Coronavirus COVID 19

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.