings in our body, and we can also release our worries and anxiety through our body and our mind. Here is a great script for helping children go through the exercise of progressive muscle relaxation and here is a helpful YouTube cartoon video that teaches kids the importance of this exercise and a visual “how to”.
  1. Connection– In a previous COVID update we provided a discussion on how to hold space for loved ones during this challenging time sharing the three techniques” Empathize, connect, and redirect”. These techniques are helpful in talking through anxiety and worries with our kids. Here is a link to that COVID update if you are interested in reviewing this helpful post.
  1. Gratitude- Expression of gratitude is a great way to shift perspective from worry to ways we feel thankful. I encourage parents in teaching children the importance of gratitude expression at a young age. A way to incorporate gratitude is by reflecting on the day as a family, identifying your favorite things and something you feel thankful for. Expressions of gratitude may not take away someone’s anxiety, but it can shift the perspective from out of control to feeling blessed or thankful.  

The phenomenon of Zoom fatigue?

  1. Humans communicate even when they are quiet by taking in a host of non-verbal cues such as whether someone is looking at you, if the other person is fidgeting or if they inhale quickly as they are about to interrupt you. 
  2. Perceiving these cues comes naturally to most humans and lay the groundwork for effective communication and emotional intimacy. 
  3. Video calls, however, eliminate a lot of these non-verbal social cues and require sustained attention to verbal communication instead which can be exhausting. 
  4. Multi person screens exacerbate this problem and gallery view where everyone is positioned around the periphery challenge the brain’s central vision which forces it to decode so many people at once that no one comes across meaningfully, not even the speaker.
  5. While some pride themselves on the ability to multitask, when the brain is called upon to have this type of continuous partial attention, you lose the ability to focus on any one activity
  6. Video chats become like siloed panels where only two people are talking while the others are listening.  But on a video chat, you are unable to pick up on the behaviors of the non-active participants because you can’t see them with your peripheral vision
  7. This prolonged split in attention creates the terrible feeling of being drained while having accomplished nothing.  The brain is overwhelmed by the unfamiliar excess stimuli while being hyper-focused on searching for non-verbal cues it cannot find.
  8. Interestingly, people with autism find this new Zoom environment more helpful because it has reduced their social interaction and they are less focused on the non-verbal cues.  For an article on how patients with autistic spectrum diseases deal with the internet click here.  https://cyberpsychology.eu/article/view/6757/6215

So what is a person to do?  Cyberpsychologist Claude Normand suggests the following

  1. Turn off your camera:  Consider turning off your camera to save your energy for when you need to perceive the few non-verbal cues that come across
  2. Move to phone calls:  Consider switching to a phone call and walk while you are talking.  The walking reduces stress considerably and improve creativity
  3. Minimize large Zoom meetings:  Try to reduce the number of large Zoom meetings so that you can focus on as few people as possible

How to have a Happy and Safe Mothers Day:  With Mothers Day being celebrated this Sunday, a few thoughts on how to maximize safety and minimize risk:

  1. Setting up your driveway or backyard with chairs that maintain appropriate physical distancing but allow for social integration
  2. If young grandparents have been quarantined for a long period and so have their children and grandchildren, expanding the COVID community to include this group should be okay
  3. Older grandparents over 65 should continue to be physically isolated as they continue to be at highest risk until the Stay at Home Order is lifted

As always, please keep your comments and questions coming to care@senderspediatrics.com.

Parenting Tips & Takeaways 5.6.20 update – https://mailchi.mp/1959039c6c83/parentingtips-438035

Coronavirus COVID 19 infection 5.4.20 update

COVID 19 Watcher:  With so much unknown at the beginning of COVID 19 spread in the US, closures were made on a macro level.  States imposed Stay At Home orders that did not look at the nuances of a specific area (the total population, crowding numbers, numbers of tests etc).  As states and cities begin to loosen restrictions, it has become ever more important than ever to have a tool that tracks COVID 19 data on a daily basis at a county level rather than at a state level.  Three online tools have done just that (the New York Times (click here), Johns Hopkins (click here) and the COVID Tracking Project of The Atlantic  https://covidtracking.com/about-data.  Unfortunately, for these vehicles to be useful, it takes some IT sophistication to extract data from the data sets.  Researchers at Cincinnati Children’s Hospital have developed an online tool that aggregates (combines) all the data being collected in the US and delivers it in a format that public health authorities, school districts and individuals can use easily, click here to review. COVID 19 Watcher displays COVID-19 data from every county and 188 metropolitan areas in the U.S. and includes rankings of the worst affected areas and auto-generating plots that depict day to day changes in testing capacity, cases, and deaths.  Because of reporting variations, no tool is helpful to use on a daily basis.  But check this tool once a week to see how we are doing in Cuyahoga County (and feel free to forward this to your friends around the country as it can be used anywhere). https://covid19watcher.research.cchmc.org/ As we move into the next phase of identifying clusters of cases, it will be more important than ever to identify hotspots and not take a one size fits all approach to closures.  

IGM/IGG antibody testing:  We have mentioned that we would begin a program of antibody testing for patients and their families who believe they have had symptoms of COVID and who want to see if they have developed immunity.  We have been in discussions with health authorities about how to conduct these tests and unfortunately, while we have the tests in stock, we will not be ready to roll out this program for another 2 weeks or so.  Stay tuned for more info.  

One of the positive things to come out of school closures:  Kids are getting more sleep.  In our anecdotal experience, we have found that children at all ages, but particularly teenagers, are getting an appropriate amount of sleep for their age.  A recent article looked at 455 high school kids in 5 schools over a 3 year period.  2 of the schools delayed the start of school by 60 minutes and served as the study group.  The other three began at 7:30 AM.  The delay in school start was associated with 24 extra minutes of sleep per day in year one and 34 minutes per day in year two.  In other words, starting school later did not cause kids to go to sleep that much later.  The authors’ conclusions were “that delaying high school start times could extend adolescent school night sleep duration and lessen their need for catch-up sleep on weekends.”   As the discussion surrounding school openings for the fall begins, it would be valuable to consider a later start to all high school educational programming.  Getting 8 hours of sleep improves concentration and creativity for everyone and especially for those with attentional disorders. Click here for article. 

Working from home can be very stressful to your relationship:  Tech site, Gear Hungry https://www.gearhungry.com/quarrels-in-quarantine/ surveyed 3000 people in all 50 states and found some amazing statistics:

  1. 2/3 found that working from home put a strain on their relationship
  2. 8 days is the longest the average person felt they could work from home before things became tense
  3. 72% say they do not have enough space to work comfortably from home while their spouse does the same
  4. 50% felt they were more productive working from home
  5. 79% said they spend more time with their spouse and their kids
  6. The percentage identifying strains in their relationships varied by state.  The lowest was MN at 14% and the highest was RI at 75%.  As with many other things, OH was right in the middle at 50%
  7. Some suggestions to relieve the stresses:
    1. Get dressed and shower.  33% said they don’t shower daily and 18% don’t get out of their sleeping attire. 
    2. Use headphones to relieve the background noise
    3. Exercise together or separately each day.  View exercise like a pill.  Just like you take a pill to treat your strep and you don’t forget, make sure to exercise everyday.  It releases serotonin which helps relieve stress
    4. Connect with coworkers.  As we have emphasized before, connecting by face (not by phone) releases oxyPreviewtocin which is another relaxing chemical

Three stages of a pandemic:  British Introvert Coach (she specializes in coaching introverts to thrive in an extroverted world), Gabrielle Treanor, has put together a nice graphic to help everyone deal with the challenges of our new world.  Borrowed from the Kubler-Ross and  Kessler models of grief (see the 4/24/20 update), she identifies 3 stages: survival, acceptance and growth.  Take a moment to see where you are on the continuum and recognize that, as with stages of grief for a loved one, you can go in and out of stages and not necessarily see a linear path. https://gabrielletreanor.com/3-stages-of-pandemic-response/

  1. Survival
    1. You feel overwhelmed by the changes, the uncertainty, the news and everyone’s feelings
    2. You try to make it through each day
    3. You are angry with other people’s behavior
    4. You are constantly checking the news and find it hard to think of anything else
    5. You are powerless, lethargic and unproductive
    6. You are grieving the loss of your past life
  2. Acceptance
    1. You don’t like what’s happening but you are not as angry
    2. You realize that its not so helpful to listen so much to the news or social media
    3. You’ve created a new routine
    4. You’re noticing the little things that make you smile
    5. You’re figuring out how to make a new life online
    6. You’re longing to get back to the “good old days”
  3. Growth
    1. You are looking ahead to what life will be when this stage is over
    2. You are getting a sense of which one of the “old ways of life” you want to jettison as you make a new “normal”
    3. You are savoring the present rather than bemoaning the past or worrying about the future
    4. You are fully aware of the dangers that lie ahead but you are appreciating how much more difficult life is for others and your eyes are opening to what you have taken for granted

Managing screen time while homeschooling your child:  A recent survey found that nearly 50% of respondents have school age children who spend more than 6 hours a day on screens up from 8% just two months ago.  Some suggestions on dialing back quarantine screen time include:

  1. Enforce a schedule – don’t use screens as your default but build in screen time for vegging out after school or during preparation for dinner
  2. Distinguish between school devices and entertainment devices:  Try to keep Chromebooks and other school devices in a central location instead of a bedroom to prevent toggling back from YouTube to schoolwork
  3. Set screen time limits:  It is easy for an hour of screen time for your children to morph into 3 while you are working from home.  Circle (click here),  a one time subscription and Bark (click here), a monthly subscription,  are two parent control devices that can be used to set time limits or screen breaks on a child’s device.
  4. Try a screen break:  Check out Screen Strong https://screenstrong.com/about-us/ and challenge yourself and your family to find other creative ways to spend the time.   

Primary care practices are struggling:  According to the Primary Care Collaborative which studies independent primary care practices nationwide, primary care practices are struggling to cope with COVID 19 related challenges which include providing non reimbursable guidance, inability to see well visits and lack of PPE.  Up to 20% expect to close or sell to hospitals or venture capital companies over the next year.  Unfortunately, when independent practices sell to hospitals, costs rise with one study showing up to a 14.1% rise in costs.  Click here for study.  Senders Pediatrics is an independent practice that is committed to providing you with creative solutions to the problems you face.  From insuring that your children get the wellness care and vaccines they need in a healthy environment, to seeing your ill children in a safe manner in our Acute Illness Clinic, to providing a clean air standard that is a best practice, to bringing you realistic, thoughtful guidance on all aspects of dealing with the disease, we expect to be there for you now and in the future.  While we deal with the day to day challenges of a COVID 19 environment, we are hard at work at the next generation of services which include:

  1. A state of the art website with hundreds more pages of educational materials
  2. Continued growth of our behavioral health program that provides you with integrated clinical and behavioral health services
  3. A patient portal to allow for seamless transfer of clinical and lab data and bidirectional transfer of forms
  4. A weight management program to help deal with post COVID 19 challenges
  5. New clinical research studies targeting meningitis, RSV, influenza, ear infections and pneumonia

One of the best ways you can help us help you is to recommend us to your friends and family, especially to those who are pregnant.  For our UH and CCF patients, you know it but many of your friends and colleagues don’t yet know that we are Tier 1 for both institutions.  Please spread the word online and in resident forums.  Vote for us as Best Pediatric Practice on the Northeast Ohio Parent Magazine poll 2020 Parent Choice Awards.  And thank you for your ongoing support.

For any personal questions or comments, please continue to contact us at care@senderspediatrics.com.

Coronavirus COVID 19 infection 5.1.20 update

A grand compromise:  On April 27, Governor DeWine announced Responsible RestartOhio, Ohio’s plan to responsibly restart Ohio’s economy as the next phase of dealing with the COVID 19 outbreak which begins in a phased manner on May 4.  The focus is threefold:  to get Ohio back to work, to support continued community efforts to contain the COVID virus and do all this while protecting the health of employees, customers and their families. 

We believe our political leadership is trying to craft a grand compromise.  In talking with hundreds of our patients over the past few weeks, it is clear that there is a growing divide between those who are worried that we are moving too fast and those who believe that we are moving too slowly.  While there are legitimate concerns on both sides, the way to bridge the differences is for each side to give a little so that we can function as a society.  That means those who want to open up more quickly are being asked to actually wear more masks in more situations.  And those who are worried about opening up too quickly will be asked to watch the results of the slow opening carefully and if there is no significant increase in the number of cases and number of deaths, to be willing to open up further in the next few weeks.  Compromises are messy but despite the physical, emotional and financial stresses on all of us, if we can tamp down the rhetoric and emotion and adopt evidence based solutions, we can truly restart Ohio responsibly.

How Responsible RestartOhio will affect you in the workplace:

  1. Wearing masks:  Face coverings are required while employers and employees are on the job unless:
    1. Wearing a mask is not advisable for health reasons.  Patients with respiratory diseases such as asthma or COPD may be excused.
    2. Wearing a mask is not practical.  This may be the case in call centers where talking cannot be heard above a mask.
    3. Wearing a mask is not documented industry best practices. 
  2. Physical isolation: In general there should be a minimum of 6 feet between individuals or the installation of physical barriers
  3. Limiting congregations in cafeterias and in other areas

Customers are exempted from wearing face masks but are strongly encouraged to do so.  This was not made mandatory as a middle ground to protect Ohioans who cannot wear face masks including those with disabilities such as autism, respiratory illnesses and a variety of anxiety conditions.

So what about play dates and visiting with friends? Today, Dr. Acton issued the Stay Safe Ohio Order through 5/29/20.  In this order, she is continuing to prohibit public and private gatherings of more than 10 people occurring outside a single household.  Camps and day cares continue to be closed.  This suggests that play dates where children or teens are playing together at a distance of less than 6 feet continue to be prohibited.  The governor did announce that additional guidance will be provided throughout the month as more information becomes available.  That means to us that as the opening up activities of businesses continue, if there is no significant spread of disease, there may be opportunities for further expansion of play activities.  But not yet.  So this weekend with temperatures in the high 60s both days, please encourage your children to go outdoors and for older children especially, encourage them to use a beach chair and have a “teenage play date” with 1 or 2 friends at a distance of 6 feet or allow them to go on a run with their friend running across the street. 

And what about grandparents?  The state is continuing to treat people over 65 as higher risk.  And in our discussions with health officials, the consensus that seems to be emerging is that even as we open things up, there will be a heterogeneity in the groups that open up.  It may be that after we open up businesses, we open things up for children who continue to be at low risk especially in the US.  Or we open up rural areas with low levels of crowding before suburban areas and suburban areas before urban areas.  But one of the last groups to be opened is likely to be people over 65.  And yet, we have cautiously allowed grandparents to become part of the ‘COVID network’ of their children provided that the network does not include multiple families and both parents and grandparents limit their outside exposures.  We are happy to address questions about private situations through our care@senderspediatrics.com email address.

So how are we going to get out of this mess?  We are all thinking the same thing.  We have been on a war footing now for at least 6 weeks.  Our kids have had no school, many of us are out of jobs, we have no real summer plans right now and we are looking at similar ups and downs until fall, 2021, when vaccines may help us develop herd immunity (or protection of our most vulnerable).  As we have noted on multiple occasions, part of the answer will be to get point of care testing (rapid COVID tests) into the hands of primary caregivers so that we can quickly identify patients who will spread the disease.  But the answer to reopening schools and colleges also lies in the true R factor.  The R factor is the number of people infected by one individual.  In a fascinating study, click here, researchers came up with a new statistical model that looks at the impact of various interventions (school closures, Stay At Home orders, bans of public events  and physical distancing).  The current R factor is 0.96 (one person infects less than one person) which reflects the effectiveness of all of these non pharmaceutical interventions.  As we open things up, we will need to follow this R factor closely.  The author has prepared an interactive link to follow this R factor, click here.

Infections in pregnancy with COVID 19 and other respiratory viruses are rarely if ever transmitted to the fetus:  Georgia researchers report that there have been no confirmed cases of intrauterine transmission reported with COVID 19 or any other coronaviruses, click here to review. In addition, despite over a billion annual cases of influenza each year, there are almost no case reports of intrauterine transmission of that virus as well.  RSV and metapneumovirus (common causes of pneumonia) and parainfluenza virus (the cause of croup) have also not been transmitted.  All 5 of these viruses are RNA viruses which means they function by essentially commandeering the genetic code of the human host cell causing it to become a factory for the production of more virus.  The placenta serves as a barrier for transmission of virus and also immunologically defends the fetus from a variety of infectious agents.  Placental cells called primary human trophoblasts (PHTs) can also transfer resistance in culture and are an avenue of research for developing an immune treatment for the disease.  The message to women in their 3rd trimester is that their newborn babies are at almost no risk for infection and while there have been a few cases of infants infected with COVID, their course has been mild and no different than the course of other babies under 2 months who present with a fever. 

Operation Cuyahoga Cares:  Cuyahoga County Children and Family Services has developed a mechanism for helping some of our hardest hit families make it through the next few months.  Donors will be matched with a family in need and will be given information on options for gift cards to appropriate retailers.  A $50 gift card will provide food and other necessities for one child for a week.  There is no overhead, click here to learn more.

Mental health issues in school age children under quarantine:  In a study of 2330 students, grades 2-6 in Wuhan Province who had been in quarantine from January to April, 22.6% reported symptoms of depression and 18.9% reported symptoms of anxiety.  These numbers are twice as high as numbers previously reported in Chinese children, click here to review. In a similar study of school age children interviewed six months after 9/11, 29% had anxiety or depression, 25% had difficulty concentrating and 24% had sleep issues.  Click here for study.  We are on the front lines for dealing with these behavioral issues.  In addition to Drs. Sharon Bursky and Laurel Green Kaiser, we are proud to announce the hiring of Dr. Rebecca Boyle, to help meet your children’s mental health needs.  Dr. Boyle, who is an elected school board member in one of the local school districts, brings decades of experience in working with the educational needs of children.  She is an expert on the IEP/MFE/504 process and will be a real resource to those who are struggling as a result of all the school closures.  Dr Boyle will begin seeing patients via telehealth once she is credentialed with local insurance companies sometime in mid June.  So stay tuned.    

Finally, we need your help:  Each year, Northeast Ohio Parent Magazine seeks your guidance on the Best Pediatric Practice.  We have been fortunate to have been chosen for 3 years in a row.  If you feel that we continue to provide you with outstanding care and guidance, please take a minute to vote at:  2020 Parent Choice Awards.  Thank you for your support. 

4.29.20 The Task of the Mask – Download your copy of an e-book we wrote to help young children understand why people are wearing face masks. http://mailchi.mp/a92cf134f52f/taskofthemask

Coronavirus COVID 19 infection 4.27.20 update – http://mailchi.mp/b32b735f34da/covid19april27

Coronavirus COVID 19 infection 4.24.20 update – http://mailchi.mp/345b064ec69a/covid19april24

Parenting Tips & Takeways – 4.22.20 – http://mailchi.mp/1f4cb5d57407/parentingtips

Coronavirus COVID 19 infection 4.19.20 update – https://mailchi.mp/a388732f79b8/covid19april19

Parenting Tips & Takeaways – 4.16.20 – http://mailchi.mp/908feadf0bd9/parentingtips1

Coronavirus COVID 19 infection 4.13.20 update – http://mailchi.mp/85287b1fea15/covid19april13

Coronavirus COVID 19 infection 4.8.20 update – http://mailchi.mp/eb9ef2be5f4a/covid19april8

Coronavirus COVID 19 infection 4.6.20 update – http://mailchi.mp/0dca1b97f280/covid19april6

Coronavirus COVID 19 infection 4.3.20 update – https://mailchi.mp/ef6d95f94f61/covid19april3ID 19 infection 4.2.20 update – http://mailchi.mp/6516c1b4e276/covid19april2

Coronavirus COVID 19 infection 3.30.20 update – http://mailchi.mp/b550a3a88895/covid19march30

Coronavirus COVID 19 infection 3.27.20 update – http://mailchi.mp/2e7658bde103/covid19march27

Coronavirus COVID 19 infection 3.25.20 update – http://mailchi.mp/50ff6e49cab5/covid19march25
 
virus COVID 19 infection 3.23.20 update – https://mailchi.mp/0a46903b2950/covid19march13-437928
 
Coronavirus COVID 19 infection 3.22.20 update – http://mailchi.mp/d1513ce1442a/covid19march22
 
Coronavirus COVID 19 infection 3.17.20 update – http://mailchi.mp/543923b0699a/covid19march17
 
Coronavirus COVID 19 infection 3.15.20 update – http://mailchi.mp/7b94481e54a4/covid19march15-437916
 
Coronavirus COVID 19 infection update #2 – 3.13.20 – https://mailchi.mp/eb38bac3395a/covid19march13-437912
 
Coronavirus COVID 19 infection update #1 – 3.13.20 – https://mailchi.mp/409a7901642d/covid19march13

Coronavirus COVID 19 infection 3.11.20 update – https://mailchi.mp/9d490f8c8109/covid19march11

Coronavirus COVID 19 infection 3.10.20 update – https://mailchi.mp/b180c9b8b2ed/covid19march10

Coronavirus COVID 19 infection 3.5.2020 update – http://mailchi.mp/f5879432b19c/covid5marchhtt

Coronavirus COVID 19 infection 3.1.2020 update – https://mailchi.mp/6c727acdfbdc/coronavirus

  • includes 2.28.2020 communication (edited for updates and corrections) 

Community Resource Guide:  We are excited to provide you with the first version of our Community Resource Guide for COVID 19 with activities

and resources for families. Please visit https://www.senderspediatrics.com/communityresourceguide/ to access and feel free to pass it on.