Coronavirus COVID 19

Coronavirus COVID 19 infection 4.2.20 update 

Almost everyone is aware of the rising mortality rate from COVID 19 with over 5000 deaths in the US and over 400 deaths today in NY State alone.  It is sobering to hear so many prognosticators agreeing on the possibility of deaths in 6 figures despite all of our efforts to quarantine and shelter at home.  Closer to home, the news is a bit better.  IHME to whom we have looked for realistic modeling for some time projects that Ohio will hit its peak on April 19 and settle down by the end of May. Please click here for more information. Unlike many states, it looks like we will have enough beds and ICU beds to help those who suffer severe disease successfully recover. 
 
So what does summer and the fall look like for our patients? 

  1. Our sense is that after this first shudder, things will begin to normalize in June and July and physical distancing will be lifted. 
  2. It seems very likely that there will be no in-school classes for the balance of this academic year. 
  3. We are counseling parents to not expect summer camps to take place this summer, at least in their current form.  That means figuring out ways to navigate summer (pools, barbecues, backyard camps) and we commit to help you as time gets closer. 
  4. It seems increasingly likely that there will be another flare up of disease in the fall and possibly another one in the winter/early spring 2021 causing more school closings and economic disruption. 
  5. The challenge is that after this first horrible period, the number of COVID positive Americans is still likely to be low, possibly under 10%.  Since we have not done enough testing, we don’t know how low that denominator of “infected patients” truly is. 
  6. The good news is that we expect primary care pediatricians like us will soon have access to both a rapid COVID PCR test as well as an IgM/IgG antibody test.
  7. The PCR test, like the ones our local hospitals are currently using for COVID and like other rapid tests with which you are familiar (strep, flu and mono), finds active disease in your system and determines if you have the disease NOW.   Again, like other rapid tests it only measures a point in time and doesn’t answer the all important question of “are you protected”. 
  8. The IgM/IgG antibody test determines if you have had the disease in the past and have made antibodies to COVID.  IgM antibodies can be measured first and then disappear.  IgG antibodies come out later and persist, indicating the presence of long lasting immunity.  Many researchers are assuming that the presence of COVID specific IgG antibodies indicates protection for at least a year but that assumption remains to be proven.
  9. Ultimately, it is the IgG antibody test that is likely to have to most benefit in determining long lasting immunity as well as the presence of herd immunity
  10. Herd immunity or protection to those who have not been infected from protection of the “herd” (those who have been infected) occurs when 60 or 70% of society are infected.  Getting from 10% where we are likely to be now to 70% is the challenge.  That may not happen until we have a vaccine which we believe as a practice with an active research department, will not likely happen until spring or summer, 2021.  While we know the havoc that this will wreak on all of us personally and on our society as a whole, we think it is important for our families to plan for intermittent rolling shutdowns for the next year.  This may take place on a regional level, a state by state level or a national level.
  11. While we hope we are wrong, our realistic guidance to parents and to schools is to prepare for a real roller coaster ride for the next year.  There will need to be a lot of long distance learning but our school leaders will need to find best practices to educate not just those who can pay attention but those with special needs.  Industry will adapt, small businesses will adapt, restaurants will adapt and government will adapt.  We know we will adapt because we have adapted for almost 250 years (the USA 250 year anniversary is only 6 years away) with international wars, a civil war, other pandemics, a Great Depression and 9/11.  We have survived and grown as a nation from each of our tragedies and we will here too.  At Senders Pediatrics, we will be with you for the ride and beyond, providing honest, caring and practical suggestions at every step.

Are Face Masks Helpful?  Many people have read the piece online that suggests that universal face mask wearing could  be helpful in reducing COVID 19 disease citing the experience in Japan, South Korea, Hong Kong and Singapore.   https://www.maskssavelives.org/   Some states are even recommending universal face masking.  Going to local groceries, it is now common to see as many people with surgical face masks walking around as those without them.  Of interest, if you go to the local hospitals, you will see far fewer employees wearing masks. The CDC is still not currently recommending universal mask wearing for the following reasons:

  1. There is no evidence that wearing a surgical mask helps the mask wearer.  It does reduce the spread of viral particles from the mask wearer to others.   But it doesn’t protect the mask wearer unless it is an N95 mask which is almost impossible to find.   
  2. Surgical masks (the pleated ones) are really one and done.  You would have to replace them regularly for them to have even the aforementioned effectiveness
  3. There are no surgical masks available.  To simply stock our respiratory clinic for the next 6 weeks, took over 2 hours on Amazon and cost hundreds of dollars.  You can buy a lot of masks that will arrive in June but not so many that will arrive in April.

Our recommendations are the following:

  1. If you have a mask and it makes you feel better to wear it, wear it but don’t use it as an excuse to let up on physical distancing because that is much more likely to prevent the spread of disease
  2. Don’t waste your money scrounging up surgical masks.  It will only make it harder for first responders to get them.
  3. We have heard a lot about kids being asymptomatic carriers.  So far that doesn’t appear to be the case at least locally.  None of the patients we have sent from our respiratory clinic for testing have been positive to date. And in unpublished data from one of the local hospitals that does do testing, fewer than 5% of children tested have been positive. 
  4. This may all change if the number of COVID positive people rises significantly.  But right now that is not the case at least locally. 

Building Resilience in Children:  We are excited to welcome Laurel Greene Kaiser LISW, who joins Dr. Sharon Bursky as in-house therapists.  Laurel begins seeing patients (initially via our secure telehealth link) at the end of April.  Laurel’s area of expertise is “building resilience” and we asked her to share some of her thoughts about “building resilience in the shadow of COVID 19” in today’s post. 

  1. Support your kids:  The single most common factor for children who develop resilience is at least one stable and committed relationship with a supportive parent, caregiver, or other adult. 
    1. Being strong doesn’t mean weathering the storm alone. It is knowing you have someone standing by your side, listening and coaching but not solving
    2. With COVID 19, ask them how they are feeling about the quarantines, about being at home, about being isolated from their friends and about their parents working from home
  2. Help your kids see themselves as resilient
    1. If we want our kids to be resilient, we need to see them and help them see themselves as resilient and notice the aforementioned protective factors in themselves and in their situation
    2. With COVID 19, start with a conversation.  Ask them if they know what resilience is, how they see evidence of resilience in their teachers, parents and friends and then how they see resilience in themselves
  3. Help your kids appreciate that they have choices
    1. Giving kids the opportunity to make choices sends the message you believe they are capable of making good choices.
    2. With COVID 19, help them understand that while the big choices such as going to school, meeting up with their friends and seeing their grandparents are now beyond their control, they still have choices over some of the smaller things such as choosing what is for dinner or what game they play on family game night.  They may not have control over doing homework but they can choose when to start their homework. 
  4. Help your kids appreciate that their voices are important
    1. When kids are asked important questions, when they are given the opportunity to help resolve problems, they feel important.
    2. With COVID 19, when asked how parents can be helpful to them, children responded:
      1. “I think it is important to have family meetings, so kids know what is going on.” –age 10
      2. “Provide kids with enough information, but not so much that they panic.” – age 12
      3. “You can make a card, it could be a Valentine’s card even though it’s not Valentine’s Day. It could say, “I love you.” You could play some toys and also do a puzzle, and make flowers and tape them to your windows.”   -age 6
      4. “Have something we can take care of in the house, like helping with a pet, or if you don’t have a pet, helping bake something.” – age 10
      5. “Try to keep them entertained if you can tell they are bored, but don’t be too annoying.  You can offer to watch a show with them or take a walk, but if they say no, that’s okay.” – age 15
      6. “Parents can let teens know they can tell them anything, I know when my mom says that it really helps.” – age 17

Building resilience is not a one and done project.  It takes time, energy and thoughtfulness and an ongoing commitment.  First, we have to build resilience in ourselves and then we can model it for our children.  Let Laurel, Sharon and our entire Senders Pediatrics team help you build resilience in your family so that when we emerge from this challenge, we emerge stronger and better able to handle future challenges.
 
Resilience References
https://developingchild.harvard.edu/science/key-concepts/resilience/  
https://www.aap.org/en-us/professional-resources/Reaching-Teens/Documents/Private/Building_7Cs_handout.pdf
http://www.fosteringresilience.com/resilience.php

More great resources for parents: 

  1. Mom’s Desk:  Sarah Frantz is a mom who decided to use her web-tech skills to create a “mom’s desk” that organizes all of the amazing free child resources out there.  https://momsdesk.org/?fbclid=IwAR1cncyCRkn-uEuNk_JKCK_bR_n2Hc3Y-y84V1skvDBaTtV8v9A9Rb5skfs
  2. Self Help Suggestions:  Dr Eileen Feliciano, a clinical psychologist in NY State who has spent the past few weeks counseling people about COVID.  She put out a to-do list about a week ago.  After reviewing dozens of lists, I think it is probably the best collection of self-help suggestions that I have seen. https://energyresourcing.com/blog/mental-health-wellness-covid-19/
  3. Resources for Special Needs Children:  The Child Mind Institute in NY is an organization has expertise in dealing with children with severe anxiety, depression autism and other disabilities.  They are pricey to see in person but have a wealth of free information available on their website https://childmind.org/coping-during-covid-19-resources-for-parents/
  4. Free mindfulness apps for children:
    1. Breathe, Think, Do Sesame Street- ages 3-5 strategies for kids to calm down, identify their feelings, and work to solve their problem. https://sesamestreetincommunities.org/activities/breathe-think-do/
    2. Ninja Focus ages 4-8 -a digital mindfulness coach to inspire better focus, sleep, and positive behavior  https://www.ninjafocus.com/

This week at Senders Pediatrics

  1. We continue to see patients in our respiratory clinic although the numbers have dropped somewhat from last week. 
  2. We continue to screen all patients for the presence of respiratory symptoms prior to entry into our main office.  Our office continues to be safe from exposure to COVID disease.
  3. We are now asking about travel from a different state.  Given the fluctuating levels of exposure in other states, we are asking that anyone who had travelled from a different state not come in for a well visit for 14 days.  Ill visits for such patients will take place in our respiratory clinic.
  4. We are scheduling lots of telehealth visits for a variety of illnesses that do not require a visit in the office.
  5. We are scheduling lots of well visits.  We continue to believe that it is safe for children of all ages to come for a well visit.  Almost all of our well visits include a discussion about COVID 19 which includes helping parents with the challenges of balancing work at home with home schooling.  Now more than ever, that kind of visit can be helpful.  And remember, with UVC treatment of the air in our building, you and your child have an added layer of protection. 

Please keep your comments and questions coming to care@senderspediatrics.com.  It is what keeps us going. 

Coronavirus COVID 19 infection 3.30.20 update 
Almost everyone is aware of the rising mortality rate from COVID 19 with over 5000 deaths in the US and over 400 deaths today in NY State alone.  It is sobering to hear so many prognosticators agreeing on the possibility of deaths in 6 figures despite all of our efforts to quarantine and shelter at home.  Closer to home, the news is a bit better.  IHME to whom we have looked for realistic modeling for some time projects that Ohio will hit its peak on April 19 and settle down by the end of May. Please click here for more information. Unlike many states, it looks like we will have enough beds and ICU beds to help those who suffer severe disease successfully recover. 
 
So what does summer and the fall look like for our patients? 

  1. Our sense is that after this first shudder, things will begin to normalize in June and July and physical distancing will be lifted. 
  2. It seems very likely that there will be no in-school classes for the balance of this academic year. 
  3. We are counseling parents to not expect summer camps to take place this summer, at least in their current form.  That means figuring out ways to navigate summer (pools, barbecues, backyard camps) and we commit to help you as time gets closer. 
  4. It seems increasingly likely that there will be another flare up of disease in the fall and possibly another one in the winter/early spring 2021 causing more school closings and economic disruption. 
  5. The challenge is that after this first horrible period, the number of COVID positive Americans is still likely to be low, possibly under 10%.  Since we have not done enough testing, we don’t know how low that denominator of “infected patients” truly is. 
  6. The good news is that we expect primary care pediatricians like us will soon have access to both a rapid COVID PCR test as well as an IgM/IgG antibody test.
  7. The PCR test, like the ones our local hospitals are currently using for COVID and like other rapid tests with which you are familiar (strep, flu and mono), finds active disease in your system and determines if you have the disease NOW.   Again, like other rapid tests it only measures a point in time and doesn’t answer the all important question of “are you protected”. 
  8. The IgM/IgG antibody test determines if you have had the disease in the past and have made antibodies to COVID.  IgM antibodies can be measured first and then disappear.  IgG antibodies come out later and persist, indicating the presence of long lasting immunity.  Many researchers are assuming that the presence of COVID specific IgG antibodies indicates protection for at least a year but that assumption remains to be proven.
  9. Ultimately, it is the IgG antibody test that is likely to have to most benefit in determining long lasting immunity as well as the presence of herd immunity
  10. Herd immunity or protection to those who have not been infected from protection of the “herd” (those who have been infected) occurs when 60 or 70% of society are infected.  Getting from 10% where we are likely to be now to 70% is the challenge.  That may not happen until we have a vaccine which we believe as a practice with an active research department, will not likely happen until spring or summer, 2021.  While we know the havoc that this will wreak on all of us personally and on our society as a whole, we think it is important for our families to plan for intermittent rolling shutdowns for the next year.  This may take place on a regional level, a state by state level or a national level.
  11. While we hope we are wrong, our realistic guidance to parents and to schools is to prepare for a real roller coaster ride for the next year.  There will need to be a lot of long distance learning but our school leaders will need to find best practices to educate not just those who can pay attention but those with special needs.  Industry will adapt, small businesses will adapt, restaurants will adapt and government will adapt.  We know we will adapt because we have adapted for almost 250 years (the USA 250 year anniversary is only 6 years away) with international wars, a civil war, other pandemics, a Great Depression and 9/11.  We have survived and grown as a nation from each of our tragedies and we will here too.  At Senders Pediatrics, we will be with you for the ride and beyond, providing honest, caring and practical suggestions at every step.

Are Face Masks Helpful?  Many people have read the piece online that suggests that universal face mask wearing could  be helpful in reducing COVID 19 disease citing the experience in Japan, South Korea, Hong Kong and Singapore.   https://www.maskssavelives.org/   Some states are even recommending universal face masking.  Going to local groceries, it is now common to see as many people with surgical face masks walking around as those without them.  Of interest, if you go to the local hospitals, you will see far fewer employees wearing masks. The CDC is still not currently recommending universal mask wearing for the following reasons:

  1. There is no evidence that wearing a surgical mask helps the mask wearer.  It does reduce the spread of viral particles from the mask wearer to others.   But it doesn’t protect the mask wearer unless it is an N95 mask which is almost impossible to find.   
  2. Surgical masks (the pleated ones) are really one and done.  You would have to replace them regularly for them to have even the aforementioned effectiveness
  3. There are no surgical masks available.  To simply stock our respiratory clinic for the next 6 weeks, took over 2 hours on Amazon and cost hundreds of dollars.  You can buy a lot of masks that will arrive in June but not so many that will arrive in April.

Our recommendations are the following:

  1. If you have a mask and it makes you feel better to wear it, wear it but don’t use it as an excuse to let up on physical distancing because that is much more likely to prevent the spread of disease
  2. Don’t waste your money scrounging up surgical masks.  It will only make it harder for first responders to get them.
  3. We have heard a lot about kids being asymptomatic carriers.  So far that doesn’t appear to be the case at least locally.  None of the patients we have sent from our respiratory clinic for testing have been positive to date. And in unpublished data from one of the local hospitals that does do testing, fewer than 5% of children tested have been positive. 
  4. This may all change if the number of COVID positive people rises significantly.  But right now that is not the case at least locally. 

Building Resilience in Children:  We are excited to welcome Laurel Greene Kaiser LISW, who joins Dr. Sharon Bursky as in-house therapists.  Laurel begins seeing patients (initially via our secure telehealth link) at the end of April.  Laurel’s area of expertise is “building resilience” and we asked her to share some of her thoughts about “building resilience in the shadow of COVID 19” in today’s post. 

  1. Support your kids:  The single most common factor for children who develop resilience is at least one stable and committed relationship with a supportive parent, caregiver, or other adult. 
    1. Being strong doesn’t mean weathering the storm alone. It is knowing you have someone standing by your side, listening and coaching but not solving
    2. With COVID 19, ask them how they are feeling about the quarantines, about being at home, about being isolated from their friends and about their parents working from home
  2. Help your kids see themselves as resilient
    1. If we want our kids to be resilient, we need to see them and help them see themselves as resilient and notice the aforementioned protective factors in themselves and in their situation
    2. With COVID 19, start with a conversation.  Ask them if they know what resilience is, how they see evidence of resilience in their teachers, parents and friends and then how they see resilience in themselves
  3. Help your kids appreciate that they have choices
    1. Giving kids the opportunity to make choices sends the message you believe they are capable of making good choices.
    2. With COVID 19, help them understand that while the big choices such as going to school, meeting up with their friends and seeing their grandparents are now beyond their control, they still have choices over some of the smaller things such as choosing what is for dinner or what game they play on family game night.  They may not have control over doing homework but they can choose when to start their homework. 
  4. Help your kids appreciate that their voices are important
    1. When kids are asked important questions, when they are given the opportunity to help resolve problems, they feel important.
    2. With COVID 19, when asked how parents can be helpful to them, children responded:
      1. “I think it is important to have family meetings, so kids know what is going on.” –age 10
      2. “Provide kids with enough information, but not so much that they panic.” – age 12
      3. “You can make a card, it could be a Valentine’s card even though it’s not Valentine’s Day. It could say, “I love you.” You could play some toys and also do a puzzle, and make flowers and tape them to your windows.”   -age 6
      4. “Have something we can take care of in the house, like helping with a pet, or if you don’t have a pet, helping bake something.” – age 10
      5. “Try to keep them entertained if you can tell they are bored, but don’t be too annoying.  You can offer to watch a show with them or take a walk, but if they say no, that’s okay.” – age 15
      6. “Parents can let teens know they can tell them anything, I know when my mom says that it really helps.” – age 17

Building resilience is not a one and done project.  It takes time, energy and thoughtfulness and an ongoing commitment.  First, we have to build resilience in ourselves and then we can model it for our children.  Let Laurel, Sharon and our entire Senders Pediatrics team help you build resilience in your family so that when we emerge from this challenge, we emerge stronger and better able to handle future challenges.
 
Resilience References
https://developingchild.harvard.edu/science/key-concepts/resilience/  
https://www.aap.org/en-us/professional-resources/Reaching-Teens/Documents/Private/Building_7Cs_handout.pdf
http://www.fosteringresilience.com/resilience.php

More great resources for parents: 

  1. Mom’s Desk:  Sarah Frantz is a mom who decided to use her web-tech skills to create a “mom’s desk” that organizes all of the amazing free child resources out there.  https://momsdesk.org/?fbclid=IwAR1cncyCRkn-uEuNk_JKCK_bR_n2Hc3Y-y84V1skvDBaTtV8v9A9Rb5skfs
  2. Self Help Suggestions:  Dr Eileen Feliciano, a clinical psychologist in NY State who has spent the past few weeks counseling people about COVID.  She put out a to-do list about a week ago.  After reviewing dozens of lists, I think it is probably the best collection of self-help suggestions that I have seen. https://energyresourcing.com/blog/mental-health-wellness-covid-19/
  3. Resources for Special Needs Children:  The Child Mind Institute in NY is an organization has expertise in dealing with children with severe anxiety, depression autism and other disabilities.  They are pricey to see in person but have a wealth of free information available on their website https://childmind.org/coping-during-covid-19-resources-for-parents/
  4. Free mindfulness apps for children:
    1. Breathe, Think, Do Sesame Street- ages 3-5 strategies for kids to calm down, identify their feelings, and work to solve their problem. https://sesamestreetincommunities.org/activities/breathe-think-do/
    2. Ninja Focus ages 4-8 -a digital mindfulness coach to inspire better focus, sleep, and positive behavior  https://www.ninjafocus.com/

This week at Senders Pediatrics

  1. We continue to see patients in our respiratory clinic although the numbers have dropped somewhat from last week. 
  2. We continue to screen all patients for the presence of respiratory symptoms prior to entry into our main office.  Our office continues to be safe from exposure to COVID disease.
  3. We are now asking about travel from a different state.  Given the fluctuating levels of exposure in other states, we are asking that anyone who had travelled from a different state not come in for a well visit for 14 days.  Ill visits for such patients will take place in our respiratory clinic.
  4. We are scheduling lots of telehealth visits for a variety of illnesses that do not require a visit in the office.
  5. We are scheduling lots of well visits.  We continue to believe that it is safe for children of all ages to come for a well visit.  Almost all of our well visits include a discussion about COVID 19 which includes helping parents with the challenges of balancing work at home with home schooling.  Now more than ever, that kind of visit can be helpful.  And remember, with UVC treatment of the air in our building, you and your child have an added layer of protection. 

Please keep your comments and questions coming to care@senderspediatrics.com.  It is what keeps us going. 

Coronavirus COVID 19 infection 3.30.20 update 

COVID 19 continues to be a serious disease.  One week into our Ohio State Stay at Home order, this disease continues its deadly march.  In past posts, we have used the worldometers website https://www.worldometers.info/coronavirus/country/us/ for real time data on the number of documented cases and the number of deaths.  With almost 600 new deaths over the past 24 hours in the US, the rate of daily deaths has risen steadily from 10 at the beginning of the month to over 2500 currently.  The worldometers site does a good job of reporting current data but does not provide information on trends and projections of resources necessary to deal with the pandemic.  The Institute for Health Metrics and Evaluation (IHME) at the University of Washington, has accurately predicted most of the current trends and is a valuable resource for looking into the future based on current physical distancing activities.  It looks at the country as a whole and drills it down state by state to predict peak resource use and whether there will be sufficient ICU beds and ventilators for that peak.  Peak resource use for New York State is expected on April 6 with predictions of a 35,000 bed shortage.  That is why the Federal and State governments are building temporary COVID hospitals in many locations.  The good news is that according to IHME, peak resource use in Ohio is expected on April 16 with no predicted bed shortage.  https://covid19.healthdata.org/projections  There is no question that Stay at Home orders in our state have flattened the curve of a worst case scenario.  Sadly, however, more and more of us know someone who knows someone who has been hospitalized or has died.  For coronavirus, there are now only 2 degrees of separation.

Table Manners and COVID 19:  Nationally syndicated food writer, Bee Wilson, writes, “Until recently, we were living through the most open and diverse era of public eating the world has ever seen.  Never in human history had there been such a variety of cafes and restaurants, street food markets, sushi joints, taco trucks and noodle bars, all of them full of people innocently enjoying delicious things with friends outside the home.”  Physical distancing has changed all the rules.  While most studies do not suggest that COVID 19 is transmitted IN food, it can be transmitted in the process of SERVING food (if you blow your nose and touch the hands of someone else who then touches their nose).  So suddenly it no longer seems rude to refuse someone’s offer to share food.  Ms. Wilson notes 2 positive takeaways of the new reality

  1. It will likely force people to wash their hands more before eating and potentially reduce the transmission of contagious illnesses. 
  2. Cocooning at home has reacquainted people with their recipe books and is allowing people to give the preparation of food the attention it deserves

And her conclusion is “I yearn for the day when the restaurants reopen and we once again trust each other enough to eat from hand to well washed hand.”  We couldn’t agree with her more.  In the meantime, to prevent many of those beloved eateries from going out of business, try to ORDER IN from those same establishments at least as often as you used to EAT OUT from them before this virus changed our lives.  Try to order healthy options both for your kids and for yourself but support our local food establishments.  And please just dispose of the bag in which it arrives. 

Seasonal allergies in the era of COVID 19:  Spring is slowly making its way to Northeast Ohio.  The birds are singing and the trees are budding.  While nighttime temperatures this week will still be around freezing, we can expect the trees to be blooming any week and that means lots of sneezing and runny noses – and lots of fear about COVID 19 which can present in a similar fashion.  For those of you with spring allergies or with children with spring allergies, it might be time to start using your allergy medicine of choice.  Our preference is either a combination of Zyrtec in the AM and Benadryl at night or Allegra in the morning and night.  While COVID 19 is almost always associated with a fever and spring allergies are not, if you are not sure what to do or whether to be concerned, this is a perfect use for a Telehealth visit. 

Selected activities for children, adolescents and even some young adults including podcasts and games.  Wall Street Journal writer Ellen Gamerman has collected amazing digital options that thrill as well as teach.  They are presented below with some of her and some of our comments. 

  1. Bloom: Musician Brian Eno helped create this app, which mixes instruments and artwork.  Unique melodies can be created simply by tapping the screen but a generative music player takes over when Bloom is left idle creating an infinite selection of musical compositions and their accompanying visualizations. http://www.generativemusic.com/bloom.html?mod=article_inline
  2. Brains On!: The podcast uses science and history to explore questions about the world, tackling subjects from black holes to narwhals. https://www.brainson.org/?mod=article_inline
  3. Eleanor Amplified: A brave radio reporter has adventures in this podcast series that also offers a lesson in media. https://whyy.org/programs/eleanor-amplified/?mod=article_inline
  4. Khan Academy:  Kids can access free online courses in math, science, computer programming and other subjects from kindergarten through high school.  One of my kids made it through college statistics only with the guidance of Khan Academy.  https://www.khanacademy.org/?mod=article_inline
  5. The Kid Should See This: The site offers more than 4,000 eclectic children’s videos that also aim to entertain adults.  https://thekidshouldseethis.com/?mod=article_inline
  6. Mission US: This series of interactive American history games delves into subjects like the Revolutionary War and the Great Depression. https://www.pbslearningmedia.org/resource/mu10.vk8soc.7-8.nation.crownorcol/mission-us-for-crown-or-colony/?mod=article_inline
  7. Monument Valley:  The puzzle app has been compared to an M.C. Escher drawing, except here an elfin person moves through mazes of increasingly complex buildings.  It is designed to connect mothers and daughters in a very interactive manner.  https://www.monumentvalleygame.com/mv2?mod=article_inline
  8. Mystery Science:  The site features video lessons for elementary-school children and offers hands-on activities that are designed to inspire kids to love science.  https://mysteryscience.com/?mod=article_inline
  9. Outschool:  Students can learn about everything from raising chickens to “Harry Potter” in these live online classes, which operate via video chat for ages 3 to 18.  Some of the classes cost $5 each but during this COVID 19 period, many are free.  https://outschool.com/?mod=article_inline
  10. Scratch: A free programming community from the Massachusetts Institute of Technology that gives students a chance to create interactive stories, games and animations. https://scratch.mit.edu/?mod=article_inline
  11. Thinkrolls: The physics and logic app is geared toward children ages 3 to 8.  https://avokiddo.com/apps/
  12. Toontastic 3D: Geared to future authors, directors, musicians, inventors and anyone else who wants to turn their brilliant ideas into 3D cartoons.  https://toontastic.withgoogle.com/?mod=article_inline
  13. Babbel:  https://www.babbel.com/  While this is not on Gamerman’s list, it is an amazing way to learn a new language in a creative interactive manner.  We highly recommend it for high school students and above who have always wanted to learn a new language but who have found the traditional approaches too boring.   

Creating a health care community:  We understand that many individuals providing essential services have the heavy burden of finding new childcare options with the closure of schools and many childcare resources. We’ve created a communication tool to help connect individuals seeking services with those who may be able to assist. We have not seen much activity to date but we hope that teens and young adults will use it to indicate their ability and willingness to provide babysitting for those parents who desperately need short term child care options.  Please click here to learn more.

Donate blood.  It is safe to do so and current donations are down 40%.  The American Red Cross and America’s Blood Centers which together collect most of the blood donations in the country report that over 12,000 blood drives have been cancelled in the past few weeks resulting in 355,000 fewer blood units available for emergencies.  In previous emergencies, blood donation centers in other parts of the country have ramped up to meet the need.  But with COVID 19 restrictions, donations are down across the country.  To ensure physical distancing, all blood donation centers are urging potential donors to schedule an appointment online and then blood can be drawn in a safe manner.  And remember, COVID 19 has not been transmitted in blood!  If you are healthy, please contact the following sites and enter your zipcode to find the center nearest you.

  1. American Red Cross:  www.redcrossblood.org
  2. America’s Blood Centers:  www.americasblood.org
  3. Blood Centers of America: www.bca.coop
  4. Armed Services Blood Program: www.militaryblood.dod.mil

More about how to get a good night’s sleep in this high stress period:  To understand how to get a better night’s sleep, it is first important to understand what happens when you sleep.  For more information, check out Ben Greenfield’s new book, Boundless

  1. Body temperature, heart rate, respiratory rate and BP all slow down and muscles relax
  2. The brainstem and hypothalamus which control alertness, produce GABA, a chemical that calms the nervous system
  3. Our hormones are very active.  The stress hormone cortisol drops, insulin which regulates blood sugar spikes to keep blood sugar steady and the ghrelin, the hunger hormone and leptin, the satiety hormone balance out
  4. Neurochemicals such as melatonin and serotonin help synchronize our circadian rhythm

Given these biological patterns, if we want a good night sleep we should be doing the following

  1. Practice Time-Restricted eating.  Try to eat all your food in a 10-12 hour period where the first meal is eaten an hour after rising and the last is eaten 3 hours before bedtime.
  2. Try to eat a large breakfast with protein, a nutrient dense lunch and a lighter dinner
  3. Eat sleep friendly foods that calm the brain and maintain glucose metabolism such as high serotonin foods (kiwi), high melatonin foods (tart cherries, oatmeal and walnuts), tryptophan rich foods (turkey, tofu, miso, bananas, chicken, eggs, almonds and milk), GABA rich foods (miso, kimchi, chamomile, passionflower and lemon balm teas) and magnesium and zinc rich foods (oysters, clams, walnuts and dark leafy veges)
  4. Don’t go to bed hungry.  If you do, your body will go into starvation mode and you will wake up in the middle of the night craving food
  5. Avoid caffeine in the evening.  Chocolate and coffee have a 6-9 hour half life which delays your circadian rhythm and can lead to next day sleepiness
  6. Take a cool shower before bedtime to cool the body

Questions from the care@senderspediatrics.com mailbag:

  1. Is it okay to go jogging or running?  Yes and yes.  Take advantage of the warming weather over the next few weeks and clear your mind while your body produces the chemicals necessary to deal with the stresses of otherwise staying close to home.  Just don’t jog “with” someone else unless they are far enough ahead or behind you. 
  2. Is there any place that is safe to travel now?  The US State Department has issued a Level 4 advisory for all international travel which means DO NOT TRAVEL.  Domestically, there are more and more states clamping down on travel from and travel to.  We strongly recommend that you simply stay put for now.  A reminder that people travelling from COVID 19 hotspots – if they have not been quarantining at home previously – should quarantine upon arrival here for 14 days.
  3. Can I get tested to see if I have had COVID 19 and if I am immune?  There are two types of tests for COVID 19.  The one that is currently being uses looks at whether you are currently infected. That is called a PCR test and it is currently being done only by one of the large institutions if you meet strict criteria.  We are told that a version of this test will be becoming available to primary care providers over the next few weeks so that more people can be tested in real time.  We will let you know when we have access to this test.  The one that will ultimately be most helpful is a rapid COVID 19 test that looks at IgM and IgG antibodies.  As with infectious mononucleosis (mono), the IgM antibody appears within the first 7-10 days, peaks at 14-21 days and then disappears at a month.  This indicates a recent infection.  The IgG antibody appears at about 14 days, peaks much later and stays high indicating the presence of more durable immunity.  Ultimately, as more and more people become exposed, it will be this second test that helps us understand who needs to be quarantined and who doesn’t.  More about this test as it becomes available.  

Please keep your questions, comments and interesting articles coming our way at care@senderspediatrics.com

Coronavirus COVID 19 infection 3.27.20 update 

Predicting the next COVID 19 hot spots:  Sports analyst, Ben Falk, doesn’t have much sports to analyze so he has turned his attention to analyzing COVID 19. Click here to read the article. He has evaluated ILIs or influenza like illnesses (an ILI is defined as a fever greater than 100 degrees F and a cough and/or sore throat without a known cause other than influenza). 

  1. Every year, the CDC reports weekly on the number of such illnesses (the FluNet system) so that medical personnel like us know the trends and can better prepare for what is coming. Click here for the CDC weekly report.
  2. Analyzing data from many years, Falk notes that every flu season there is a double peak of activity.  It rises, falls, rises again and then falls for the season. 
  3. This year, in certain geographic areas, there has been a third peak.  Falk, I think correctly, believes that, hidden in plain daylight, the third peak represents a rise in COVID 19 illnesses rather than influenza illnesses.  
  4. In addition, every week for 10 years, (with only 2 exceptions) there has been a strong correlation between the peaks in children and the peaks in adults >65 except for this year. 
  5. This year, that third peak is seen only in the elderly and not in children.  Once again, Falk believes this correlates with a COVID 19 outbreak which has hit the elderly disproportionately and relatively spared the children. 
  6. If you follow the geographic areas with triple peaks where there is a mismatch between children and the elderly, you can pick up the signal of states where there is likely to be an upcoming spike in COVID 19 activity. 
  7. In NYC, Yale epidemiologist Dan Weinberger has looked at similar ILI data Click here to access data. and has found the exact same pattern which has correlated with the spike in COVID 19 activity in that city. 
  8. Florida doesn’t use the CDC FluNet system and has its own system of graphs.  This week, while the total ILI activity is amongst the lowest in the country and there is a drop in ILI activity in almost all areas, there is a significant rise along the South Florida coast from West Palm to Miami suggesting that there might be a surge of COVID 19 activity in that area in the weeks to come perhaps correlating with spring break mixing. Click here for reports. (Figure 6). 
  9. Similarly, Pennsylvania has shown a large 3rd peak over the past 2 weeks. Click here for PA flu data (Figure 4) suggesting that this state might also become a hot spot. 
  10. The good news is that Ohio has seen a decrease in ILI activity over the past 2 weeks which suggests that we should not expect a huge surge in COVID 19 activity in the next few weeks. Click here for OH flu data.
  11. That doesn’t mean we should let up on our vigilance and our distancing.  It simply means that our efforts at flattening the curve may be helping. 
  12. This Falk analysis may not be accurate.  But it might.  And it is a great example of what makes our country so great.  We have the capability to use business tools of analysis to help us in our war against the virus that causes COVID 19.

Should you clean your iphone to protect against COVID 19? In the 3.27.20 edition of the Wall Street Journal, after interviewing infectious disease experts from around the country, technology writer, Joanna Stern suggests that it may not be necessary.  Emma Hayhurst, microbiologist at the University of South Wales and author of the 2012 article, Why Your Cellphone Has More Germs than a Toilet, says that in generally healthy people, the germs on your cellphone are not a problem.  Since for most of us, cellphones are an extension of our hands, we should thoroughly clean our hands, don’t touch our face and not worry about our cellphones.  Keep your phone to yourself and no one will sneeze on it and you will be fine.  For those germaphobes, Apple, Google and Samsung have all updated their websites to allow up to 70% alcohol (standard sanitizing gels) on the surface of their smartphone brands

Physical distancing instead of social distancing:  “We’re changing to say physical distancing and that’s on purpose because we want people to still remain connected,” Dr Maria Kerkhove, a WHO epidemiologist said in the press briefing. “So find ways to do that, find ways through the Internet and through different social media to remain connected because your mental health going through this is just as important as your physical health.”   We couldn’t agree with this more.  So going forward, we will no longer be using the expression social distancing.  We want social connection with physical distancing.  That means when you take a walk and you see someone else, make eye contact from across the street, say hi and smile.  Or when your kids want to play outdoors, let them play on your sidewalk and let the neighbor play on his/her sidewalk.  As long as they are not getting close to one another, let them play together.

Managing COVID 19 stress from Virginia Veterans Authority psychologist, Dr Brian Meyers:

  1. Limit your exposure to depressing or stressful content.  This means in the media, books, movies, newspapers, and TV shows.  No more than one hour per day – and yes, that includes information about the coronavirus.  Limit screen time, and increase reading; visuals are much more powerful emotionally. Increase content exposure to pleasant things.
  2. Focus on what you can control, and try to let go of what you can’t.
  3. Start a gratitude journal.  Write down 3 things each day you are grateful for, and write down different ones every day.  Do this for at least 3 weeks.  21 days of gratitude journaling has been found to be an effective antidepressant.
  4. Limit junk food intake.  When you are stressed, sugar, salt, and fat taste much better; unfortunately, they also make your body feel worse.
  5. Focus on what you can do now, and don’t worry about what you have to do tomorrow. It will come anyway, and you can focus on it then.
  6. Be kind to yourself.  Remind yourself that you are doing as much as you can.
  7. Get 3-4 hours of aerobic exercise every week, split into at least 3 different days.  Exercise is a natural antidepressant.
  8. Practice mindfulness meditation every day.  Daily meditation lasting 20-45 minutes for 8 weeks has been shown to change your brain, leading it to become calmer in the face of stress.
  9. Get 6.5-7.5 hours of sleep each night.  Less sleep than that makes you irritable, tired, less productive, and less effective.
  10. Plan at least one pleasant thing to do every day.  If you don’t plan it, it won’t happen.
  11. Self-soothe with your senses.  Look at pretty pictures or pictures of people you love. Listen to calming or uplifting music. Fill your home with smells like from candles, scents, and foods. Take long baths and pet your pets. Savor your favorite foods.
  12. Engage in a hobby that has nothing to do with work or relationships.  That way, when other things in your life are stressful, you can still enjoy your hobby.
  13. Practice yoga. It has both physical and mental health benefits.
  14. Have at least one person in whom you can confide:  a family member, friend, minister, priest, rabbi, or therapist. 
  15. Ask yourself what gives you joy and what gives you meaning?  Increase the amount of time you spend doing both.
  16. Develop a self-care action plan.  Split it into five sections:  mental, physical, emotional, social, and spiritual.  Do at least one thing from the plan each day, and one thing from each category each week.

Good news from Senders Pediatrics

  1. Nurse Practitioner, Taylor Knight is coming back this week.  Out for maternity leave for the last 3 months, Taylor will be returning this week on an abbreviated schedule.  If you are a beloved Taylor patient, schedule your well visit with her today.  We know you will enjoy hearing her practical, kind and wise counsel as much as we will.
  2. Remember that we are an independent practice.  That means we are TIER 1 for BOTH University Hospitals and the Cleveland Clinic.  If you know a UH or CCF employee who is looking for a great pediatric provider, let them know that we can be their provider… and that we are open for business.
  3. We are completing our first week of in-office respiratory clinics.  While it takes double staffing to field both respiratory and non-respiratory clinics, we are committed to keeping our main office free of COVID 19 exposures to enable us to see healthy children for well visits. 
  4. Come in for your children’s well visits:  If you are off from work again this week, and you and your child are healthy without any respiratory symptoms, use this as an opportunity to bring him/her in for their well visit. This is particularly important for our youngest patients under 5, many of whom need the protection against whooping cough, meningitis, some ear infections and rotovirus stomach virus infections.
  5. We hope you are enjoying our telehealth visits.  We have dramatically expanded our telehealth capabilities for all of our providers.  It is an opportunity to speak to a provider and have him/her help you with a variety of medical issues that do not involve examination of a throat or an ear. 
  6. Our in-house therapist, Sharon Bursky, is conducting all visits via ZOOM.  Stay tuned for our next post for the opportunity to schedule ZOOM visits with our parent coach, Joan Morgenstern.  Her popular potty mastery series is a must for the parent of all 2 year olds.  And remember, if the signs are there, potty mastery can be achieved in many kids during this time of enforced home time.     

Please continue to send your questions and resources to care@senderspediatrics.com.  We attempt to respond to all questions as expeditiously as possible.   

 
Coronavirus COVID 19 infection 3.25.20 update 
 
Creating a health care community:  We understand that many individuals providing essential services have the heavy burden of finding new childcare options with the closure of schools and many childcare resources. We’ve created a communication tool to help connect individuals seeking services with those who may be able to assist. Please click here to learn more.

Sage advice from General Stanley McChrystal, commander of the US Army Special Ops during the second Iraq war to leaders on the front lines of this pandemic:

  1. Don’t hunker down.  Be visible to your organization, your community and your family
  2. Demonstrate candor and demand it from every level of leadership in your organization. 
  3. Give up more authority than feels natural.  Be connected, listen and adapt to what the people on the front lines are telling you
  4. Be more compassionate than you think you need to be.  Take your culture online and reinforce camaraderie, esteem and compassion via digital platforms. 

Click here to read the full article.

TelePlay Supplementary Workbook for parents of young children.  Our in house therapist, Dr Sharon Bursky recommends this workbook as a great reference for parents of young children at home during the COVID 19 Stay At Home order. Thriving at Home Workbook

How to improve your sleep during the COVID 19 pandemic.  The dissemination of information about this pandemic has increased exponentially in the past few months leading to an unprecedented increase in anxiety, just about what new information is coming our way tomorrow.  In a study of 100 participants in Wuhan, China, researchers randomized patients to mindfulness or mind wandering approaches to see whether it was possible to reduce the sleeplessness that arose from information overload.  Mindfulness reduced anxiety and improved sleep patterns significantly. Click here to read more. We repeat here the link that our in house hypnotherapist, Tom Gigliotti has prepared to help you fall asleep and stay asleep in a world filled with so much unknown.  Click here for video. 

Which moral argument is most persuasive in changing behavior about social distancing?  Psychologists at Yale examined which of 3 approaches is most persuasive in helping shift the paradigm from carefree to careful:  deontological which focuses on the duties, obligations and responsibilities we have to our families, communities and country, utilitarian which focuses on the consequences of failing to slow the spread of the virus and virtue, considering what the ideal person would do in this circumstance.  In a study of over 1000 adults who represented a cross section of the American population, the deontological approach which emphasized our responsibility to one another was the most effective while the utilitarian approach which focuses on consequences was the least effective.  This actually reinforces the approach that we find works best in raising children.  Emphasizing that it feels good to do the right thing rather than it feels bad to do the wrong thing works in parenting and now we learn, also works in messaging about COVID 19. https://psyarxiv.com/9yqs8/

COVID 19 and breastfeeding:  From Dr Ann Witt, Director of Breastfeeding Medicine of Northeast Ohio which is housed in our practice: While there are only limited studies on women with COVID-19 to date, the virus has not been detected in breast milk, although further study is needed. Breast milk provides protection against many illnesses, and given what is known, mothers with COVID-19 can breastfeed. A mother with confirmed COVID-19, or who is a symptomatic with possible COVID-19, should take all possible precautions to avoid spreading the virus to her infant. Before breastfeeding:  Wash your hands before touching the infant and wear a face mask, if available, while feeding at the breast.  If pumping: Wash your hands before touching any pump or bottle parts and follow CDC recommendations for proper pump cleaning after each use: Click here for more information.  If your baby is receiving bottles and it is possible, consider having someone who is well care for and feed the expressed breast milk to the infant.

From the care@senderspediatrics.com mailbox:

Is it okay to open mail if the letter carrier was diagnosed with COVID 19 – There should be no concern about transmission in mail for the following reasons.

1. While in vitro (in the lab), COVID 19 can live for a period of time on paper and cardboard (up to 24 hours), most believe that in-vivo (in real life), given temperature and movement issues, that is not an issue,  According to the WHO, “The likelihood of an infected person contaminating commercial goods is low and the risk of catching the virus that causes COVID-19 from a package that has been moved, travelled, and exposed to different conditions and temperature is also low.”  The CDC has offered similar recommendations about letters.    

2. Most letter carriers are wearing gloves these days

Is it okay to take my kids to the playground?  No.  The reason is less about catching something from the teeter totter and more because your child is likely to be playing with another child and not practicing social distancing.

Is it okay to become pregnant?  Yes, while there is some data that suggests a higher incidence of spontaneous miscarriage in women who contract COVID 19 in the first trimester, the percentage is still very low and with further testing is likely to be lower.  We are a hopeful country and we should not temper our optimism even in the midst of a real pandemic. 

Is it okay to have cleaning help?  Maybe…It depends on who is doing your cleaning and if your household is currently healthy.  Please make sure that you know where your help has been.  If he/she has been in risky areas, you should consider postponing the cleaning for a  few weeks.  Remember the goal is to protect the elderly and those with chronic issues at high risk.  So if your cleaning help is over 65, has a chronic disease, or family member with a chronic disease then please consider paying them for their time this month and encourage them stay home.  If your own family is sick then make sure you and your family stay in isolation and do not have anyone into your home.   It is a great opportunity for children to step up to the plate and take on more household responsibilities. 

How long should people travelling from Italy, Europe and Israel quarantine?  It is a good idea for them to quarantine for 2 weeks given the high incidence of COVID 19 in those countries.

For a video replay of a webinar on COVID 19 and Passover observance given by Dr Shelly Senders to members of the Jewish community on 3.22.20click here.    

How we are supporting you at Senders Pediatrics during this period

  1. We are trying to create a community by sending these email blasts.  Lord Rabbi Jonathan Sacks, former Chief Rabbi of the British Commonwealth distinguishes between a crowd and a community.  A crowd, he notes, is where “individuals lose their individuality. A kind of collective mentality takes over, and people find themselves doing what they would never consider doing on their own…Sometimes this expresses itself in violence, at other times in impulsive economic behavior giving rise to unsustainable booms and subsequent crashes. Crowds lack the inhibitions and restraints that form our inner controls as individuals.”  A community, by contrast, “is a group of individuals who unite together not in a frenzied act of fear, or with a destructive lack of control, but because they are similarly focused on one goal, one purpose. Communities build; they do not destroy. They bring out the best in us, not the worst. They speak not to our baser emotions such as fear but to all our higher aspirations.  At Senders Pediatrics, we have tried to create a health care community for over 30 years.  We believe it is the best bulwark against the challenges of a disjointed and often crazy world.
  2. We are seeing your children and young adults with respiratory symptoms – As COVID 19 spreads throughout the country, we are hearing about and seeing more and more patients with symptoms that can be confusing.  We are seeing those children either by telehealth or in our specially designed isolation rooms.  These rooms are not accessible through the main entrance and such patients cannot spread disease to anyone in the slide and treehouse area
  3. We are seeing your children for a variety of non- respiratory illnesses, some by telehealth, some in person.  Kids with rashes, constipation, broken bones, mental health issues and ADHD still need to be seen.  Medicines need to be prescribed.  We are open for business for these issues in our healthy well space. 
  4. We are seeing your children for well visits.  As we have repeatedly said in these blasts, we have always viewed well visits in a very expansive manner.  In some ways, they are an excuse to talk about your global concerns about your child.  Sometimes, it allows us to talk about bullying, sometimes about speech delay, sometimes it is about a family crisis.  Now it is about COVID 19.  Take advantage of the wisdom and experience we can provide – as well as the preventative vaccines and testing and continue to bring in your children for well visits.
  5. We are helping reinvent healthcare as we go.  We believe that healthcare will never be the same.  We will never go back to the same 1990s silo view of healthcare where you came to your doctor, got your vaccines and went home.  We are developing innovative ways to guide you and your children as you navigate the future and we are trying to instill an optimistic and thoughtful approach every step of the way.  Thanks for your support.     

Keep the questions coming to care@senderspediatrics.com.  We will continue to try to answer all in a timely fashion. 

Coronavirus COVID 19 infection 3.23.20 update 
 
FAQs on the Ohio Department of Health Stay at Home Order

Yesterday, Governor Mike DeWine and Ohio Department of Health (ODH) Director Amy Acton issued a directors order to require all Ohioans to stay in their homes to prevent the further spread of COVID 19 beginning at 11:59 tonight, Monday, 3/23/20 for 2 weeks ending 4/6/20. According to the ODH website, “this order prohibits gatherings of any size and closes all nonessential businesses.  It DOES NOT prohibit essential activities such as going to the grocery story, receiving medical care or taking your pet for a walk.  Residents can return home from out of state and can leave the state.  We present some of the FAQs on the website for discussion and comment.  A full listing of FAQs can be found here. https://content.govdelivery.com/attachments/OHOOD/2020/03/22/file_attachments/1407841/Stay%20At%20Home%20FAQ%2003.22.20.pdf

I work in an essential service.  How will the police know I’m allowed to be outside my house?   Law enforcement officials will not stop residents who are on their way to or from work or who are out for necessities like going to the pharmacy or getting groceries, or just taking a walk. People gathering in any size group may be asked to physically distance themselves or go home. Ohioans should abstain from all nonessential activities. Adhering to the order will save lives and it is the responsibility of every Ohioan to do their part. We are in this together. 
Senders Says:  Voluntary social distancing was the first step.  This is the next step.  It is mandatory in the sense that it is required but there is no punishment for those who ignore it.  If this “soft touch” approach doesn’t work, the next step will be fines and punishments.  The disease has spread dramatically in New York State over the past few days with tens of thousands of new cases and almost 100 deaths.  There are many who believe that as the weather improves, it will hit us just as hard and the governor is not waiting to find out.  Listen to the rules for your good and for the good of your friends and colleagues. 

Will grocery stores be open? Yes, essential services will still be operational including, but not limited to: • Grocery stores • Gas stations • Pharmacies • Police stations • Fire stations • Hospitals, clinics and healthcare operations • Garbage/sanitation • Public transportation • Public benefits (i.e. SNAP, Medicaid) hotlines
Senders Says:  It is okay to go out for food, gasoline and to see us.  Ill children should absolutely be seen.  We are providing as many services online as we can.  For moderate respiratory illnesses, ear infections and sore throats, the risk of delayed diagnosis is potentially worse than the risk of COVID 19, especially in children and those children will be seen in our respiratory isolation clinic on the north side of the building (closest to Mayfield).  We believe that well visits for patients 5 years and under should be continued.  This is a vulnerable age group whose parents are dealing with a variety of day in and day out problems such as feeding, sleeping, toileting and behavioral issues that can rapidly spiral out of hand without a guiding hand especially when the challenges to their parents presented by COVID 19 are layered on top.  Moreover, most of these visits are associated with vaccinations and vaccines should not be pushed off for 3-4 months since there are some who believe that childhood vaccines may be contributing to the relative protection provided to children during this pandemic.  For older children, our interpretation of the governor’s order is that well visits for older children fall under the category of essential activities.  With the extreme stresses that parents and children are experiencing, we believe that connecting and providing educational, behavioral and emotional guidance is necessary to prevent many of the unfortunate physical and mental health consequences of prolonged quarantine.  We certainly understand those who would prefer pushing off these visits for the initial 2 weeks of this Stay At Home order.  However, if, as we believe this order will be extended for weeks or months, we will begin encouraging you to schedule well visits for all of your kids.  We believe that just as it is necessary and permissible to go out for the physical sustenance provided by food, gasoline and dry cleaning, it is necessary and permissible to go out for the emotional and medical guidance and sustenance that comes with a well visit.  This is truly the meaning of a Patient Centered Medical Home (PCMH).  These emails are one aspect of being your PCMH.  Increasingly, we believe you will find well visits to be another equally important aspect. 

How can I get medical care if I need it? If you are feeling sick, call your doctor, a nurse hotline, any telehealth hotline set up specifically for COVID 19 (check with your insurance company) or an urgent care center. If you are experiencing symptoms or are currently in isolation, you should stay at home and follow the guidelines provided by your physician. Do not go to an emergency room unless necessary. Nonessential medical care like eye exams and teeth-cleaning should be postponed. When possible, healthcare visits should be done remotely. Contact your healthcare provider to see what tele-health services they provide.
Senders Says:  We agree.  Please do not self-refer to ERs because you are likely to get exposed to worse illnesses.  Let us be your 24/7 guide for dealing with COVID 19 symptoms especially since children have tended to have fewer complications.

Will public transportation and ridesharing be available?  Public transportation and ridesharing should be used for essential travel only. When possible, walk, or drive yourself.
Senders Says:  When you fill up for gas, please make sure to use hand sanitizer after touching the pump.  If you must use public transportation, don’t share a seat with another passenger.

Can I take a flight out of state? Planes and any other form of travel should only be used for essential purposes.
Senders Says:  We have had a lot of questions about children who have flown in from out of state.  Anyone flying in from Europe or Israel where COVID 19 is present in large numbers, should self quarantine for 14 days.  Those who have flown domestically should consider quarantine for 14 days if they have spent a lot of time in bars, restaurants or other closed-in spaces.

Can I visit friends and family? For your safety, as well as the safety of those in your community, you should remain at home to help fight the spread of COVID 19. However you may travel to care for elderly, minors, dependents, persons with disabilities, or other vulnerable persons. If possible, it is recommended that you drop off supplies, food, and medication to those relatives in need of assistance, but minimize interaction.
Senders Says:  Passover and Easter are coming up.  According to 2015 statistics, 85% of Americans celebrate Easter and up to 20% attend or host a seder on Passover.  Attending an Easter meal or Passover seder at a friend’s house should be off limits this year.  Passover seders should include only nuclear families (you and your children).  Other arrangements should be made to provide the Passover seder experience to people over 60 including using ZOOM for those who are able to use electronic conferencing .  For those who are too feeble, religiously restricted or IT challenged, we are recommending that only 1-2 individuals join them for the Passover seder.  Remember, however, that the mortality for people over 80 is very high and be very cautious about unnecessary exposures.  As for play dates, in the past, our interpretation of social distancing allowed for “insular playdate communities” of 1-2 individuals.  With this next level, we are encouraging parents to not bring members of another family into their home under any circumstances.  Outdoor playdates supervised by adults in which kids play on adjacent driveways and have fun in a separate environment can be an alternative.   

What about my pet? You may walk your dog and seek medical care for your pet should they require it. Be sure to practice social distancing while out on walks, maintaining at least 6 feet from other neighbors and their pets.
Senders Says:  Walking a dog is one of the best forms of exercise.  With the weather warming up, this is going to help reduce the incidence of obesity and is strongly recommended.

Does the Stay at Home order mean I can’t take my kids to the park? Families will still be able to go outside, including to parks and outdoor spaces that remain open, and take a walk, run, or bike ride but should continue to practice social distancing by remaining 6 feet away from other people. Playgrounds are closed because they pose a high risk of increasing transmission.
Senders Says:  Yes, by all means, go to the park.  Our MetroParks are an amazing gift that many of us have rarely experienced.  As the weather warms up, pick a different part of the Emerald Necklace and visit it each week.  See how many parks you can enjoy before this is all over. 

Can I leave home to exercise? Yes. Outdoor exercise like running or taking a walk is perfectly acceptable; however, exercise gyms, fitness centers and associated facilities are closed to reduce the spread of coronavirus. While exercising outside, you should still practice social distancing by running or walking at least six feet away from other people.
Senders Says:  Notice the focus of these FAQs on exercise.  Exercise is a way to reduce stress and build your immunity. 

Can I pick up meals being provided by my child’s school? Yes. Many districts and schools are continuing to support students by providing breakfast and lunch in non-congregate settings. To find a meal site near you, use the Ohio Department of Education’s interactive map http://education.ohio.gov/Topics/Student-Supports/Coronavirus/Supporting-Whole-Child-Nutritionor check your local district’s website or social media channels for meal distribution locations and times.
Senders Says:  A large number of children rely on these meals daily.  The goal of this order is to keep you and your children healthy.  Make sure they get fed. 

Can I go out to do laundry? Yes. Laundromats, dry cleaners and laundry service providers are considered essential businesses that will remain open.
Senders Says:  Keeping clean is also an integral part of staying healthy.

How can I deal with the stress and help my children deal with the stress?  This is not a state FAQ question but may be the most important one on the list.  We are fortunate to have hypnotherapist, Dr Tom Gigliotti on staff at our office.  Tom has prepared a 6 minute relaxation piece which I recommend that everyone view and view again.  Send it on to your friends and loved ones.  Tom has been on medical leave for few weeks but will be back in the saddle in early April for telehealth visits to help build on this video to help our patients deal with the stress.   https://www.youtube.com/watch v=M7kXKS47Ygw&feature=share&fbclid=IwAR3skH_1h4Yq3uijWA2rzA41UvH8gEUEfNu7H_WGyRUPeh5ZXyxXsYVy3UQ

Conclusions:  This Stay at Home order is designed to reduce social interaction by keeping people out of each other’s space and away from each other’s home.  We support these interventions.  While they are currently in place for 2 weeks, these are likely to be a critical 2 weeks in reducing the spread of the virus.  In our hearts of hearts, we expect this to be in place for at least 6-12 weeks or until we slow the arc of the disease.

Additional references:
https://content.govdelivery.com/attachments/OHOOD/2020/03/22/file_attachments/1407840/Stay%20Home%20Order.pdf
https://coronavirus.ohio.gov/wps/portal/gov/covid-19/home/resources-for-economic-support
 
If you have any further questions, please contact us at care@senderspediatrics.com.  We will continue to respond to your questions as expeditiously as possible. 

 
Coronavirus COVID 19 infection 3.22.20 update 
 
The total number of total cases continues to rise.  As of this morning, there were 26,900 cases with 348 deaths.  More worrisome is that there was a big jump in the number of serious or critical cases to 708, click here to read more. 
 
COVID disease in children:  In a new study just out which is the first large study of affected children in China, researchers reviewed the characteristics of 2143 children diagnosed with COVID 19, click here for study.  94% were asymptomatic or mild, 6% were severe.  The percentage of severe illness was significantly lower than the percentage in adults (18.5%).  Characteristics of severe symptoms in children were fever, difficulty breathing, cyanosis or blueness of the skin and often severe diarrhea.  Presentation was rapid averaging only 2 days.  Only one child is reported to have died.  This study which is likely to be widely reported in the days to come will, no doubt, raise anxiety about pediatric illness.  Our interpretation remains cautious.  Whether your child has severe respiratory symptoms from RSV, the flu or COVID 19, if he/she suddenly gets seriously ill, we need to know and we will refer you to the appropriate ER for treatment.   A lot of children have diarrhea.  Unless there is fever and severe respiratory symptoms (can’t catch his/her breath), diarrhea alone continues to suggest a stomach virus and can be managed at home or by telehealth.  While it is clear from this study and likely others to come that children are not entirely spared from COVID 19, this study does point out that COVID 19 disease continues to be less common and less severe in children.  Why this is remains to be determined.   One interesting hypothesis is that children have more respiratory illnesses and have greater circulating antibody protection against all viruses.  Another is that because children have been vaccinated with a variety of antiviral vaccines (Rotavirus, MMR, Varicella, HPV), they have high circulating levels of general antiviral antibodies which may cross protect against COVID 19. https://doi.org/10.1002/ped4.12178. This may not turn out to be accurate.  But especially since there is little to no downside, it provides yet another reason to not postpone well care visits and make sure to have your child receive the vaccines that come at those visits. 
 
Treatments on the horizon:  Scientists in multiple institutions are looking at potential therapies for COVID 19.  As has been reported in the media, chloroquine, a widely used anti-malarial drug and remdesivir, a drug being used to prevent and treat Ebola virus have shown activity in-vitro (in the laboratory) against the virus that causes COVID 19.  That is a far cry from demonstrating that it works in-vivo (in human beings) and so we all need to temper our enthusiasm until we have in-vivo studies that show that either of these drugs works in actual patients. Click here to read the article.
 
Caring for a family member with COVID 19:  Thus far, the numbers of infected individuals in Ohio appears to be lower than those in many other states.  There could be a variety of factors at work, not least of which has been our continued low temperatures.  This may change as the weather improves towards the end of the week.  The CDC and local hospitals continue to not recommend testing for individuals with mild symptoms.  As adults, if you have a temperature of 100.5 or over, a dry cough and fatigue, there is a chance that you have the disease and should quarantine yourself.  The current recommendations for people with confirmed or suspected COVID 19 is quarantine for 7 days from the start of symptoms or 3 days after all symptoms have resolved  WHICHEVER IS LONGER.  Family members exposed to such individuals still need to quarantine for 14 days.  Our expectation is that over the next couple of weeks, many adults will have such symptoms.   It is not clear what the intra-family spread is in this country.  Some studies in Chinese patients show that it is as low as 10%.  The true answer may be much higher.  How do you keep COVID 19 from spreading within your house? 
 
  1. Designate personal sleeping space for the affected individual – Much of the spread is via droplets and the bedroom is likely to be the most contaminated by droplets from sneezing and nose blowing.   Place food outside the room so that there is minimal contact between individuals.
  2. If possible, identify a separate bathroom – Again, there are lots of secretions that end up on sinks, shower doors and door knobs.  Just the act of tooth-brushing can deposit virus on bathroom surfaces.  Not everyone has this option available but if you do, it will likely reduce intra-family spread
  3. Open your windows and increase ventilation – Although some studies have shown that the virus can persist in the air for short periods, having good ventilation (turn the fan from auto to on) and opening the windows especially as the weather improves, will help dissipate any lingering virus.  There is no reason to freeze if the weather remains cold.
  4. Do not share household items such as dishes, drinking glasses, cups, eating utensils, towels, bedding, or other items with the person who is sick. After the person uses these items, wash them thoroughly with hot water or in a dish washer.
  5. Continue to wash high touch surfaces with an appropriate cleanser.  Since it is almost impossible to get commercial cleansers in stores or on Amazon, consider making your own, click here for resources on the CDC website.
  6. Wash laundry thoroughly on high settings.  That should suffice to kill the virus.  Use gloves to handle soiled items and clean your hands after removing your gloves.  Place all contaminated gloves in a lined container and dispose with regular trash. 
Helping children connect with each other during a time of disconnections – Our in-house therapist, Dr. Sharon Bursky has the following comments:  Social distancing goes against the innate need for human connection.  For children, socializing is an essential part of their development and one of the most important developmental tasks adolescents and teens experience. Although adults are able to get creative in finding alternative ways to connect with others, children are less able to do so on their own. Here are some unique ways to help facilitate connection for your children:
 
  1. Use of technology– Our society urges parents to reduce technology use for kids, adolescents, and teens. Under the circumstances it would be appropriate to encourage socialization through the use of technology. This can include FaceTime or using Zoom video with friends and family and sending video clips of messages to friends and family. As Dr. Senders shared in his last COVID-19 update, eye contact releases oxytocin and oxytocin has shown to reduce stress, elevate mood, and can reduce depression and anxiety symptoms.
    1. For elementary aged children– Facebook recently released a Facebook messenger for kids. This particular messenger is made for kids but monitored by parents.
    2. For adolescents/teens– Encourage your children to plan an online lunch or dinner get together with a friend or two. Sharing a meal is a typical way in which we connect with friends. Allow your adolescent/teen to have some privacy during this time to catch up with friends so they can feel like they are engaging in something they would typically do, despite it being via technology.
  2. Making cards, drawing pictures, or sending letters- Back in the day this was the most typical way in which we let people know we were thinking of them. Have your child draw a picture for a friend or a loved one, write a note, or make their very own postcard to send. This activity can both spark creativity and be an expression of thoughtfulness to let friends and family know we are thinking of them.
  3. Neighborhood Rainbow Hunt– This idea originated in Philadelphia and many surrounding neighborhoods engaged! Residents create some kind of rainbow art and hang it visibly in their windows or on their doors, and then parents lead their kids on walks to find them. It’s a great excuse to get outside and see your neighborhood, while keeping a safe separation to prevent the viral spread.
  4. Sidewalk chalk notes for neighborhood friends– This is a great motivator for getting kids to take a walk outside and surprise a friend or neighbor that lives nearby. Take a walk and bring some sidewalk chalk to leave messages and/or draw pictures on a friend’s or neighbor’s driveway. This will certainly excite your children and hopefully be reciprocated.
   

Regaining an appreciation for books:  While your children are home and spending more time on screens for school or to pass the time, don’t forget to encourage them also to pull out a paper book and read it just for fun.  American University linguist Naomi Baron, author of the 2016 book, Words Onscreen:  The Fate of Reading in a Digital World, explores how technology is reshaping our understanding of what it means to read.  While there are wonderful advantages to e-readers, not least of which are convenience, cost savings and the ability to bring free access to literature to people around the world, there are some significant disadvantages.  Users are easily distracted by other temptations on their devices, multitasking becomes rampant (and many studies show that multitasking is not helpful for learning) and screens entice us to skim rather than do deep reading.  It also appears that touching real pages helps us reconstruct the chronological aspects of the reading section much more than e-readers do.  “What came first” is an important part of remembering what we have just read, click here to learn more.  Finally, while most parents think that their digital-native children (those raised in a digitally saturated world as opposed to digital immigrants which is all the rest of us) are not interested in physical books, in an as yet unpublished study of 212 middle and high school students completed last year by Dr. Baron and Norwegian social scientist, Dr. Anne Mangen, the researchers  found that many of the students preferred physical books over their digital counterparts for their tactile qualities.  “I like turning pages”, I can feel the paper in my hands” were some of the comments.  So pull out those old Harry Potter books and use these days and weeks to reconnect your children to the joys of reading a good old paper book. 

What we are doing this week at Senders Pediatrics:

  1. All patients with respiratory illnesses are now being seen in our specially designed isolation rooms. 
    1. We have repurposed 3 rooms on the north side of the building (side closest to Mayfield) with a separate entrance and isolation precautions.  Please park in the specially designated areas.
    2. As we have done for the past week, when you pull up, you will be given a special phone number to contact us about your arrival.
    3. One of our providers will call you and take the history.
    4. When it is time to be seen, we will instruct you when to come to the door and a member of our provider team in full Star Wars protective equipment will meet you at the door and escort you to your room.
    5. Testing for strep and influenza may be completed if warranted and you will then be escorted out.
    6. All rooms are cleaned between each patients in a CDC approved manner.
    7. Unfortunately, we do not have a bathroom in our isolation area.  We will have a portable potty available for emergencies but please make sure that your child has gone to the bathroom prior to the visit to prevent such emergencies. 
  2. Our main office continues to be respiratory illness free
    1. We are screening all patients for COVID like symptoms on the phone and upon arrival.
    2. We are screening all employees for COVID like symptoms
    3. We have removed all toys and books.  Please bring your own small cache of toys and books to occupy your child.
    4. We are wiping down all surfaces after each patient has been seen.
    5. Our UVC treatment of the air is in place and is functioning with 12 circulations per minute.  Any airborne infectious particles are neutralized immediately.
  3. We have ramped up our telehealth capabilities.  According to current federal laws, we may even be able to convert some phone calls to a telehealth visits to better assist you and determine the appropriate medical course of action.
  4. We are working with Parent Coach, Joan Morgenstern to develop our Zoom conferencing capability to help guide you on the many issues arising because of school closures.  More about this capability in our next posting.
As usual, if you have any comments or questions, please send them to care@senderspediatrics.com.  We will try to answer them as expeditiously as possible.     
 
Coronavirus COVID 19 infection 3.17.20 update 
 

Sobering data from the Imperial College modeling study on the potential outcome of the COVID 19 pandemic.  By now, online and on TV, many of our readers have heard reports about this study which describes the potential for COVID 19 to cause up to 2.2 million deaths in the US.  https://www.imperial.ac.uk/media/imperial-college/medicine/sph/ide/gida-fellowships/Imperial-College-COVID19-NPI-modelling-16-03-2020.pdf  That sounds pretty scary and, as has been our position, it is really important to look at these and all new data objectively.  This study is not from a breathless fear mongering group.  It is a sobering look at the COVID 19 pandemic from a purely epidemiological and scientific perspective.  It relies primarily on understanding the concept of reproductive ratio or R0 which is the expected number of cases generated by 1 case in a population where all members are susceptible to the disease.  The R0 for measles for example is very high at 12-18 while the R0 for the previous SARS outbreak was 2-5.  The assumptions for this study are

  1. That the R0 for COVID 19 is 2.4 which means one person will infect 2.4 others. 
  2. That the incubation period (the period it takes for it to show symptoms) of 5.1 days and that infectiousness occurs from 12 hours before (in symptomatic individuals) to 4.6 days after (in asymptomatic individuals).
  3. That 2/3 of patients will be sufficiently symptomatic to self-isolate and that the mean time to hospitalization is 5 days. 
  4. That 30% of hospitalized patients will require critical care
  5. That 50% of those requiring critical care will die

It discusses the two epidemiological approaches now being discussed on a national level.  Suppression which aims to reduce R0 to below 1 and mitigation which aims to slow the progress but not reduce R0 to below 1
 
It then goes on to look at 5 approaches to dealing with the pandemic

  1. CI-Case isolation in the home where symptomatic cases stay at home for 7 days, reducing non-household contacts by 75% for this period. Household contacts remain unchanged. Assume 70% of household comply with the policy.
  2. HQ-Voluntary home quarantine. Following identification of a symptomatic case in the household, all household members remain at home for 14 days. Household contact rates double during this quarantine period, contacts in the community reduce by 75%. Assume 50% of household comply with the policy.
  3. SDO-Social distancing of those over 70 years of age.  This will reduce contacts by 50% in workplaces, increase household contacts by 25% and reduce other contacts by 75%. Assume 75% compliance with policy.
  4. SD-Social distancing of entire population.   All households reduce contact outside household, school or workplace by 75%. School contact rates unchanged, workplace contact rates reduced by 25%. Household contact rates assumed to increase by 25%.
  5. PC-Closure of schools and universities.  Closure of all schools, 25% of universities remain open. Household contact rates for student families increase by 50% during closure. Contacts in the community increase by 25% during closure.

The conclusions are “Overall, our results suggest that population-wide social distancing applied to the population as a whole would have the largest impact; and in combination with other interventions – notably home isolation of cases and school and university closure – has the potential to suppress transmission below the threshold of R=1 required to rapidly reduce case incidence. A minimum policy for effective suppression is therefore population-wide social distancing combined with home isolation of cases and school and university closure. And it recommends maintaining these policies in place for up to 18 months until supplies of an effective and safe vaccine are available.”
 
Our thoughts:

  1. Yikes!  This report is a sobering assessment of the worst case scenario in all areas
  2. It makes assumptions about the R0 or infectivity for this virus which may be way too high.  If the RO is lower than predicted as suggested by the report excerpted below by the chief epidemiologist of the Chinese CDC, these numbers will drop significantly
  3. It does not take into consideration the effect of temperature and specific humidity in mitigating the spread. In studies in the Chinese outbreak, the virus seems to have spread most effectively between 5-11 degrees Centigrade (approx. 40-55 Fahrenheit).  It is not clear what will happen once the weather warms up considerably.  file:///C:/Users/SENDERS/Downloads/SSRN-id3553027.pdf
  4. But this study sounds the alarm for not taking this outbreak lightly.  To be sure, this season we have seen 22,000 deaths from influenza in adults and 144 in children and so far the numbers of deaths from COVID 19 have been under 100.  But because the entire population does not have immune protection from a COVID 19 vaccine and will likely not have access to one for 12-18 months, we have to take the precautions necessary to protect us from a worst case scenario which means the following:
    1. Stay home as much as you can and make sure your children do the same
    2. For the time being, do not go to synagogue or church or other religious institutions where there are more than 10 people
    3. Marriages, funerals and other life cycle events will need to be done with a minimum of attendees
    4. Go shopping to make sure you have food at home.  Do not stockpile.  There is no evidence anywhere that there will be true food shortages
    5. Pick a group of 1-3 friends for your children and make them part of your “insular community”.  Do not have play dates with different children each day
    6. Teenagers need to do the same.  No parties, no gatherings of more than 2-3 people and no closed space get-togethers
    7. Go outdoors. Take walks in the park with your “insular community” but stay 6 feet away from others
    8. IF YOU ARE SICK, STAY HOME – take this seriously and don’t accidentally expose others
    9. Use lots of hand sanitizer and hand washing.  Notice how much you pick your nose and stop doing so
    10. Do not touch a piece of food unless you have washed your hands or used hand sanitizer
    11. Don’t let people into your house unless you can be sure that they are healthy.  If you have cleaning help, make sure that you vet them as much as you would vet anyone else coming into your home

More encouraging data on COVID spread from the Chinese CDC.  In a 3/11 presentation to at the Conference on Retroviruses and Opportunistic Infections, Zunyou Wu, chief epidemiologist of the Chinese CDC said the following which can be heard in its entirety at https://special.croi.capitalreach.com/.

  1. The rate of spread to family members was 10% early in the outbreak but fell to 3% with quicker recognition and isolation
  2. Patients were most infectious at the onset of symptoms, when they spiked a fever. 
  3. Shedding in saliva and other body secretions lasts 7-12 days in mild to moderate cases
  4. What worked in China was that a billion people were told to stay home and 60 million in Hubei were effectively isolated
  5. There is no evidence of perinatal transmission and the virus has not been detected in amniotic fluid, cord blood, neonatal throat swabs and breast milk
  6. The mortality rate in pregnancy and post-partum is no greater than in the regular population
  7. 80% have mild to moderate cases and most recover spontaneously
  8. There is no meaningful difference in distribution between the sexes

While this report is less dire than the previous one, it should not be a reason for letting up on the 3 critical foundations of COVID 19 management:  social distancing, home isolation of sick people – that means fever and respiratory symptoms you stay home and continued closing of schools and universities. 
 
On taking ibuprofen for respiratory illness:  Last Friday, the French Health Department issued a warning not to use ibuprofen (Advil or Motrin) for respiratory illness because of experimental evidence that it can exacerbate symptoms of COVID 19.  Similar warnings have been issued by members of the British health community and have popped up on physician blogs.  While there are sporadic cases of adolescents on ibuprofen with COVID 19 disease, there has been no causality demonstrated.  And to our knowledge there has been NO study of this association.  Our approach is to shift to acetaminophen (Tylenol) as much as possible but to not yet issue a blanket warning until we have more information. 
 
The mental health effects of quarantine:  In a review of 8 studies on the mental health effects of quarantine for a variety of problems, not surprisingly, researchers found increased levels of anxiety, depression, insomnia, low self esteem and lack of self control.  file:///C:/Users/SENDERS/Downloads/Mental-Health-Quarantine-Hossain-et-al.pdf. Irritability was found in 57% of those studied.  Human beings are social animals, even the most introverted amongst us.  We crave interactions with others.  As said previously in these posts, the antidote to post traumatic stress is post traumatic growth.  A few things to do to make that transition:

  1. Acknowledge emotional angst both in your children and in yourself – Anxiety is the social impact of our limbic system which is designed to help protect us from danger, sort of like a Marvel Comics flamethrower.  In cave men days, if you didn’t have a limbic system, you would go over to the saber tooth tiger and say, “here kitty, kitty” and you would be eaten by the saber tooth tiger. 
  2. Build your pre-frontal cortex.  Those of us who survived the saber tooth tigers and the T rexes evolved a special part of our brain called the pre-frontal cortex which essentially serves as a barrier or wall against our limbic system.  You can build your prefrontal cortex in the following ways:
    1. Exercise – 30-45 minutes of active exercise builds your pre-frontal cortex
    2. Eat well.  Make sure to eat breakfast each day and add protein to your diet.  It releases energy to your system throughout the day
    3. Sleep – Adults need 7 hours a night, teens 8 hours, 9 -11year olds need 10 hours and children under 9 need 11 hours
  3. Help others – One of the best ways to reduce anxiety and depression is by doing things for others.  Within the barriers of social distancing, find ways to support others either online, with Facetime or other social media platforms or by developing a daily buddy system with someone else who is being isolated. 
  4. Keep a happiness journal – Multiple studies show that if you keep a daily journal (you have to write it down) of 3 things that make you happy, make you optimistic or give you gratitude, you will be happier 1 week, 1 month, 3 months and up to 6 months later.  We all still read The Diary of Anne Frank 80 years later, not because our circumstances are the same.  But because that teenage girl captured the feelings of being cooped up, the fears and the hopes.  It remains inspirational to us because it captures universal feelings.  Who knows which one of your kids will keep the diary that gets read 80 years from now and inspires the next few generations!

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.
 
This week at Senders Pediatrics:

  1. Curbside Car Care – our curbside car care clinics have ramped up.  We saw 4 on Saturday 3/14, 15 on Sunday 3/15 and 35 on Monday 3/16.  What we have learned is that the vast majority of children do not have symptoms suggestive of COVID 19. 
  2. COVID 19 testing stations – UH and CCF now have multiple such stations in different parts of the city.  All require a requisition.  The CCF requires a telehealth visit before they will write you a requisition.  UH does not.  We are still working out the mechanism for referring patients whom we have seen in our Curbside Car Care clinics and who may need COVID 19 testing.  More about this tomorrow.  So far, however, we have only sent 5/54 patients in for further testing.
  3. We have ramped up our telehealth capabilities.  We can see patients for ADHD, depression, anxiety, most rashes, most conjunctivitis (pink eye), nausea and vomiting, constipation, seasonal allergies and all behavioral problems by telehealth.  And it looks like with new legislation at the state level, all of these visits are likely to be paid for by insurance companies.  
  4. Our office continues to remain a healthy place to be for well visits
    1. We are in the middle of installing UVC treatment of forced air HVAC system which will serve as an additional barrier to the spread of disease. 
    2. Our Curbside Car Care providers wear caps, gowns and other protective equipment and do not see healthy patients after seeing children with respiratory illnesse
    3. Our rooms are cleaner than they have ever been and there are no toys or unnecessary play equipment in any room
    4. We have a monitor standing at the door to insure that healthy children are indeed, healthy.  Please be a good citizen and if you are ill or your child is ill, please cancel.
    5. Children need vaccines and if this is going to be a long term issue, please make sure they come in for their regular well child visits so that they remain up to date for vaccinations.

As always, please send your questions via email to care@senderspediatrics.com.  Our advice calls have doubled this week so please be patient with our Advice Nurse staff as they wade through the questions.  We have added staffing to keep up with the volume. 

Coronavirus COVID 19 infection 3.15.20 update 

With increased nationwide testing, the number of diagnosed cases of the disease continues to rise with the US death toll now over 60.  With schools closed, gatherings of people limited and religious institutions shuttered, social isolation is beginning to take root.  While the incidence of this disease in children has continued to be negligible, because the disease continues to be a disease of the elderly and the immunocompromised, our focus is on preventing disease in children who are often the cause of spreading disease to their grandparents.

Please stop using elderberry/Sambucol products for the time being.  Readers of these emails know that we were an early recommender of Sambucol brand elderberry products because of the very positive data found in the treatment of influenza.  However, new information about the mechanism of action of COVID 19 infection calls this recommendation into question.  As your guide during these uncertain times, it is our responsibility to provide updated info as it becomes available and to provide thoughtful but well sourced information.  In studies noted in the reference section below, COVID 19 appears to do its damage by increasing the production of inflammatory cytokines or chemicals that do direct damage to multiple organs of the body, most notably the lungs.  The virus impacts on cells in the body called T lymphocytes which release chemicals that cause blood vessels to become leaky and when that happens in the lungs, lung tissue stops oxygenating and the body is in trouble.  This so called ‘cytokine storm’ has been documented in multiple studies of patients infected with COVID 19 in China.  The mechanism of action of elderberry/Sambucol which is so helpful in the treatment of influenza is to increase immune protection against the virus by increasing production of those same inflammatory cytokines.  In some patients with COVID 19, this may actually make the clinical course worse.  Practically speaking:

  1. If you are using elderberry/Sambucol, please stop taking it.  There is no evidence that the biochemical effects last more than a day so there should be no adverse effects by the following day.  We are taking this position out of an abundance of caution rather than because there has been any study that elderberry/Sambucol has caused any side effects to anyone
  2. If you are not using elderberry/Sambucol please do not start until we have more information about the mechanism of disease in COVID 19

What are the symptoms of COVID 19? There continues to be confusion about the symptoms.  In a review of 72 reports on COVID 19, 62 of which were from China and 10 others from a variety of other countries, the most common symptoms were fever (present in 83%,) cough (61%) and fatigue (38%).  Less common symptoms were sore throat (14%), headache (12%), GI symptoms such as nausea, vomiting (9%), upper respiratory symptoms such as runny nose and nasal congestion (8%) and diarrhea (6%).  We have received many questions about patients with some of the lower percentage symptoms.  Remember, fever and cough are still the most important symptoms to look for.  If your child has predominately GI symptoms, it is still more likely to be a common GI virus and should be treated accordingly (Drip Drop or Gatorade in small amounts for vomiting and starchy foods for diarrhea).

Testing for COVID 19:  By now many have heard about the CCF/UH consortium that will be testing for COVID 19 in an outdoors parking lot in University Circle.  This testing program is still very rudimentary, with only the capacity for testing 500 people a day with more significant symptoms and will require a doctor’s prescription.  We will have a telehealth program in place shortly to help patients who meet the criteria for testing, get the prescription that will enable them to be tested.  More to come in tomorrow’s posting.

How long are the school closures likely to last? The CDC has put together an algorithm for school closures with the pros and cons of shorter versus longer closures. The decision in Ohio will be up to the governor and his health care advisory team.  However, since the virus appears to spread most rapidly with outside temperatures of 40-55 degrees Fahrenheit, we will likely see more spread in the weeks ahead.  As our temperatures rise into the 60s, there is a lot of optimism that things will slow down. Our best guess is that while the governor has only closed schools for 3 weeks, we should gear up for an 8 week closure and possibly for the balance of the school year.  While optimism is always helpful, realism will more helpful for those who have to make child care plans. Considerations for School Closure – CDC

More on play dates and sleepovers.  Every decision we make as parents is a risk/benefit analysis.  This is compounded during this period of uncertainty about COVID 19 because we need to temper individual needs with the health risks to the community.  We have had many questions about the wisdom of having individual play dates and sleepovers during this period.  The CDC has developed mitigation strategies for reducing the spread of disease.  https://www.cdc.gov/coronavirus/2019-ncov/downloads/community-mitigation-strategy.pdf   Even with significant spread of disease they are not recommending complete social isolation but reducing groups of healthy individuals below 10 individuals.  We continue to believe that having individual home play dates or sleepovers with healthy children or individual outdoor play dates on a backyard swing-set (spending time outdoors or exposed to the sun is particularly helpful) is okay and will help reduce cabin fever without endangering the health of the community.  Of course, this means limiting the play date partners to a small number.  If your child plays with 2 different other children per day for a few days, that is as bad as playing with 10 at once and defeats the purpose of school closures especially in the preschool population.  So pick 1-2 friends and schedule only with that small group and if there are any respiratory symptoms, please cut out the play dates.  Please remember that if there is any routine exposure to an adult over 60 either in the house or in the community, we believe that exposures to other children should be eliminated. And obviously, adolescent congregation is a real no-no.  

Putting the oxygen on ourselves.  Make sure to protect yourself by getting more sleep than you might normally get.  While we are all online and glued to the TV, reducing electronics as we get closer to bedtime and getting 7 hours of sleep a night may be the best thing we can do to protect ourselves.  It is the oxygen analogy.  When you fly on a plane with a child and the pressure drops, you need to put the oxygen on yourself and then help your child.  We parents and health care professionals need to put the oxygen on ourselves. Social isolation may reduce the spread of disease but can have significant downstream effects on children who are prone to anxiety.   Here are some good pieces on dealing with anxiety in adolescents and young children recommended by Dr Sharon Bursky, our in house therapist   

  1. https://www.nytimes.com/2020/03/11/well/family/coronavirus-teenagers-anxiety.html
  2. https://www.pbs.org/parents/thrive/how-to-talk-to-your-kids-about-coronavirus
  3. https://660919d3-b85b-43c3-a3ad-3de6a9d37099.filesusr.com/ugd/64c685_319c5acf38d34604b537ac9fae37fc80.pdf

Protecting the elderly:  We are very concerned about the impact of school closings on the elderly.  The CDC suggests that having so many children at home will put a tremendous strain on working parents to have grandparents babysit for them.  Since people over 60 and particularly over 80 are at greatest risk (the mortality rate for people under 50 in some studies is as low as 1%), our job as a community is to protect our elderly.  We have reached out to school leaders to help implement the following:

  1. Help recruit teenagers who are at low risk for complications to become part of a shareable list of potential sitters and caregivers for young children
  2. Find some teenager who might serve as a point person in our community to set up a website and/or app as a means for dissemination. 

We expect that a centralized program to help protect our elderly will come into place in the next few days.  We will be publicizing these efforts as they become available and are calling on our patients and their families to be on the front lines of creating a COVID 19 Caring Community for our most vulnerable.
 
Curbside Car Care – On Saturday and Sunday, we have trialed this approach which has worked wonderfully.  This is the approach we will be using on Mon-Thursday afternoons starting at 1 PM. 

  1. All patients with respiratory symptoms are being evaluated by our RN staff for the need to be seen. 
  2. Home treatment programs are being recommended for those for whom this is appropriate. 
  3. For those who need to be seen, we are taking down car makes and license plate numbers, taking payment of copays by credit card and providing a hot line number to call when you arrive. 
  4. We have designated spaces on the south side (closest to Cedar) of our parking lot. 
  5. A designated provider will call and take the history and another will don personal protective equipment and see your child in the car. 
  6. Please bring only one adult and one child to each visit unless more than one child needs to be seen.
  7. Most other practices are referring such patients to the ER.  We believe that this approach and the construction of 3 isolation rooms by the end of the week will provide maximum protection to you, your child and our staff with the least amount of ER exposure.
  8. We continue to recommend that children come to our main office for routine well care and vaccinations as these are proven ways to protect against diseases that are potentially worse for children than COVID 19
  9. Now that the governor is requiring insurance companies to cover telehealth visits, we will be developing a plan for telehealth care for patients with behavioral health conditions (ADHD, depression, anxiety).  More to come. 

As in previous posts, below are some additional references for those who want to read more:
https://www.ncbi.nlm.nih.gov/pubmed/11399518
https://www.medrxiv.org/content/10.1101/2020.02.16.20023903v1
https://www.sinobiological.com/cytokine-storm-cytokine-storms-a-5800.html
https://papers.ssrn.com/sol3/papers.cfm?abstract_id=3541136
https://www.medrxiv.org/content/10.1101/2020.03.07.20032573v2

Please continue to send your questions to care@senderspediatrics.com.  We will try to answer your questions as expeditiously as possible.  

Coronavirus COVID 19 infection update #2 – 3.13.20 

As of this afternoon, there are now 13 confirmed cases of COVID 19 in NE Ohio and the expectation is that with further testing, many more will be identified over the coming days.  As we noted earlier today, we are focused on protecting you and your children both physically and emotionally.

Curbside car care this weekend: Given the increased identification of cases, we are committed to keeping our main office clean.  Accordingly, any patient with respiratory symptoms calling on Saturday 3.14.20 or Sunday 3.15.20 will be referred to our RN advice nurse staff.  If appropriate to be seen, we will schedule a curbside car care visit in designated areas on the south side of our building (closest to Cedar).  Our RN will ask for the model, color and license plate of your car and one of our providers will call you and get the history.  When that is complete, a gowned and masked provider (Dr Sangree this weekend) will come to your car and evaluate your child.  If flu or strep testing is needed, we will do that testing and provide you with results.  We have even figured out how to give albuterol treatments. If your child is on albuterol or flovent, we ask that you bring the inhaler and the chamber to the visit.  We will not be able to draw blood on Saturday or Sunday.  We also ask that you only bring one child to these visits to help facilitate care.  And in advance, we ask for your patience and indulgence as we try to hone our workflow to maximize efficiency.  Rashes and orthopedic problems and any other non-respiratory illnesses can be seen in the main office as usual.

Talking to your kids about COVID 19:  We have had many calls about how to speak about this outbreak to your children.  Most younger children, especially those under 6 or 7 years do not have very sophisticated abstract thinking ability.  This means they cannot see beyond what you tell them.  That is fortunate because you can reduce anxiety by simply reassuring them and telling them that all these precautions are just temporary and that they will be going back to normal soon.  For children with more “seeing beyond the facts” ability, anxiety can become a big issue.  Seeing this play out on television in great detail, noting their prayer opportunities to be lost at places of worship, finding their social outlets to be reduced and seeing their beloved sporting events cancelled can be profoundly disturbing.  Our best advice is along the lines of the comments in today’s earlier post.  Acknowledge anxiety about the future and about the health of loved ones, avoid large scale human interaction but continue to maintain smaller scale relationships, provide information about the relative safety of all children and younger adults (their parents) and point out the positives of no school, no religious services, and no pressures.  Model kindness for others who are less well situated, practice gratitude for all the things we do have and express optimism for the future.  As pointed out in today’s previous post, based on strong mathematical modeling, when the temperature rises, it is likely that this will all get better. 

Please continue to send your questions to care@senderspediatrics.com.  We will try to answer your questions as expeditiously as possible over the weekend.  

Coronavirus COVID 19 infection 3.13.20 update

As of late last evening, the number of cases of COVID 19 has continued to rise with 37 confirmed deaths nationwide.  In Ohio, there are now 5 confirmed cases, 3 in Cuyahoga County, 1 in Stark County and 1 in Trumbull County.  Governor DeWine has issued an order closing all public, private and charter schools for at least 3 weeks beginning end of day Monday, 3/16 and many daycare providers and preschools have followed suit.  The governor has also issued a ban on gatherings of more than 100 people in auditoriums, stadiums, arenas, conference halls, cafeterias, parades and festivals.  The stock market continues to be battered as more and more businesses are affected.  And lots of the parents of our patients now find themselves trying to make sense of it all.  Below are some of our continuing thoughts and responses to online questions on the COVID 19 outbreak.

Who is affected by the governor’s ban and who is not?  The focus of the governor’s ban appears to be on mitigating the spread of the virus by reducing long and more intimate exposures such as those that occur in schools, sporting events, conferences and parades.  A good rule of thumb is that if you can smell someone’s breath, you are probably at risk for transmitting or contracting the disease.  Since social distancing has been shown to reduce spread, the fewer large gatherings the less likely there will be spread.  Gatherings that are not included in the ban are airport, bus and train facilities, shopping malls, restaurants, grocery stores and religious facilities, mostly because these areas are more wide open spaces.  However, many local religious leaders have taken precautions to conduct services in the shortest possible manners in the largest auditoriums possible.

Some philosophic thoughts about dealing with school bans and quarantines 
We, as a country have not recently experienced the type of medical, social and financial upheaval that we are all experiencing today.  Our lives may be at danger, our social fabrics have been disrupted, weddings are being cancelled, stores are bare, schools are closed and even our beloved sporting events have been shuttered.  Many of our patients and their parents are experiencing anxiety, depression and a sense of helplessness, all emotions that are completely understandable.  Some of my family members reached out yesterday to Jewish human rights activist and hero, Natan Sharansky, who spent 9 years in solitary confinement in Soviet jails in the late 1970s and early 1980s for some words of wisdom .  An inspirational speaker and Israeli leader for the past 30 years, Mr. Sharansky brings a unique perspective to the COVID 19 issue.  The following is a summary of his thoughts.

  1. You call this a quarantine?  It is helpful to put things in perspective.  9 years of torture in solitary confinement is a true quarantine.  This may be intense and challenging, but it will end some day and life will go on.
  2. Choose to view these 3 weeks plus as an opportunity, not a punishment.  Sharansky noted that when he was young, he was always told he should never sing, that he had a terrible voice.  In those years in solitary confinement, he sang and sang and sang – because he could.  Read that book you always wanted to read, learn that language online that you always wanted to master and spend some time really talking to your kids, without the phone and all the electronics.  Focus on what you do have, not what you don’t have.  I firmly believe that at the end of this epidemic, we will have learned a lot about ourselves as individuals and as a nation.  New industries will be spawned, new businesses will be developed and new relationships will be formed.  But that will happen only if we focus on the possibilities. 
  3. Concentrate on being part of a community.  When he was struggling for those 9 years, Sharansky said he was able to survive and even thrive because he knew there was a Soviet Jewry movement behind him that was holding rallies and lobbying congressmen.  While you may be at home either sick, in quarantine or just caring for your school-less children, remember you are not alone, that there are literally millions of people who are a part of your community doing the same things and throwing you virtual hugs and words of encouragement.
  4. Don’t let yourself fall into despair by having unrealistic expectations.  Sharansky said he never expected to get out at any particular time.  But he always was optimistic and hopeful.  Even on the last day, he knew something could happen and the Soviet Union might change its mind.  The key to dealing with a long haul is to keep your expectations low and your goals high.  We don’t know how long this COVID 19 outbreak will last or how many will be affected.  The best way to deal with it is to be optimistic that after the first pass, it will dissipate in the summer and life will go back to normal.

It is worth adding some thoughts from the world of positive psychology.  There is abundant evidence that when you are anxious and depressed, writing down 3 things each day that make you happy, optimistic or for which, you have gratitude will make you happier one week, one month, three months and even 6 months later compared to a control group that does not practice this type of happiness journaling. Over the past few months, unrelated to the COVID 19 outbreak, we have recommended this approach to many of our teenagers with great success.  Many parents have found that sharing their own 3 things with their teenagers has opened avenues of communication that never existed before.  Try it over the next few weeks.  You may be pleasantly surprised how this helps you deal with the very real and very intense issues with which you are dealing every day. 

And now for some practical suggestions on what to do.   With schools and day cares closing, a lot of adults will either be stuck at home or scrambling to find care for their children so that they don’t lose their jobs.  A few thoughts:

  1. If day cares are closing, that means a lot of day care workers are looking for a means of supporting themselves.  Call them and ask them if they are interested in working for you and a group of your friends at your home.  But be cautious and avoid using people over 60 years as sitters – for their protection. 
  2. There will suddenly also be a lot of teenagers who are out of school.  This opens up the pool of potential babysitters.  Again, pool resources with your friends.  There is absolutely nothing wrong with having 4-5 kids together for a day long play date in a different house each day.
  3. Plan for sleepovers.  We have been asked about the propriety of having sleep overs during this outbreak.  Our feeling is that again, in small groups, this is a fine activity.  Providing your child with things for which to look forward is really critical in preventing cabin fever.  But also remember that for every hour of missed sleep, your immune system is thought to take a 10% hit.  Make sure that sleepovers start early and that all participants get plenty of sleep. 
  4. Go outdoors.  It is fortunately expected to be in the 50s in the next week.  Plan outdoor activities at the homes of your friends with swing-sets and jungle gyms.  A little mud is not bad.  And the fresh air is one of the best ways of keeping the virus at bay.
  5. For teenagers who may be expected to log on and complete online work, take a page out of the playbook of some of our home schooled families.  Set specific times for waking and working on school work and projects.  Check in at prearranged times to ensure that there are no questions.  Set limits for the use of electronic devices during these “school-related” periods just as teachers would do in class.  Remember, that your teens are just as worried as you but may not have the words or the emotional development to express those worries in a socially acceptable manner.  Expect some anger and some back talk.  Try to see behind the anger even as you are dealing with your own anger and frustration.  And reach out to us if you see that the frustration is boiling over.  We can help. 

Which are characteristics of COVID 19 infection and which are not?  In a review of 18 studies on COVID 19 involving over 1400 patients, fever was seen in 89%, severe respiratory distress in 67% and fatigue in 46%.  These are obviously very non-specific signs and symptoms.  Remember that fever and cough continue to be much more likely caused by the flu or a variety of other viral illnesses.  It is the severe respiratory distress and the fatigue that sets this disease apart.  Dizziness, conjunctivitis (eye redness) and abdominal pain were NOT associated with COVID 19 infection.

Who might be infected?   Based on the community spread to date, Dr Amy Acton of the Ohio Department of Health estimates that 1% or up to 100,000 Ohioans may be infected with the COVID virus. That is actually good news because it means that once tests become readily available, we will all realize how many of us have already had an asymptomatic or mild form of the disease and the quarantines and school closings will end.  Remember, all studies to date suggest that the percentage of asymptomatic patients is over 80% and there are very few children who have had any serious manifestations.  That means that our patients and their parents are likely to pass through these next few weeks relatively unscathed.

What about testing?  Many of you have heard that the Cleveland Clinic has begun conducting testing on its most fragile or symptomatic patients.  This test is not available currently for patients in outpatient settings or patients with minimal symptoms.  We expect more testing to be available by the end of next week.    

Temperature and humidity characteristics of cities with high COVID 19 outbreaks.  In a fascinating study of the outbreaks in Wuhan, Tokyo, Qom, Seattle and Milan, researchers found a strong relationship between temperature and humidity and community spread.  Temperatures between 42-52 degrees and relative humidity of 47-79 degrees were affected.  The virus responsible for COVID 19 does not appear to be able to live below 32 degrees or much above 52 degrees.  Cities predicted to be affected in the weeks to come include:  London, Berlin, Prague, New York, St Louis and Vancouver.  As the temperature rises, this research team suggests that the disease will move northward into Canada and ultimately affect smaller and smaller groups of people in the extreme northward territories.  This has some major implications for our community.  The unseasonably warm temperatures may put us in the crosshairs of this outbreak but if it dips down into the twenties and thirties or rises into the 60s for any period of time, we may catch a break. 

What about travel? We continue to take a day by day approach to this matter.  By now, it is clear that many of the venues to which we might be travelling (Disney parks are closed) during spring break are closed.  Airlines have cut back on flights significantly and there are daily reports of COVID 19 exposures on planes.  If you don’t have to travel by plane, please don’t.  Travel by car is fine and stopping at gas stations and convenience stores are also fine.  Just wash your hands.  While there are many reports that the virus can live for days on different surfaces, it can’t infect you if you don’t let it in.  This virus, by and large, lives on surfaces.  So if you don’t let it into your nose, your ears or your mouth, you are fine!

How about pregnant women?  A lot of questions have been raised about risks to the unborn.  We are not experts in this area and will certainly defer to our OB/Midwife colleagues.  But data published this week from China is encouraging for women in their third trimester.  In a study of 9 pregnant women with COVID 19 who delivered babies (all by C section to prevent transmission from a vaginal delivery), none of the babies had symptoms of the infection.  Cord blood, amniotic fluid and neonatal throat swabs were negative for the coronavirus.  This pattern is similar to the one seen previously in the SARS-1 epidemic in 2003.  There is one previous report of a newborn diagnosed with COVID 19 thirty six hours after birth but it is not clear if that was transmitted in-utero or after birth.  Suffice it to say that if you are pregnant and in your third trimester, even if you do contract COVID 19, your baby is likely protected.  The data is less positive in the first trimester.  If you are newly pregnant, treat yourself like someone over 60, avoid lots of social contact and be extra careful about hand washing and using sanitizers. 

What you can expect from Senders Pediatrics:  In keeping with public health expectations that are causing schools to be close end of day Monday, 3/16 (with expected doubling of symptomatic cases every 2 days), we are engaged in the following preparations:

  1. We are already screening ill patients to ensure no travel to areas with high COVID 19 activity and/or exposure to a known case
  2. We will continue to see ill patients of all stripes through the weekend in our regular offices
  3. Beginning Monday, 3/16, we will be conducting telehealth or car visits for patients with respiratory symptoms and sore throats.  Call as usual for an ill visit and if YOU or YOUR CHILD has any of these symptoms, and if we feel that a telehealth visit is appropriate, we will give you the log in instructions for such a visit.  If we feel we need to see you, we will be in contact with you by cellphone and a designated provider who will use cap, gown and mask to evaluate your child at the car window during the hours of 1-4 PM.  Designated parking spots will be on the south side of the building (closest to Cedar Road).
  4. On Wednesday, 3/18, our new UVC air treatment system will be installed, ensuring that the air in our building has been treated to eliminate viruses, bacteria and fungi.
  5. On Friday, 3/20, we will have outfitted 3 isolation rooms on the north side of the building (closest to Mayfield) and we will no longer be conducting car visits.  You will be called by cell phone and your child will be masked and brought into an isolation room.  We will evaluate your child and do appropriate testing.  Currently, there is no provision of COVID 19 testing except in emergency rooms but once that becomes available, we will conduct such testing in those designated areas.
  6. We will continue to see healthy patients or patients with non respiratory illnesses in our main offices.  We expect that the risk of contracting COVID 19 in our waiting area or in our main clinic areas to be minimal. 

As has been our practice, the following are references for those interested in reading more. 

  1. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3256323/
  2. https://www.sciencedirect.com/science/article/pii/S0140673620303603#bib16
  3. https://doi.org/10.1016/S0140-6736(20)30365-2
  4. SF Wong, KM Chow, TN Leung, et al. Pregnancy and perinatal outcomes of women with severe acute respiratory syndrome Am J Obstet Gynecol, 191 (2004), pp. 292-297
  5. CC Shek, PC Ng, GP Fung, et al. Infants born to mothers with severe acute respiratory syndrome. Pediatrics, 112 (2003), p. e254
  6. https://papers.ssrn.com/sol3/papers.cfm?abstract_id=3550308
  7. https://www.medrxiv.org/content/10.1101/2020.03.04.20030965v1

You may direct questions regarding this update to care@senderspediatrics.com and we will try to answer them expeditiously.  Thank you for your trust.  

Coronavirus COVID 19 infection 3.11.20 update

Dear Families,
 
The COVID 19 outbreak continues to spread.  There are no additional confirmed cases in Cuyahoga County.  The approach locally continues to be to quarantine patients who have come in contact with a confirmed case for 14 days.  However, at least 2 counties at the center of the outbreak, Kings County in the Seattle, Washington area and Sacramento County in the Sacramento, California area have abandoned the quarantine approach and are focusing more on preventing transmission from actually ill patients.  We have received many questions over the past few days and would like to use this forum to discuss some of the more relevant ones.
 
What COVID 19 IS NOT.  This is very important to consider.  In one of the best studies to date of the Chinese experience done in collaboration with the Johns Hopkins Department of Public Health, nausea, vomiting, diarrhea and conjunctivitis were NOT symptoms of COVID 19.  While we await larger studies, we can be very reassuring that if you or your child are exhibiting any of these symptoms, it is unlikely that you have to worry about having COVID 19.
 
What should patients with a history of cancer or rheumatological and GI diseases who are being treated with immunosuppressive drugs such as methotrexate, Imuran or remicade be doing about COVID 19?  Earlier this month, in the Lancet Oncology, there was an analysis of the first 42,000 Chinese patients and over 1000 deaths.  There was a suggestion that in patients with cancer, either in treatment or just past treatment, the incidence of COVID 19 was higher and the severity greater.  Those data were called into question because they were skewed by a large number of patients with lung cancer and there is some data suggesting a higher incidence of COVID 19 in cigarette smokers.  There is no data on COVID 19 in rheumatological diseases such as lupus or GI diseases such as Crohns Disease.  However, Actemra, a drug approved for rheumatoid arthritis in adults which inhibits the process of overproduction of inflammatory factors has shown some promise for the treatment of COVID 19 which appears to cause the same overproduction of cytokines or inflammatory factors.  If this proves to be true, ironically, some patients on immunosuppressive drugs may actually be at lower risk for serious COVID 19 disease.  The current recommendation, however, is for such patients to stay out of crowds and away from people who might be sick and make extensive use of hand sanitizers and handwashing.  We are not recommending that such children be excluded from school at this time.
 
What about travel?  The biggest problem with travel is the uneven use of quarantines.  As mentioned above, even within the same state there are often different recommendations.  Many local hospitals have told their medical staff not to fly on a plane, not because of the danger of contracting the disease but because they may be stuck being quarantined for 14 days.  Currently, that is our recommendation for our medical staff as well.  With spring break coming up, there is the distinct possibility that if you travel to Florida, you will be forced to be quarantined before you return.  However, because there appears to be a crack in the national policy and it is likely that the quarantine approach will be abandoned at some point, we are not recommending that travel plans for April be abandoned at this time. 
 
What about patients with asthma or other respiratory diseases?  In the Chinese experience, there appears to be a preponderance of cases in adults with respiratory illnesses such as COPD.  However, that does not seem to be the case in children.  There are only a few dozen cases that have been reported in children out of the over 100,000 cases reported worldwide and with the high incidence of asthma in childhood, it seems unlikely that having asthma is a significant risk factor for contracting COVID 19.  Therefore, our recommendation is that patients with asthma be treated symptomatically as usual, that they receive albuterol as an acute treatment for mild disease and an inhaled steroid such as Flovent, Pulmicort or QVAR as their controller medication in more severe cases.  If you have specific questions about the management of your child’s asthma, or the typical meds are not working, please speak to our advice nurses.
 
Can other forms of elderberry be substituted for the Sambucol brand?  The original studies in preventing colds and influenza were done using 10-15 ml of the Sambucol brand which has 3.8 grams of elderberry/10 ml.  This is why we have recommended this brand.  A number of patients have asked about other forms of elderberry. It can be hard to find an equivalent amount of elderberry because there isn’t a standardized measurement. If you can find a product that has published data which provides you with 3.5-4.0 grams of elderberry per day, then that would be an appropriate substitute.   Lozenges have 175 mg per lozenge which is much lower.  Gummies have 125 mg per gummie as well as zinc and vitamin C.  We CANNOT recommend gummies because to get enough elderberry to make a difference, you would overdose on zinc.
 
More information about how we at Senders Pediatrics will be dealing with COVID 19

  1. Our intention is to keep our main office area free and clear of any potential exposure to COVID 19.  Towards that end, we have and will introduce the following precautions.
    1. According to local public health authorities, the likelihood of significant spread in pediatrics continues to be small.  We are assuming that will remain the case at least through Sunday, 3/15. 
    2. Beginning, Thursday, 3/12, we will phone screen all patients for potential exposure to an active case of COVID 19 either locally or through travel. Any patient with known exposure will be excluded from the office and will be evaluated by phone or by telehealth.
    3. As previously mentioned, we have removed all toys from our waiting rooms for the foreseeable future
    4. Beginning Monday, 3/16, we will no longer conducting a Monday walk-in clinic from 7:30-8:30.  All patients will need to be prescreened.  For your convenience, our office will open at 7:00 AM on all Monday mornings to schedule early appointments.  Only patients without respiratory symptoms will be scheduled during this period.  
    5. Beginning also on Monday, 3/16, any child with respiratory symptoms (runny nose, wheeze, cough, fever etc.) will be referred to our advice nurse staff who have been in-serviced to make the determination if a telehealth visit or a car visit is appropriate.  If a car visit is recommended, a provider in cap, gown, mask and glasses will conduct a visit with you and your child in the parking lot.  Because such patients will remain in their car, there is no concern for other patients who might be in the parking lot.
    6. Beginning Wednesday, 3/18, our UVC treatment of inside air will commence. This form of treatment will kill most viruses, bacteria and fungi and with our new HVAC system in place, circulation of air will take place 12x per minute. 
    7. Beginning Friday, 3/20, we will have access to 3 isolation rooms on the North side of the building.  Access will be through a separate entrance and we will have the capacity to see up to 50 ill children a day with appropriate protection for both your child and our staff.  More about this as we get closer to implementation.
  1. THERE IS NO REASON TO CANCEL WELL CHILD CARE VISITS – With the above modifications in place, your child is at no greater risk for catching any illness in our office than in most other buildings and because of our air treatment and surface treatment implementation, he/she may be considerably less likely to catch an illness.  At all ages, including infancy, not getting routine well visits, including vaccines, puts your child at much greater health risk than the small potential for exposure to any virus in our pediatric clinic. 

Please keep the questions coming but please submit them to care@senderspediatrics.com so that we can best help you and all of your fellow patients.  Thanks as always for your trust.  
    
As always, for those interested in more reading material, please peruse the following references.   

  1. https://www.thelancet.com/journals/lanonc/article/PIIS1470-2045(20)30096-6/fulltext
  2. https://www.npr.org/sections/health-shots/2020/03/10/813990993/coronavirus-sacramento-county-gives-up-on-automatic-14-day-quarantines
  3. https://www.fiercepharma.com/pharma-asia/china-turns-roche-arthritis-drug-actemra-against-covid-19-new-treatment-guidelines
  4. https://www.medrxiv.org/content/10.1101/2020.03.03.20028423v1
  5. https://doi.org/10.1101/2020.03.03.20028423
  6. https://doi.org/10.1016/j.jff.2019.01.031
  7. https://journals.sagepub.com/doi/abs/10.1177/147323000403200205

For additional information on the COVID19 outbreak see the following links:

  1. https://www.cdc.gov/coronavirus/2019-ncov/index.html
  2. https://odh.ohio.gov/wps/portal/gov/odh/know-our-programs/Novel-Coronavirus/Resources-for-the-Public/

Coronavirus COVID 19 infection 3.10.20 update

Dear Families,
 
On Monday, March 9, 3 cases of COVID 19 were diagnosed in Cuyahoga County prompting Governor DeWine to announce a state of emergency.  All three cases were in middle aged individuals in their mid-50s.  Two were a couple who recently returned from a trip along the Nile River and the 3rd individual recently attended the American Israel Public Affairs Committee (AIPAC) annual convention in Washington DC. 160 Clevelanders attended that same convention and many rode with the infected individual on a bus home from the convention.
 
What does a state of emergency mean?  The term, state of emergency, doesn’t mean this is a true emergency.  It simply allows state agencies to better coordinate activities and makes it easier to sign contracts.
 
What happens to those who were in contact with the infected AIPAC attendee? The Cuyahoga County Board of Health has recommended that all those who traveled on the bus be self-quarantined for 14 days.  Family members of those travelers do not need to be quarantined unless they become symptomatic.  Remember, EXPOSURE TO AN EXPOSURE IS NOT AN EXPOSURE. 
 
What does quarantine mean?  It means no contact with other humans within 6 feet.  It does not mean you cannot walk outdoors on your patio or sit on your porch.
 
Today is the Jewish holiday of Purim which is a very festive occasion with parties and communal meals.  What precautions should be taken?  Children and adults who are healthy and have not been in contact with an infected individual can participate in synagogue activities and communal meals as well as deliver food packages to the elderly.  As previously mentioned, good hand washing or use of sanitizing wipes or gels are more important than ever.    
 
What about older adults?  Those over age 60, especially those with underlying breathing problems are at the highest risk for infection and serious complications.  This group should probably not participate in communal meals with more than 10-15 individuals.
 
What is the incubation period of COVID 19? In an article to be published on 3/10 in the Annals of Internal Medicine, 181 non-Chinese patients with COVID 19 were evaluated.  The median incubation period, that is the median time before symptoms were noted was 5.1 days.  97.5% saw symptoms within 11.1 days.  The current 14 day quarantine is based on picking up 99% of cases by 14 days but especially for those who were at the AIPAC conference a week ago, if you haven’t had symptoms yet, there is a good chance you are in the clear. 
 
What is the natural history of the disease in children?  We have access to an, as yet, unpublished article that looks at COVID 19 in 10 Chinese children in Wuhan province (the epicenter of the disease).  The children ranged in age from 3-131 months.  80% had fever, 60% had cough, 40% had sore throat and 30% had a stuffy nose.  All recovered uneventfully.  The take home from this small study suggests that COVID 19 in children is likely to present like a cold or flu virus and is likely to run the same course of these diseases.  Larger scale studies confirm that COVID 19 tends to have a more benign course in children than in adults. 
 
How is COVID 19 spread?  Right now, the CDC is still suggesting that it can be spread by airborne particles which means that one needs a negative pressure room before doing the nasal swab that confirms the disease.  However, the University of Washington Department of Infectious Diseases in Seattle (one of the hard hit areas in the US) and other US health centers have changed to droplet or contact precautions which just means the need for a mask, cap, gown and glasses.  This distinction may seem trivial but it has major implications for mass testing.  There are few negative pressure rooms in town but every facility has the capability to do a nasal swab with proper precautions.
 
How quickly does COVID 19 spread?  In another, as yet, unpublished article of 391 COVID 19 patients in Wuhan province and 1286 of their close contacts, the household attack rate was only 15% and children were as likely to be infected as adults.  91% had mild or moderate symptoms and this was particularly the case amongst children.   
 
Who needs to be tested?  Right now, the CDC and the Ohio Board of Health are sticking to their recommendations that only very ill hospitalized patients should be tested.  There is currently no mechanism for easy testing of exposed individuals.  All testing is still being done in the ER or in local hospitals and performed through the Ohio Board of Health.  There is currently no mechanism for outpatient testing for COVID 19.
 
What is coming?  According to local health authorities, the spread still appears to be slow.  This is good news because it will still be about 2 weeks before local labs have the capacity to do a 24 hour turn around test.  The current testing available to hospitalized patients is still 3-4 days, painfully slow for those of us used to 15 minute flu tests.  Most experts believe that approach is no longer containment but mitigation meaning that we can’t stop the spread but we can minimize it. 

What are we doing at Senders Pediatrics? 

  1. We will be removing toys from all the rooms by the end of the week since we know that COVID 19 can be spread on surfaces.
  2. On Wednesday, 3/11, we will begin phone screening for potential exposures to COVID 19 for all patients with respiratory symptoms.  We recognize that the vast majority of patients with respiratory symptoms will have the flu or other viral illnesses.  Please remember that if you hear hoof-beats outside your window, it could be a zebra but is likely to be a horse.  We will look for COVID 19 but it is still a zebra.  We will be focusing on the flu (we diagnosed over a dozen cases today) because it is a horse. 
  3. Beginning 3/16, we will be cancelling our Monday morning walk in clinic to minimize the chances of unexpected exposure. We will still see patients early on Monday but you will need to make an appointment before coming in.  We will communicate more about the details in the days to come. 
  4. On Wednesday, 3/18, we will be installing a state of the art UVC treatment of our air system.  With circulation of air 12x per minute, this will provide you and your child as much of a germ free environment as possible.
  5. By Monday, 3/23, we will have 3 designated isolation rooms in our facility with a separate entrance.  When COVID 19 becomes more prevalent in our community and screening tests are readily available, we will be amongst the first to be able to isolate sick children so that we can provide ready diagnosis to those who are sick and yet, maintain a healthy environment for those who are healthy.
  6. We will continue to update you with useful and relevant information as it becomes available.

As a reminder, we are including the link to hand sanitizers from a previous post. https://www.nea.gov.sg/our-services/public-cleanliness/environmental-cleaning-guidelines/guidelines/interim-list-of-household-products-and-active-ingredients-for-disinfection-of-covid-19

For those interested in additional information, please see the following references.  Please remember that some of the articles are not peer-reviewed yet.  That simply means that the information must be taken with a grain of salt. 

  1. https://annals.org/aim/fullarticle/2762808/incubation-period-coronavirus-disease-2019-covid-19-from-publicly-reported
  2. https://doi.org/10.1101/2020.03.03.20028423
  3. https://doi.org/10.1007/s12519-020-00343-7

 
For additional information on the COVID 19 outbreak see the following links:

  1. https://www.news5cleveland.com/news/continuing-coverage/coronavirus/3-cases-of-coronavirus-in-ohio-gov-dewine-confirms
  2. https://www.cdc.gov/coronavirus/2019-ncov/index.html
  3. https://odh.ohio.gov/wps/portal/gov/odh/know-our-programs/Novel-Coronavirus/Resources-for-the-Public/

You may direct questions regarding this update to care@senderspediatrics.com and we will try to answer them expeditiously.  Thank you for your trust.  

Coronavirus COVID 19  – Questions & Answers

March 5, 2020 Update

As of now, the virus responsible for COVID 19 disease has spread to 13 states with over 150 cases and 11 deaths. We have been in touch with local health authorities, infectious disease experts and CDC physicians to help our patients make sense of the rapidly evolving situation. 

Our CDC expert likened the current situation to what happens many years in South Florida during hurricane season.  The Weather Channel describes a “monster” slow moving hurricane forming in the Caribbean.  Some believe it will make landfall and score a direct hit on Miami, others think it will move up the Eastern coast and cause rain and wind damage and still others believe it will move out to sea with no impact.  That is where we stand right now.  No one knows anything for sure just as in the hurricane situation, no one knows which direction the hurricane will move.  For reasons described below, it is likely that we will know a lot more in the next 2 weeks and we are committed to helping you figure out how to keep you and your loved ones healthy.

Basic Questions
What is COVID 19? It is a betacoronavirus that has likely jumped from animals to humans.  It is similar to the SARS and MERS coronavirus infections that previously affected Southeast Asia and Saudi Arabia.  Of note, because it is not a human coronavirus (as first thought), we have less experience with how it will spread and what will be effective as therapy.

How does the COVID 19 virus spread?  It appears to be communicated by person to person spread (within 6 feet) and with respiratory droplets that get inhaled into the lungs or are swallowed.  It is possible that it can also be spread by touching surfaces on which infected patients have coughed but this doesn’t seem to be the major source of infection.

What are the symptoms of COVID 19? – Fever, cough, runny nose and difficulty breathing.  Lots of people this time of year have fever, cough and runny nose.  The key symptom here is the difficulty breathing. 

What percentage of people are asymptomatic? In initial published studies of the China epidemic, 81% were classified as mild (flu like symptoms), 14% were moderate (difficulty breathing) and 5% critical (hospitalized or in an ICU).

Can it spread from asymptomatic individuals?  It is not clear.  Most cases are transmitted from infected individuals.

How long does it take to see symptoms?  2-14 days.

What ages are affected? In the Chinese study, 3% were over 80, 87% were 30-79, 8% were 20-29, 1% were 10-19 and 1% were 0-10.  That means that in our patient population at Senders Pediatrics, the likelihood of anything more than asymptomatic infection is small. The people at highest risk are over 70 years.

What is the Case Fatality Rate (CFR)? The CFR is the number of deaths divided by the number of infected people.  The World Health Organization just released the global CFR of 3.4% which caused most to panic since that is much higher than influenza with a CFR last year of 0.1% (up to a CFR of 1% during the H1N1 outbreak in 2009).  However, this is likely related to poor estimates of the number of people infected (the denominator).  In South Korea where they are testing 10,000 people a day, the CFR is 0.6% (37 deaths out of 6088 people infected).  It will take weeks to months for us to appreciate the CFR in the United States.

Why is the CDC emphasizing self-quarantining for direct exposures?  The CDC likely wants to delay the spread of the virus for three major reasons:

  1. We are in the middle of a nasty flu season with over 30,000 deaths in adults and over 125 deaths in children.  A huge epidemic of COVID 19 at the same time would overwhelm our health system.
  2. There is some hope that, like flu, COVID 19 will burn itself out after the winter ends.  Delaying its spread may help it become self-limited.
  3. There is hope that if this infection gets postponed long enough, we will have a vaccine or an anti-infective that works.

Diagnosis
Is there a test for the virus that causes COVID 19?  There are two basic tests, the one in use around the world and the one in use in the USA.  The two tests focus on different genes in the corona or crown of the virus.  It takes 2-3 weeks to validate a test and despite the urgency, it is critical to make sure there are no false positive or false negatives. So for now there is no test (rapid or lab based) that is available.  This should change within the next few days. 
 
Can I be tested?  There is no current test available in Cleveland.  Currently, the CDC can only process 350 tests a day in their central lab. 

When the test is available who should be tested?  The CDC criteria for testing (once testing is readily available) is flu like symptoms and a history of exposure to someone with known COVID 19 disease (either directly or through travel to an affected country).  The key is the history of exposure.  Second degree exposures (exposed to someone who was exposed) should not be tested. At some point, testing will be more readily available and anyone who wants to be tested will be able to be tested. More info to come. 
 
Prevention
What can I do to prevent infection? 

  1. We recommend the following useful approaches to keeping yourself healthy from disease, many of these recommendations come from coronavirus researcher Dr. James Robb.
    1. No handshaking and no hugs– use an elbow bump or a bow.  Thankfully, many local religious leaders have embraced this approach in places of worship.  We can go back to normal social graces when we know a bit more.
    2. Use your knuckles to touch light switches and elevator buttons.
    3. Lift the gasoline dispenser with a paper towel.
    4. Open doors with your closed fist.  Do not grasp the handle unless there is no other way to open the door.
    5. Use disinfectant wipes at supermarkets to wipe down grocery carts and child seats.
    6. Wash your hands for 10-20 seconds with water or use hand sanitizer whenever you return home.  Look at the following link for a list of environmentally safe hand sanitizers and wipes that are effective in killing COVID 19. https://www.nea.gov.sg/our-services/public-cleanliness/environmental-cleaning-guidelines/guidelines/interim-list-of-household-products-and-active-ingredients-for-disinfection-of-covid-19 Of interest, while many have recommended ethyl alcohol 60%, much of the data on coronavirus suggests that you need 70%.  Products with this high level of alcohol are usually very drying and not suitable for regular use.  Try benzalkonium chloride 0.05% (which is what we use in our office) for a softer and more tolerable product.
    7. Keep a bottle of hand sanitizer in your car and in your office.  Always use it before you eat. 
    8. Carry a bottle of hand sanitizer to use in synagogue and church.
    9. If you are sick, do not go to synagogue or church and do not attend large gatherings.  Be a good citizen and do not put other people at risk.
    10. Do not walk around with a mask unless you are sick.  The standard masks do not prevent you from getting the disease but can reduce the amount of virus that is shed if you happen to be infected with coronavirus.
  1. Get a flu vaccine
    1. Remember that flu is a far more common disease this time of year.  If our news outlets had a ticker that showed how many people died that day from flu, we would be way more aware of the seriousness of this disease.  Yet despite the over 30,000 adult deaths and more than 125 pediatric deaths, 2 people refused to get a flu vaccine today
    2. Flu vaccine may not prevent all cases of flu.  But it will likely reduce the effects and it has been shown to be very effective in preventing hospitalization and death from flu
  1. Consider the use of Sambucol elderberry prophylactically (for prevention)
    1. The dose for the syrup in 4 years and older is 10 ml (2 tsp) daily and for a child 1-3 years, 5 ml (1 tsp) daily
    2. The dose for chewables in 4 years and older is 2 chewables and for a child 1-3 years, 1 chewable daily
    3. We do not recommend the gummies because if you need to use the treating dose, they cannot be scaled upward
    4. Sambucol during pregnancy – there are no clinical trials of elderberry in pregnancy.  One should balance this unknown with the potential effect of contracting coronavirus.  If this becomes very prevalent, we think the benefit of treatment may outweigh the risk 
    5. Sambucol for patients with immunodeficiencies or on immunological medications like Imuran and remicaid – This is not recommended at this time
  1. Keep Zinc on hand
    1. As with elderberry, there is a lot of experimental data that zinc can inhibit the activity of coronavirus and influenza in a laboratory.  Again, pathologist Dr James Robb recommends:  Start zinc lozenges at the first sign of a cold and continue to take them daily for 7 days. 
    2. Zinc gluconate (the active ingredient in Cold EEZE) has been studied intensively since a 1996 Cleveland Clinic study found that adults with cold symptoms from a variety of viral sources taking 6 lozenges a day (2 lozenges 3x per day) had a reduction of symptoms from 7.6 days to 4.6 days. 
    3. Over the years, some studies have continued to show benefit while others have found little more than a placebo effect.  The reason for this disparity is possibly that zinc works only if the total daily dose is 75-90 mg and if there are no interfering substances that bind zinc or reduce its potency.  Cold EEZE has 13.3 mg of zinc per lozenge, is released without interference and has no binders to reduce potency. 
    4. The reason we all feel ill with a cold is that when the virus ends up in our nose or our mouth (we forgot to use sanitizer), it replicates rapidly and binds to receptors in our mouth and nose causing leaky blood vessels (the runny nose), inflammation (the achiness and the fever) and irritated throat and lungs (the cough).  Zinc competes with cold viruses for those same receptors. 
    5. We are cautiously optimistic that taking 2 zinc lozenges 2x per day in 12-17 year olds and 2 lozenges 3x per day in adults may help reduce the side effects of colds, influenza and coronavirus with minimal side effects.  Whether it works with COVID 19 is not clear but there is little downside except for cost.
    6. The ideal way to take zinc lozenges is to lie down and let the lozenge dissolve in the back of your throat and nasopharynx
    7. What about young children?  There are no data in children under 12 but it seems reasonable to try 1 zinc lozenge 3x per day in the 6-11 year olds.
    8. There are many zinc products on the market.  We are currently only recommending the lozenges – not the pills or gummies because it is the local effect of the zinc on your throat that seems to be most effective.   
    9. Stay away from zinc nose spray.  It could cause permanent loss of smell.  And don’t use Cold EEZE for longer than 7-10 days.  Long term use can lead to copper deficiency.

What about travel

  1. The CDC is not recommending travel to China, Iran, Italy or South Korea at this time
  2. Israel has quarantined over 100,000 people in an attempt to prevent spread.  Once it spreads more diffusely in the US, there is the significant likelihood that Israel will not allow US citizens into the country.  This has major implications for travel to Israel for the Passover holiday.  More about this as information becomes available.

References – for those interested in reading more

On general information about COVID 19

  1. https://www.cdc.gov/coronavirus/2019-ncov/summary.html
  2. https://odh.ohio.gov/wps/portal/gov/odh/know-our-programs/Novel-Coronavirus/Resources-for-the-Public/

On Hand Sanitizer

  1. https://www.nea.gov.sg/our-services/public-cleanliness/environmental-cleaning-guidelines/guidelines/interim-list-of-household-products-and-active-ingredients-for-disinfection-of-covid-19

On Sambucol

  1. http://pharmaguri.co.il/_Uploads/dbsAttachedFiles/sambucol_research_info.pdf
  2. https://bmccomplementmedtherapies.biomedcentral.com/articles/10.1186/1472-6882-11-16
  3. https://www.ncbi.nlm.nih.gov/pubmed/19682714
  4. https://www.sciencedirect.com/science/article/abs/pii/S0965229918310240?via%3Dihub
  5. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3809029/
  6. https://www.cdc.gov/flu/about/burden/2018-2019.html
  7. https://www.thelancet.com/journals/lanres/article/PIIS2213-2600(20)30079-5/fulltext
  8. http://www.cidrap.umn.edu/news-perspective/2020/02/study-72000-covid-19-patients-finds-23-death-rate
  9. https://www.ncbi.nlm.nih.gov/pubmed/11399518
  10. https://www.ncbi.nlm.nih.gov/pubmed/24624087

On Zinc

  1. https://journals.plos.org/plospathogens/article?id=10.1371/journal.ppat.1001176
  2. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6457799/
  3. https://www.ncbi.nlm.nih.gov/pubmed/28515951

If you have questions about these recommendations, please submit them to care@senderspediatrics.com and we will try to answer them expeditiously.  Thanks for your trust.  

For your reference, 3.2.2020 communication 

Dear Families,

At Senders Pediatrics, we are not afraid to use alternative and complementary treatments if there is scientific evidence to support their use.  The nature of the scientific enterprise is such that there are often conflicting studies.  It is our job as your providers to sift through the information and provide you with evidenced based therapies that have potential benefit, limited side effects and limited cost.  We believe that elderberry fits these criteria.  The following recent studies are some of the evidenced based trials that help support our position.  While there can be a justifiable difference of opinion about the strength and validity of these studies, we appreciate the opportunity to educate our patients about alternative approaches to diseases for which there is no treatment or treatment is associated with significant side effects.
 

  1. BMC Complementary and Alternative Medicine  https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3056848/  The goal of this 2011 study was to determine the potential antimicrobial activity of a standardized elderberry liquid extract against several human bacterial and viral pathogens known to cause infections of the upper respiratory tract. It showed that the proliferation of S. pyogenes, group C and G Streptococci, and B. catarrhalis were reduced after contact with elderberry extract in liquid culture.  The liquid extract also displayed an inhibitory effect on the propagation of human pathogenic influenza viruses including Influenza B and H5N1, the bird flu disease.  This study was done in-vitro meaning it was done in the laboratory, not in human beings but demonstrated the theoretical basis of using elderberry in treating a host of viral and bacterial diseases.
  2. Nutrients https://www.ncbi.nlm.nih.gov/pubmed/27023596  This is a randomized, double-blind placebo-controlled clinical trial of 312 economy class passengers travelling from Australia to an overseas destination which evaluated whether Sambucus extract had beneficial effects on physical symptoms of viral illness especially respiratory. Cold episodes, cold duration and symptoms were noted in a daily diary.  Published in 2016, it found that placebo group participants had a significantly longer duration of cold episode days (117 vs. 57, p = 0.02) and the average symptom score over these days was also significantly higher (583 vs. 247, p = 0.05).
  3. Complementary Therapies in Medicine https://www.sciencedirect.com/science/article/abs/pii/S0965229918310240?via%3Dihub.  When there are no large scale studies of the potential benefits of an intervention, a meta-analysis is often done that combines the effects of all studies.  In this 2018 meta-analysis of multiple studies on the use of elderberry in the treatment of viral illness, a total of 180 patients were included in the analysis.  Supplementation with elderberry was found to substantially reduce upper respiratory symptoms.

For your reference, 3.1.2020 communication 

Dear Families,

As mentioned in our initial post, information on the COVID 19 outbreak is rapidly evolving.  The following information is as accurate as we can get at this time.
 
Some corrections and additional comments about the virus and its case fatality rate:

  1. The coronavirus responsible for COVID 19 is a betacoronavirus, similar to the ones that caused MERS and SARS and is likely derived from an animal to person infection.  The genetic sequence of the virus in US infections appears to be similar to the one initially reported in Chinese patients suggesting that it is likely derived from the same initial source.
  2. In two recent articles, one in the Journal of the American Medical Association (JAMA) and the other in the Lancet, the CFR or case fatality rate (rate of death divided by the number infected) for COVID 19 was found to be 2.3%. In the JAMA study of over 70,000 Chinese patients studied up to 2/11/20, the disease appears to have hit the elderly especially hard.  87% of patients were aged 30 to 79 years followed by 8% in people aged 20 to 29, 3% in those over 80, and 1% each in ages < 10 and 10 to 19 years. The fatality rate jumped considerably among older patients, 8.0% in patients ages 70 to 79, and 14.8% in patients 80 and older.
  3. 81% of cases of COVID 19 in above studies were classified as mild (with flu like symptoms), 14% were moderate (associated with difficulty breathing), and 5% critical (hospitalized or needing ICU care).
  4. By way of comparison, MERS had a CFR of 34.4% and SARS a CFR of 9.6%.
  5. The case fatality rate for influenza during the 2018-19 season was 0.1% with 35.5 million cases and 34,000 deaths. However, in a review of 12,000 articles published in 2014 in the journal, Epidemiology, about the H1N1 outbreak of influenza in 2009, the CFR ranged as high as 10%.  Influenza continues to be a serious disease and our recommendations about getting a flu vaccine ASAP remain.
  6. If COVID 19 follows the H1N1 model, it is likely to initially cause significant illness and mortality especially in the elderly and immunocompromised (and that is what we are already seeing in other countries) and once there is a significant number of asymptomatic infected individuals or a vaccine or both, it will morph into an annoying annual problem that has to be treated like influenza.   

Current CDC recommendations

  1. There has been community spread of COVID 19 in California, Oregon and Washington as well as the first death from COVID 19.
  2. There still is no rapid way of diagnosing COVID 19.  It is expected that this will change within the next week.
  3. The CDC has grown this virus in cell culture which is the first step toward more accurate identification.
  4. As of now, there is no evidence of spread to our area.
  5. The key recommendation is hand washing, hand washing, hand washing and the use of hand sanitizer which appears to kill this virus as this time.

The use of Sambucol

  1. There has been some question about this recommendation.
  2. The elderberry extract in Sambucol brand elderberry has been shown in a number of studies over the past 20 years to be effective against multiple strains of influenza.
  3. The mechanism of action appears to be stimulation of inflammatory cytokines (chemicals) that allow the body to fight the disease.  It also appears to inhibit viral replication.
  4. A 2018 meta-analysis (which looks at all known studies and separates out poorly controlled studies) found benefit in the use of Sambucol in the treatment of influenza with almost no side effects. 
  5. Because it has antiviral properties and no significant side effects except for cost, we see no reason not to use 10 ml once a day in people over 4 years and 5 ml once a day in children 1- 4 years.
  6. The largest scale studies have been conducted only with Sambucol which is why we recommend that brand.  It is possible that other elderberry extracts are equally effective but we can only recommend a product that has been studied in clinical trials.  Sambucol syrup has 3.8 grams of elderberry per 10 ml.  The chewables have 1.7 grams per tablet so you would need to take over 2 to get the same effect.  We do not recommend the gummies with zinc and vitamin C because when using the 4x per day treating dose, you will get too much zinc. The effervescent/dissolving tabs are similar to gummies and have zinc & vitamin C and should be avoided.

More to come as we find out more info. 

For your reference, 2.28.2020 communication (edited for updates and corrections)

Dear Families,

Coronavirus is the #1 news item on radio and television.  The stock market has dropped 1000 points or more for 3 days in a row.  It seems that new cases are appearing each day – in the last 24 hours over twenty new countries reported a case.  How does one make sense of what is going on?  The best answer is “we don’t know for sure”.  But as your Patient Centered Medical Home, we thought we would share the following approach to living life. 
 
First some facts:

  1. Coronavirus is an RNA virus similar to influenza and it is called coronavirus because of the crown like spikes on its surface (edited 3.1.2020) 
  2. There are 4 coronaviruses which commonly infect humans causing cold like symptoms.  In addition, there have been 2 animal coronaviruses that have evolved to infect humans, SARS which spread in Southern China in 2002-3 and MERS which spread in the Middle East in 2012.  COVID 19, the disease that began in Wuhan province earlier this year is another animal coronavirus that appears to have evolved to spread to humans.  The actual animal reservoir has not yet been identified. (edited 3.1.2020)
  3. Human viruses evolve to maximize their spread which means it is in their best interest to sicken as many as possible and kill as few as possible.  Unlike SARS, COVID 19 appears to have evolved to do just this – spread rapidly, cause mild to moderate disease but not kill rapidly (edited 3.1.2020).
  4. The Chinese approach to COVID 19 has been quarantine.  At this time, over 100 million Chinese are currently cordoned off and as of two days ago, officials in Hubei province are going door to door testing people for fevers and sending them to quarantine camps. Most US epidemiologists and infectious disease specialists do not believe this has been helpful because up to 14% of infected people are asymptomatic.  It is anyone’s guess what will happen in Washington.  But the predominant approach of local infectious disease experts is not to worry about COVID 19 any more than you should worry about the flu.
  5. The CDC is doing screening tests in 5 US cities to give us an idea of how many asymptomatic Americans are already infected.  Cleveland is not one of those cities.
  6. In Ohio, there is no readily available COVID 19 test.  Even the Ohio Board of Health has to send specimens to the CDC.

What is likely to happen:

  1. COVID 19 is coming to Cleveland at some point because it is impossible to contain a virus that is as asymptomatic and as widespread.
  2. Most people will be asymptomatic or have mild disease with symptoms like the flu.
  3. If we are lucky, COVID 19 will hit our area in April when flu season is starting to wind down which will make diagnosis a bit easier.
  4. If we are not lucky, it will hit over the next few weeks when the symptoms of COVID 19 and influenza are similar.
  5. Just as with influenza, COVID 19 appears to have a milder course in children than in adults.
  6. But unlike influenza, no one knows for sure how it will behave when no one has any immunity to the disease.
  7. The hope is that COVID 19 will behave much like the H1N1 influenza outbreak which started in the summer, caused a lot of illness and a tenfold increase in fatalities especially in the elderly and then, when a vaccination became available became an annoying but not as deadly a disease (edited 3.1.2020).
  8. Within weeks of the outbreak, Chinese scientists identified the genetic code for the virus and published this information for widespread use.
  9. There are at least 2 vaccines that are on the launching pad.  As you all know, we are a major research site for vaccine development and it is possible that we will be a site for a clinical COVID 19 vaccine trial in children.  If you are interested in being put on a list for such a trial, please let our research department know by emailing research@senderspediatrics.com.  Despite what you hear, it will likely be at least 12 months before a vaccine is ready for widespread use.

What we are doing at Senders Pediatrics

  1. Many of you remember the crane in front of our building late last year as we installed a new state of the art heating and cooling system.  Part of that upgrade has been our ability to treat the air in our facility with UVC and filter out pathogens.  Air that circulates in our facility will be cleaned and filtered thousands of times per minute meaning that some of the healthiest “inside” air in town will be at Senders Pediatrics.  This scrubbing system will be in place by mid-March. 
  2. We continue to encourage our patients to get a flu vaccine if they have not yet been vaccinated.  This has been one of the most brutal flu seasons in 25 years with lots of missed school and work.  Patients with asthma and other chronic diseases are at particular risk.
  3. There is no known treatment for COVID 19.  However, since it is an RNA virus like influenza and influenza responds to Sambucol brand elderberry, we are recommending that our patients over 4 years take 10 ml and those 1-4 take 5 ml (1 tsp) daily until this gets sorted out.  There is no down side but the cost and a significant potential upside.  Please do not use gummies as there is no evidence about their efficacy.    

CDC always recommends everyday preventative actions to help prevent the spread of respiratory diseases, including:

  • Avoid close contact with people who are sick.
  • Avoid touching your eyes, nose, and mouth.
  • Stay home when you are sick.
  • Cover your cough or sneeze with a tissue, then throw the tissue in the trash.
  • Clean and disinfect frequently touched objects and surfaces using a regular household cleaning spray or wipe.
  • Wash your hands often with soap and water for at least 20 seconds, especially after going to the bathroom; before eating; and after blowing your nose, coughing, or sneezing.
  • If soap and water are not readily available, use an alcohol-based hand sanitizer with at least 60% alcohol. Always wash hands with soap and water if hands are visibly dirty. (added 3.1.2020)

We will continue to update you as more information becomes available.