COVID19 Q & A, The Cost Of COVID19 Especially For Children

The statistics surrounding the Coronavirus outbreak continue to evolve as do guidelines for social distancing, traveling, and sheltering in place. I have been writing and re-writing this post over a couple days. Things change fast enough that the tone I strike feels relevant only fleetingly. At the beginning of this (early February) I recorded a podcast with The American Academy of Pediatrics comparing risks of flu vs RSV vs COVID19 that underestimated the risks. It was accurate at the time, but no longer exactly. We’re all learning as we go, unfortunately. Each day, it sincerely feels to me, demands a different sentiment when it comes to “messaging.” Headlines are stifling, I’m as anxious in moments as everyone else and things I read online make me feel a little bonkers. We’re acting odd. I was able to buy peanut butter two days ago; it felt like a win. I’m on a text stream this morning with a group of doctors getting masks from Hong Kong. I mean, this is novel and unprecedented.

Healthcare providers at the front line (thankyouthankyouthankyou), public health institutions, and our government are all working (together) to help “flatten the curve” currently but we’ll also need to plan for the future. Social distancing is more important than ever but after even just a week of it, we’re horrified by the challenge. The “curve flattening” is the immediate focus to protect our health systems with this sudden surge of infection, but in time we’ll need to protect our livelihood, our longterm health, and our culture, too. The political overtones really just don’t help any of us, either. Health care experts, not politicians, should be running the microphone. This piece which is somewhat optimistic, The Virus Can Be Stopped, published today is a nice overview of how to halt the infection rapidly.

This is all very real for all of us. I don’t believe an individual is spared fear or responsibility. Just a smidge of my context: I’ve been sheltered in place for a week with my boys. A beloved family member is on hospice in California. One of my best friends, a physician in Seattle, spent a night waiting for her COVID19 results to come back.  My mom lives down the street, and is immunosuppressed and 75 years old. I have two tweeny boys out of school, indefinitely. I was on the council that authored the American Academy of Pediatrics (AAP) guidelines on screen time and I’m not gonna lie, I’m struggling this week to take our own advice. Three cheers to Roblox and Dude Perfect on Youtube and a X-Plane 11 flight simulator app that have captivated my boys while we sat inside for 4 days during rainy, cold Wisconsin dreariness. Their use of tools is out the roof. We go outside, we do other things (omg, I’ve limiting the play of Monopoly to just 1 hour a day to preserve my freaking mind), but the digital captivation is a real antidote in moments for them. And I like the escape for them. We have walked outside a lot. We have baked a cake. We’ve been cooking meals together. We have been sleeping a lot. We watched Top Gun. But geesh. I’m not good at this yet. Here’s an AAP statement from today about the growing parental stress & ways parents can help take care of themselves and protect their children.

Know That Information Online Will Change

The world is very different today than it was even a week ago when CDC announced no meetings of over 50 people. That was a week ago. It will be very different next week, but the difference will be less dramatic. Last week’s dramatic change in slope was hard in indescribable ways. I’m positive we’ll develop a fitness for our new reality in the upcoming weeks. And…the hardest part about ANY medical information and advice right now ANYWHERE is data is entirely incomplete. I like the Johns Hopkins Coronavirus Resource Site – actively updated and judiciously thought about as far as I can see and I like the CDC site for doctors and the public. But we desperately need more testing for active disease (screening and diagnostic). We need serologies (blood draws to confirm you have had the virus and are immune) for those who want to know if they’ve already had COVID19. We need more protective gear for health care workers. Testing will bring clarity and certainty in a moment in our history where we have none. This will come. It will. But in the meantime I’m unsteady on what the best message is.

Bottom line: we still don’t have a full picture of the virus, we don’t know who has had it, who has it now, or how it affects our population yet, at large. Physicians and journalists are sharing information with rapidity online – but the data isn’t yet “perfect.” We have predictive data from China, South Korea, and Europe that doesn’t seem to have an accurate, consistent denominator. And I say this only to say that information you hear today may change and that’s simply because our understandings will have to evolve as the scientific understanding is un-gowned. When we unfold more testing across the US we will know more. For now, though, I’ll answer a few questions (below) as best I can. But first a big sidenote:

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The Cost of COVID19, Especially For Children May Not Be Viral

Health care is pretty good at dealing with infectious disease (a pandemic, albeit the highest degree of difficulty). Infectious disease clinicians and researchers are typically hyper-curious, hyper-intelligent, and hyper-careful. As a cohort, I just don’t know any doctors like me that would refute that. I trust them to guide us and I am overwhelmingly grateful to my colleagues everywhere. Thank you.

But what’s keeping me up at night (and rattling my soul during the day) as our ID and ER and primary care and ICU physicians work so hard right now to guide us, is that I know we’re horrible at caring for and dealing with social determinants of health. It’s my belief there will be more illness, suffering, and negative impact on our children, our families, our relatives and all those at risk in our country from the cultural, societal, and economic changes we’re making now during the surge than from COVID19 virus, itself. I’m not trying to negate the devastating effect this virus is having – in illness, morbidities, and death —  I just also worry so much about what lies in the shadows –the downstream effects of our choices now (mental health decline, poverty, hunger, hopelessness, loneliness, access to health care, community, employment) on those at lower risk for COVID19 death. We have to flatten the curve, yes, but we have to help make national and regional guidelines that take into account the WILD, unprecedented changes coming with shutting down our schools, our workplaces, our transportation, our economy, and our freedom to roam. It’s hard to breathe when you lose your job, have no physical contact, can’t leave your home, and are unsure about the future. We’re not really allowed to move. The layoffs are deeply troubling.

DO NOW: Prioritize your mental health by creating things that lighten you every day. Call your friends. Order takeout when possible. Order gift certificate to businesses in your community you adore. Give bigger tips if you can. Keep paying your housekeeper or nanny or helper of any kind if you’re lucky enough to have one. Keep working to keep the world working. Of course, support those who live near you by buying groceries for them if too risky for them to go out. Try once every couple days to just deliver cheer. Keep working from home in any way you can; spend time in each work day with your coworkers not “working.” IMO this will give you hearty purpose and I know at my core you’ll gain more than you give away…

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As you likely know, I serve as the Chief Medical Officer for a food allergy protection company, SpoonfulOne. We’re a company based in prevention. Last week, we asked our followers and customers if they would rather learn about Coronavirus, or food allergy protection. Not unsurprisingly 67% voted to open up a Q&A on Coronavirus as opposed to prevention info on allergies. I’ve aggregated the top questions we received below and provided some responses with the data and recommendations currently available. Harvard Health Publishing created a nice Q&A you can reference for questions not covered below.

Are pregnant women considered to be at greater risk like elderly & diabetic patients?

CDC Says: We do not currently know if pregnant women have a greater chance of getting sick from COVID-19 than the general public nor whether they are more likely to have serious illness as a result. Pregnant women experience changes in their bodies that may increase their risk of some infections. With influenza, for example, we know pregnant women are at higher risk. With viruses from the same family as COVID-19 women have had a higher risk of developing severe illness. It is always important for pregnant women to protect themselves from illnesses. Case reports coming out of China and Europe can help guide advice for now as our own data unfolds. CDC links for pregnant moms.

Bottom line: pregnant women should be considered an at-risk group. Pregnancy losses have been reported after pregnant women were infected with other coronaviruses, and while many healthy babies have been born to moms with COVID-19 (without vertical transmission so no infection passed to baby) experts can’t say for sure if the same will be true for COVID-19 in all women.

What about autoimmune diseases like thyroid & lupus? Are these greater risk?

Any underlying health condition can put a person at risk for more serious disease, and complications, from infection. When it comes to COVID-19 this may be especially true with autoimmune disease if on immunosuppressant medicines. Those patients should be careful to avoid exposures as much as possible.

Are newborns < 6 weeks old greater risk?

Children infected with this coronavirus are mostly showing mild symptoms, but there isn’t enough data yet to say whether infants would fall into this category. Preschoolers and babies are likely to get sicker than older children because of their immune system immaturity. They haven’t been exposed to viruses before and therefore they can’t mount an effective immune response but we’re seeing a protective factor for young children, all over the world.

Data from over 2,000 children in China found about 90% of those infected had no symptoms or mild, moderate cold symptoms. But infants were are somewhat increased risk.

RESULTS: There were 731 (34.1%) laboratory-confirmed cases and 1412 (65.9%) suspected cases. The median age of all patients was 7 years (interquartile range: 2-13), and 1213 cases (56.6%) were boys. Over 90% of all patients were asymptomatic, mild, or moderate cases. The median time from illness onset to diagnoses was 2 days (range: 0 to 42 days). There was a rapid increase of disease at the early stage of the epidemic and then there was a gradual and steady decrease. Disease rapidly spread from Hubei Province to surrounding provinces over time. More children were infected in Hubei province than any other province. CONCLUSIONS: Children at all ages appeared susceptible to COVID-19, and there was no significant gender difference. Although clinical manifestations of children’s COVID-19 cases were generally less severe than those of adults’ patients, young children, particularly infants, were vulnerable to infection. The distribution of children’s COVID-19 cases varied with time and space, and most of the cases concentrated in Hubei province and surrounding areas. Furthermore, this study provides strong evidence for human-to-human transmission.

“If breastfeeding my < 1-year-old child and I become infected should I isolate from my child?”

No.

CDC Says: A mother with confirmed COVID-19 or who is asymptomatic with the infection should take all possible precautions to avoid spreading the virus to her infant, including washing her hands before touching the infant and wearing a face mask, if possible, while feeding at the breast. If expressing breast milk with a breast pump, the mother should wash her hands before touching any pump or bottle parts and follow recommendations for proper pump cleaning after each use. If possible, consider having someone who is well feed the expressed breast milk to the infant. In limited studies on women with COVID-19 and another coronavirus infection, Severe Acute Respiratory Syndrome (SARS-CoV), the virus has not been detected in breast milk; however we do not know whether mothers with COVID-19 can transmit the virus via breast milk.

When will COVID-19 go away?

The answer to this will likely depend on how we behave as a society. In the article I mentioned earlier in the post, I agree with this magic wand type statement (scientifically),

If we are able to follow guidelines on social distancing, wash our hands, and quarantine when ill, we will fare much better. To end this outbreak, for good, we’ll need antiviral treatments or a vaccine. Those are currently being produced, and at record speeds. Researchers are working on new vaccine technologies — like mRNA vaccines that don’t use viruses at all in their production process — as well as cutting-edge therapeutic antibodies. That said, it still could be a year or more before the safety and efficacy of these pharmaceuticals are proven.

Alternatives when you run out of a baby supply like formula? 

If your child is at least 1 year of age, you can use cow’s milk. If your child is under age 1 work with your local resources for finding formula or getting support for your breastfeeding. I like this piece from Parents.com that has great guidance and states the following:

Focus on food. You should continue feeding with formula until age one, but babies older than six months can start getting more nutrition from solid foods too. “This is a great time to prioritize high quality, nutrient-dense foods,” says Dr. Young. Even new eaters can have pureed meat, pureed avocado, or baby cereal with a teaspoon of olive oil or butter stirred in. “When you provide more nutrients and calories from food, your baby will likely drink less formula.”

Reach out to your pediatrician or local hospital. If you’re in a desperate situation, Brown says that pediatricians usually get samples of formula (so do some hospitals), so reach out. If you’re eligible for WIC or SNAP benefits, both may have infant formula as well. Other places to check: Women’s shelters, food banks, and faith-based organizations that provide food assistance.

How soon after transmission can you test positive for the virus?

This is a tough one to answer and pinpoint but it is about 2 days or so. The time from exposure to symptom onset (known as the incubation period) is thought to be 2 to 14 days, though symptoms typically appear within four or five days after exposure. We don’t know the extent to which people who are not yet experiencing symptoms can infect others, but it’s possible that people may be contagious for several days before they become symptomatic. The time it takes to get test results is varying by state from 1 day to 10 days.

Are teens with confirmed COVID-19 likely experience the mild trajectory that little kids do?

Disease in children appears to be relatively rare and mild, with those under 19 years making up only 2.4% of the total cases, according to a report published Feb. 28 by the World Health Organization. Teens have few underlying health conditions, robust immune systems, but can also get a more serious infection sporadically. Of note, I sent this tweet after all the Florida spring breakers were shown to lack both insight and compassion:

Agree. However in my experience as a middle school teacher and pediatrician it’s complicated by the reality that most teens are also deeply emotional and interested in doing good FOR others.

— WendySueSwanson MD, MBE (@wendysueswanson) March 19, 2020