Addendum to “opening up” 6/19

I wish to add a few brief thoughts that I neglected to include in my post of 6/19 regarding socializing during covid.  Firstly, keep your outdoor group social groups small, to allow for necessary social distance.  Secondly, with respect to hand hygiene, use disposable paper towelettes to dry hands after washing as opposed to reused terrycloth versions. Lastly, keep background music volume modest so everyone can converse at a modest volume.  Loud talking may lead  to virus spread.

I read a few good ideas regarding food: guests bring their own condiments to avoid mixing.  Serve individual served items like hamburgers, hot dogs, or chicken wings as opposed to steaks or items that must be cut and shared.

Enjoy.

 

Open the Schools

Now that we are in ACTUAL summer vacation, our thoughts turn to the upcoming academic year.  What now?  Last month the American Academy of Pediatrics strongly stated our position that we as a society must make every effort to get children physically back to school. There are several reasons for this.

Firstly, at best, distance learning is inconsistent. While children from high income areas seem to maintain academic achievement, studies show that middle income children lost 1/3 of math progress; low income kids lost 1/2. Overall, children fall behind by about 7 months on average; minority children, those with special needs, or in rural areas lose considerably more.

Secondly, for many families, school attendance is essential to parents earning a living.  This is difficult to measure and varies by region.  The Brookings Institute estimates that 4 weeks of closure cost Los Angeles $1.1 billion and NYC $1.5 billion. They estimate that if an additional 12 weeks are lost in the upcoming year it will cost the US $130-140 billion, with secondary losses caused by the particular disruption to the healthcare work force.

A third consideration are the nutritional/health effects on children’s lives. For many children of low income families, school provides the most nutritious meal of the day. Many districts tried to address this by distributing lunches to homes via idled school buses, a helpful but limited solution. Outside of school children gravitate towards unhealthy lifestyles with less exercise and more and less healthy snacking. The Journal of Sport and Health Science estimates that a school closure just through the end of 2020 will result in 1.3 million more cases of childhood obesity in the US.

The CDC has listed a detailed plan for school openings.  Here are some highlights:

• Everyone in the building wear a mask.
• Social distance–6 ft where feasible.
• Outdoor classes where/when feasible.
• Teachers travel between classrooms, children largely stay put.
• Lunches eaten at desks.
• Temperature checks, upon entry, periodically during the day.
• Clean surfaces regularly.
• Separate children’s belongings and limit use of shared items. Encourage stocking adequate supplies for individual use.
• Modify layout of desk placement, hall traffic(all one way), tape markers on floor for spacing, physical barriers where appropriate.
• Consider staggered scheduling, additional ancillary staffing to supervise children onsite but outside of classrooms/formal learning session to assist safe spacing.
• Policies need to be IN PLACE for children or employees who test positive, in particular if those individuals have been inside the building–do you close classrooms, the building, which contacts are sent home and for how long? What accommodations need to be made for school employees at high risk(older, chronic health problems)?

1/3 of parents express concerns that school closures have negatively impacted their child’s mental health. This means we need to RAISE guidance/counseling personnel capabilities.

All of this is likely to cost money, folks, when most communities are facing significant tax revenue shortfalls. So we, as a society, are going to have to face that and figure it out. Sacrifice likely will be required from each of us for the well being of our children and the future of our communities.

Thank you for following.

 

“Opening UP” with Covid

Summer’s here and we’re all eager to enjoy great weather and more flexible social interactions.  In New Jersey, our sacrifice and effort is working: there is a clear downward trend in new cases, hospitalizations, and, most importantly, deaths from covid 19. However, this is no time for complacency. Despite claims from some public figures, it’s far from “over” and we are nowhere near “business as usual.”  New cases are INCREASING in 24 states, and only a handful of states demonstrate clear decreasing trends. Locally, there are still some pockets of increases.  So assurances by some politicians against a “second wave” are specious–we are really not out of the “first” yet.

Please note that this virus has proven HIGHLY contagious.  Claims from some self serving public figures that this is “the common cold’ or “like the flu” are not born out by science. R0 (“R naught”) for covid is 5.7–each infected person appears likely to spread it to 5.7 others on average; compared to R0 of 1.3 for flu and 3.4 for RSV.  There is evidence that the virus remains infective on many surface for hours. Recent studies suggest that toilet flushing creates a “plume” of aerosol above the bowl–and the virus is almost definitely present in stool and urine–putting the next user at risk.

Still, there are activities that are safer where people are cautious. The greatest risk is indoor gatherings of people in close contact for extended periods. Therefore, I recommend all child gatherings/parties remain outdoors whenever possible. Those with fever or significant cough should not attend.  For outside child play, where ventilation is obviously adequate and constant movement is the norm, facial coverings are less essential. Sitting at a table, maintain “social distance” and wear masks.  However, younger(<4 yrs) or very uncooperative children should not be forced. There is good evidence that children catch and spread covid less due to smaller breaths and less forceful breathing.  The emotional impact of forcing the mask on that child will likely cause the child to at least subconsciously keep touching his face or possibly cry and resist–breathing harder.  Both of those behaviors would only INCREASE the risk of infection.

Regularly clean all table surfaces–I suggest every few minutes if children are sitting there.  This requires proper adult supervision. If food is served, use disposable utensils and plates.

Anyone entering the house should sanitize their hands on entering and wash hands (> 20 seconds) upon leaving. Face masks should be worn by ALL for the ENTIRE time inside. If the bathroom is used, the lid should be lowered BEFORE flushing and surfaces should be sanitized immediately after use. Again, this likely entails close adult supervision. If a public restroom is used, again, I recommend young children be accompanied by a responsible adult. The child only touches “the essentials;” the adult will handle the toilet/flushing and the sink/washing and all other surfaces. Again–MASKS!!

This is not hard.  Taking these steps is no threat to freedom or democracy but rather merely simple, patriotic acts of responsible citizens showing concern for their friends and neighbors in their community. And you might just save your or a loved one’s life.

So be safe, have fun, and thanks for following.

Wear Your Mask(please)!

My (hopefully) biggest fan and simultaneously toughest critic (accurately so!)–Mrs. Kim Geneslaw–has recommended that I discuss mask wearing. Would I argue with my wife?

Firstly, there are different levels of facial coverings, from simple scarves, to surgical masks (either disposable paper fiber or washable cloth), to “N-95” masks–built to filter out > 95% of particulate matter. These are necessary for medical situations like my office and, more importantly, hospital ER’s and OR’s; require proper sizing and donning technique. This type of mask does offer the wearer good protection from inhaling infectious “aerosols” floating in the air.  For most people this is not available and, fortunately, not really necessary.

Most people are fine with a simple surgical mask of whichever design. These non-fitted products offer only limited protection to the wearer from inhaling infectious agents.  However they are very effective at blocking secretions from the wearer from escaping into the air around him/her due to sneezing, coughing, or even just talking loudly. Thus they are very useful for us to keep our CONTACTS safe from ourselves.  A coarse, but accurate, comparison would be to consider a world of incontinent people walking around.  If nobody wears pants, everybody gets peed on.  If I put my pants on(thank goodness!) I could get peed on but I will not pee on the next guy.  If everybody wears pants(whew!), nobody has to deal with the next guy’s pee (of course, some distance keeps the pee away, too!)

That is why the WHO now recommends that all people, and in particular those >60 years or with chronic health problems, wear masks in public situations. Outdoors without close quarters is not essential (suburban vs busy city streets, for example). We know that those COVID infected are contagious 2-3 days before symptoms start. Many infected people never get sick.  So one cannot KNOW if one is contagious and likely will not KNOW if your contacts are higher risk. The argument that people at risk can just stay home is specious–many can not, and what caring person wants to be responsible for someone–a loved one OR a stranger– in that situation?

It’s an easy thing–wearing a mask. Yes– it’s a bit uncomfortable; certainly it’s not foolproof. There are other steps we should take–frequent washing hands, avoid touching one’s face, practice “social distance.”

The President has encouraged us all to approach the pandemic situation as a wartime call to arms to protect out society from this great threat. I appreciate those sentiments. In generations past, our parents and grandparents sacrificed treasure, blood, and lives fighting World Wars to enable us to live safely in a free society. On June 6, “D-Day”, I say we honor the heroes of “the Greatest Generation” by donning our masks to provide some of that protection to our friends and neighbors as recommended by public health experts and in keeping with Mr. Trump’s exhortation to our national conscience.

Wear your mask.  Protect your friends and neighbors.  Your community will be better, safer, and more productive for your small but important sacrifice.

Thanks for following.

COVID and Your Newborn

For expectant and new mothers, please allow me to summarize the latest guidelines from the American Academy of Pediatrics regarding in hospital care for your newborn:

1. We recommend that skin to skin contact between mother/baby immediately after birth is still optimal, even if mother is COVID positive.
2. For COVID positive mothers, newborns should be tested at 24 and 48 hours (baby may be negative first test). Continue close monitoring for babies who come up negative, of course.
3. For COVID positive mothers, “rooming in” is not recommended. Ideally, the mother should be isolated from the baby, but we realize that that presents many other problems and may not be feasible. Mother should don all appropriate protective wear–gown, glove, eye/face shield with N-95 mask for ALL contacts with her baby, however.
4. Breast feeding should definitely continue. Best practice is for mother to express her milk for another uninfected caregiver to feed to the baby. However, if mother desires to nurse directly she can do so as long as she is wearing all PPE as (3) above.
5. For mothers testing negative, early discharge is not recommended.  There is no demonstrated health benefit; newborn testing (eg PKU) must wait until > 24 hours of life so leaving early can render those tests less than accurate. It can also place extra access and care burdens on new families.
6. Newborns who test positive for COVID but are symptom free can be discharged normally but must be closely monitored until they test negative twice consecutively. Sick babies, obviously, must be cared for in hospital in an NICU.
7. COVID positive parents should NOT visit in an NICU. They must be 3 days symptom free, at least 10 days since first onset of infection in order to enter the unit.

Obviously, we are dealing with a new and fluid situation, so we doctors are making the best judgements we can with the data available at this time. Careful collection and assessment of new clinical info, both as it affects individuals infected as well as from the standpoint of public health needs, are ongoing. Adjustments to these approaches would be made as later and likely better information becomes available. What we must NOT do is make decisions with potentially profound impact on the wellbeing of the youngest and most vulnerable children based on the utterances of politicians, pundits, press conferences, or public opinion polls. As Joe Friday actually never said, “Just the facts, Ma’am.”

Send along questions or comments, and thanks for following. Image from Charlotte Five.

Later School Start

In a flash, the educational system has shifted to on line learning, so change is possible. I recently attended a lecture on school start times; let’s consider that topic.

I have discussed this previously. In the 50’s-60’s schools typically started 8:30-9a. By the 90’s, larger school populations and more bused students necessitated staggering transport schedules. Districts arbitrarily opted to start middle and high schools earlier to accommodate that need.  Note there was no research and little discussion about it–it was merely expedient to start the older kids by 7am.

Since then a mountain of research clearly demonstrates the disadvantages to children’s health AND education from this choice. Among the problems are increased risk of obesity, heart disease, diabetes, and mental health problems, as well as more self destructive impulsive behaviors like risky sexual choices and substance abuse; growth suppression, even higher rates of auto accidents and sports injuries. This actually extends beyond age groups: ER’s routinely report more heart attacks on the day after clocks are turned ahead in the spring and less on the day after clocks turned back in the fall compared to the average.

Adolescent melatonin levels (brain’s sleep regulator) rise and fall 2 hours later (11p-7a) compared to adult physiology; it is simply unnatural to expect teens to get good sleep outside this time frame, and studies show currently almost 90% of HS and MS students self report < 8 hours sleep/night (9 is recommended). Accordingly, teachers universally report 1st period classes consist of sluggish students and poorer learning. The AAP says  “teaching adolescents at a time they cannot learn is an ineffective use of public funds and detrimental to public health.”

Princeton schools took up the challenge–2016-18 they gathered “stake holders”–teachers, administration, city officials, parents, students, police– to study and formulate a plan which was rolled out starting 2018. Relevant difficulties were identified: transportation and traffic, sports, teacher contracts and staff child care, coordinating with affiliated districts.  They initiated a 30 minute later start time, used block scheduling with flexible late periods(mostly gym, music classes), variable period times, HS and MS students on the same buses where feasible, traffic patterns and drop off points were modified.

The results have been dramatic. Student surveys from before and after indicate the children are sleeping the extra half hour(not just staying up later). Tardiness decreased 28% the first year and another 37% the next. Sports team schedules have barely felt the difference.

So it can be done.  There is currently no state wide initiative along these lines, so each district must address their schedule individually.  Some suggestions for advocacy:

1. Email school and district administrators.
2. Attend PTO, school board meetings.
3. Consider running for the school board.
4. Gather information. The NJAAP has an “Adolescent Sleep and School Start Task Force” that is a good source. startschoollater.net is another clearinghouse for studies; it costs $25 to join. Frankly, there is voluminous data available with a simple Google search for free.
5. Write letters to the editor–Asbury Park Press, NJ Patch.
6. Organize your friends, engage “stake holders.”

I urge all parents to take this matter seriously and do what you can. Your children’s health, education, and future will likely be better for your effort.

Thanks for following.

Lately I have tried to keep current regarding the COVID 19 outbreak, which is virtually the only thing on our minds. A great concern for pediatricians has been a marked increase in “accidental” injuries, driven mainly by 2 factors: normal routines disrupted, allowing greater opportunity for errors affecting safe practices previously built into daily schedules; and increased at home time for children resulting in more potential for harmful incidents.

Everyone  now focuses on cleanliness: clean hands, all surfaces constantly scrubbed.  Be careful! These agents are all caustic and poisonous. We pediatricians have been warning about the risk of household cleansers left out inadvertently. This was a concern before Mr. Trump’s unfortunate public comments about their use (at least hypothetically) as some form of treatment.  Whatever one’s politics, that certainly was not helpful in this regard.  Hand sanitizing agents are all high in ethyl and isopropyl alcohol, which also can cause serious toxicity when swallowed  or in one’s eyes.  We all must be vigilant in handling these materials.  Keep them high up, out of reach of all young children(<10 at least);  BE SURE to assess if older children are intellectually and emotionally equipped to use properly. Wherever possible, direct parental supervision is best.

Keep ALL medicines in original, properly labelled bottles, replace  in medicine cabinets immediately after taking the prescribed dose–DO NOT leave them on the counter where they may be discovered by children when unsupervised, even momentarily.  Don’t leave batteries, lighters, coins, jewelry around for toddlers–everything in boxes,  drawers up out of reach.

A special word about FIREARMS if you keep them in your home: both the weapon AND the ammunition should be stored in locked containers, SEPARATELY, away from all minors.  Children should NOT have access to the keys. It is always more dangerous to keep loaded weapons at home.  That is even truer now–children are home more!

Regarding emergency rooms: most pediatric ER’s are closed due to low volume with all care now shunted to the main ER.  I have previously advised against overuse of ER’s for more trivial, non-emergent matters.  Now, it seems, the opposite may be occurring.  Local pediatric ER physicians and surgeons report that the incidence of appendicitis diagnosis has shifted.  The ratio of early to perforated (later, more serious) diagnosis –previously 70/30 in favor of early, safer identification is more recently exactly the opposite– 70% of appendicitis diagnosis currently have already perforated and the children are much sicker. Likely this is due to an understandable, but in this instance misplaced, fear of being exposed to COVID.

That is just one statistic that reminds us that we must balance our legitimate worries with what we see in front of us at the time with a potentially sick child. I remind all of my patients that I am in my office and available by phone almost every day(where am I going to go?–I’m locked down too!) Please do not avoid addressing your child’s health concern.  Call me–we can discuss it, I can see them in the office, the PARKING LOT, and we are set  up for televisits as well.  I can call ahead to the ER to streamline your visit if we both agree it’s necessary.

Thanks for following.

When Can We Be “Normal?”

I hope everyone is coping with our “new normal.” We must be patient for everyone’s protection.  Currently there are press reports about “opening up” and “getting back to work.”  Everyone wants that, and be free to make choices for ourselves.  However, we also know 2 things about covid: people are contagious well before they feel sick, and there is a substantial pool of infected persons who never feel clinically unwell.  Thus, our choices effect not just ourselves but all we contact when we are out. I think all reasonable people accept that we each owe our friends and neighbors to take reasonable steps to avoid infecting each other with a potentially life threatening disease. As the saying goes, we are in this together.

Currently testing reveals about 20% positive results.  This number is so high because the total number of tested subjects is still too low–still not enough tests available. Officials indicate that a safe “+” rate is < 10%; then we know that infected people do not “slip under the radar,” spreading the infection further, but rather can be isolated for the appropriate duration, allowing all others to more safely go about as before.  The medical establishment–government officials and private industry–are working diligently to produce the necessary testing structure for that.   2 other things are necessary to return “to normal”: marked decrease in new cases, and ability for widespread antibody test to assess immune response.  Admittedly, the latter is still only partial information: the presence of antibody doesn’t guarantee immunity. Knowing that association will take longer, but we’ll have to go with the best information available.  Everyone agrees that we cannot do this forever, but, again, let’s be patient and listen to the public health experts.

We in the American Academy of Pediatrics continue to monitor children’s health.  We are concerned that the present situation, with parents too understandably fearful to keep regular well care, may allow common medical conditions to fester.  Children with  asthma, diabetes, obesity, chronic skin problems, ADHD and mental health difficulties should try and keep regular well/follow up care so we can monitor them and prevent transient exacerbations from turning more serious. Additionally, there are already reports of marked decrease in the worldwide administrating of regular vaccines.  That means we are at risk to see the return of major illnesses like whooping cough, measles, meningitis. It is imperative for us to prevent that from happening on top of corona, so we pediatricians urge parents to bring those < 2 years old and all children in need of vaccines to come in and get immunized.

My office continues to be open to help you with your child’s health needs, including routine “anticipatory guidance” regarding diet and sleep habits, child development, phone/game use, personal safety, smoking/vaping and drug/alcohol prevention, school and discipline issues, adolescent sexual health/responsibility and all other aspects as your child grows up. We have televisit capacity, are manic ourselves about cleaning surfaces and glove/mask (frankly, for our own protection too!), can administer vaccines in the parking lot–whatever we should do to keep your child healthy as I’ve enjoyed the opportunity to do for 35 years as a pediatrician.

Call with questions or concerns, and thanks for following.

More on Your Kid and COVID-19

Of course we are all dealing with unprecedented stress during this difficult time.  People are concerned for their physical and financial well being while being cooped up and unable to enjoy typical stress relievers like family/friend interaction, going out to dinner, movies/plays/sporting events (to participate or watch), as well as deeper endeavors like attending religious worship.

There are already studies chronicling the toll this may be taking on family interactions.  19% of parents admit shouting or screaming at their children now, 15% report spanking or slapping them and 11% admit to multiple such incidents.  The AAP has concerns that the incidence of child abuse and/or neglect could rise.  In many instances, a teacher, clergy, or doctor is the first person to recognize a problem and notify the authorities.  With these contacts largely on hold, some of these mistreatments may go unnoticed and unreported.

We at the AAP advocate that it is essentially never appropriate to discipline a child with acts of physical force, or to take actions that berate, belittle, or humiliate them. I cannot overemphasize how strongly we pediatricians feel about this subject.  Here are some of the Academy’s guidelines on how to limit the stresses of “shelter in place.”

With children at home so much more, there is also a greater risk of accidental injuries there.  Some suggestions/reminders:

1. Use childproof locks and gates, including on staircases.
2. No walkers–jumper/saucer seats are safer. Better yet, just let your young toddler play freely on the floor with you to supervise.
3. Be careful in the use of elevated surfaces with toddlers(changing tables). The floor is safer.
4. Secure electric wires and use electric outlet covers.
5. Secure window treatment cords.
6. No small hard foods or toys within reach of toddlers (if the object fits in a toilet paper roll in 2 planes–length and width– then it can be swallowed or inhaled)
7. Store cleansers, toxins, poisons high up, out of reach of young children.
8. Do not use space heaters in your home.
9. Never leave infants or toddlers unattended by standing water like a bathtub.  Little children can even fall head first into a toilet and drown.  Keep the bathroom door closed so they do not wander in unnoticed.
10. Keep all medicines in their original containers and store in medicine cabinets at all times.
11. Rubber bumpers on all sharp edges (coffee tables, fireplace).
12. If you own firearms, keep them and ammunition stored separately in locked containers, out of reach of children, and keep keys in separate, secure location.

Keep distance, keep safe, and thanks for following.

Talking about Corona with your Kids

All of us are living through an unprecedented experience. We must keep aware of how this is affecting children; they are witnessing these events through the outlook of youth. What should you say to your child and how should you say it? A recent article in my journal Pediatric News interviewed child psychiatrist David Fassler, MD of University of Vermont. Please  allow me to summarize his recommendations, adding a few of my own.

First, be available.  Encourage your children to speak up about their concerns.  Ask them questions–what have they heard, what do they think, what are their friends saying? Don’t push them to discuss subjects if they seem reluctant to do so. Be sure to say only what you know–if you don’t have the answer, say so. You can then look up information together. While you are doing that, remember to share with them that not everything posted on the internet is true or accurate (of course, that applies generally–good opportunity to remind them of that FACT).  Take that opportunity to screen information for them; don’t shrink from gently steering your child away from a site or information that seems too technical, confusing, and in particular that which seems alarming or inaccurate. This is a great time to remind you all that one area to definitely avoid when seeking answers is social media sites which are generally riddled with misinformation.

Talk with your children about this in a calm, balanced, matter of fact way.  Your tone, facial expressions, and body language are all important. If in discussion with other adults, be aware that children may be listening from the side. Endeavor to keep more troubling exchanges out of their earshot. Do acknowledge their fears; its ok to  calmly share your own qualms as well to your child in terms at their intellectual/developmental level. It’s best, wherever possible, to deflect specific questions about family finances in the face of the myriad shutdowns in the community. Regarding that topic, gentle and general reassurance is best. Don’t promise too much, and, again, don’t make untrue statements. Examples: “We are fine right now”; “we are going to pull together and we will take care of each other as we always do.”

Make sure your children maintain their regular healthy lifestyle habits: regular bedtimes and awakenings(in particular with teens); 3 square meals (now that so many are home a lot more, avoid excess snacking); do homework assignments promptly and regularly; read for pleasure.

Finally, and old adage says that “every challenge is an opportunity.” Your children are unable to attend school and many parents are stuck at home idled from work as well.  A great chance for  family time! Read, watch movies together; play games (for the love of Gd, board or card games some instead of just video games!!); take family walks, bike rides, play sports–have a catch, shoot baskets, hit tennis balls together (maintaining appropriate “social distance”).  At least this is happening in springtime–enjoy it.

I quoted George Harrison in my last post–“All Things Must Pass.”  With my aches and pains, I have benefited from the gaining of a bit of wisdom from aging.  I certainly don’t know when, but, eventually, we will get through this.  We just need to remain calm, patient, and–most important– supportive of each other.  ESPECIALLY OUR CHILDREN!!

Thanks for following.