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 End. This 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:
- Promoting behaviors that reduce spread
- 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.
- 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.
- Cloth face coverings (see below for discussion about face shields as an alternative)
- Adequate supplies of soap, hand sanitizer, paper towels, tissues, disinfectant wipes and no-touch trash cans
- Maintaining Healthy Environments
- 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.
- Shared objects: Each child should have his/her own supplies and equipment. Electronic devices, toys, books and other games should not be shared.
- Ventilation. There should be circulation of as much outside air as possible unless it poses a safety risk by opening doors or windows.
- 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.
- 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.
- Communal spaces. Communal shared spaces such as dining halls or playgrounds should be closed or used in a staggered fashion.
- 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.
- Maintaining Healthy Operations
- Protection for staff and children at higher risk. Higher risk individuals should be offered telework or tele-education options.
- Gatherings, visitors and field trips. Virtual group events and virtual field trips should be encouraged. Non-essential visitors and volunteers should be limited.
- Identify small groups and keep them together. Try to keep the same group of children and staff together, especially in young children.
- Stagger scheduling. Ensure that adequate physical distancing can occur at all times.
- Communicate effectively. Develop communication procedures in the event a staff member or student is diagnosed with COVID-19.
- Develop back up staffing and leave plans for teachers.
- Conduct daily temperature checks of students and teachers.
- Preparing for illness
- Isolate and transport staff members and students who are ill.
- 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.
- 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.
- 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.
- 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.
- 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.
- 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.
- 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.
- 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.
- 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.
- 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).
- 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.
- 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.
- 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.
- 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.
- 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?
- 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.
- 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.
- 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.
- 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.
- 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.
- 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.
- 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.
- The authors studied 10 different common fabrics from 100% cotton to 100% polyester, from shirts, T shirts, quilt cloths, dishcloths and bed sheets.
- 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.
- 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.
- 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.
- 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:
- 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.
- 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.
- 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:
- Higher reasoning/abstract thought: “The incidence is low in my age group and my parents are low risk”
- 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.”
- 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.”
- Planning and organization: “I have always been great at planning out my day”
- 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”
- 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.”
- Patience and hope: “No matter how long this takes, my family and I can withstand the stress. We will not remain in limbo forever.”
- 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:
- 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.
- 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.
- 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?
- 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.
- 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.
- 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.
- 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 email@example.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:
- 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.
- 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.
- 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.
- 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:
- 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.
- 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.
- 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.
- Expand the circle – Slowly expand your social circle and include one or two families of similar age into your COVID community.
- 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
- 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.
- 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+
- 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 firstname.lastname@example.org.
Parenting Tips & Takeaways 5.14.20 update – http://mailchi.mp/40c236d58e60/parentingtips4
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.
- 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.
- COVID uses the ACE2 receptor to activate the immune system and produce the cytokine cascade. Children have fewer ACE2 receptors in their lung tissue.
- 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.
- 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.
- 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.
- We have an extensive cleaning program in place for all of our rooms
- 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.
- 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.
- 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.
- 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 email@example.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:
- Local and national spread of COVID 19
- 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)
- Implementation of a measures to limit the spread of COVID 19 within the schools including:
- Sanitizing procedures
- Screening, monitoring ad testing for illness amongst staff and students
- Use of masks
- Limiting student interactions (having teachers move between classrooms rather than students
- Data about the spread of disease amongst children and adolescents. Right now it appears to be low
- The possibility of intermittent closure of schools if there are outbreaks (similar to influenza)
- A phased approach that looks at any potential spread of disease prior to full reopening
The position paper makes the following points:
- Distance learning this year could not come close to replicating in-person learning
- There is likely a widening divide between those who can learn effectively with distance learning and those who cannot
- It is also not feasible to catch kids up on all lost academic progress
- 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
- Students with disabilities are being impacted more than most with the loss of OT/PT and speech therapies and mental health
- It is likely that sporting events, practices and conditioning sessions will be limited in many locations
- 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
- 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
- Isolation measures and protocols for sick children and staff will need to be developed
- Schools will need to anticipate continued restrictions on physical distancing and group size
Our thoughts include the following:
- 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.
- Schools will have to develop more robust ways of educating both in-school, at home and in a blended learning environment
- 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.
- 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
- Effective means of providing testing and feedback to students and parents will need to be established
- 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
- 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.
- 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%
- 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
- 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:
- 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.
- 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.
- 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).
- 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.
- 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.
- 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.
- Shape breathing – here is a great resource for shape breathing to teach kids deep breathing skills
- 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”.
- 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.
- 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?
- 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.
- Perceiving these cues comes naturally to most humans and lay the groundwork for effective communication and emotional intimacy.
- Video calls, however, eliminate a lot of these non-verbal social cues and require sustained attention to verbal communication instead which can be exhausting.
- 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.
- 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
- 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
- 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.
- 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
- 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
- Move to phone calls: Consider switching to a phone call and walk while you are talking. The walking reduces stress considerably and improve creativity
- 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:
- Setting up your driveway or backyard with chairs that maintain appropriate physical distancing but allow for social integration
- 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
- 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 firstname.lastname@example.org.