July 16, 2020
Dear TLC Family,
Four months ago, we would never have guessed that we would need a 4th edition to our COVID-19 email series. Unfortunately, the marathon continues and COVID-19 (or what we’ve come to call it - “the beast”) is still here. We now want to invite you to a virtual “family meeting”. This is a long and potentially controversial one, so buckle up. The thoughts below are the opinions of TLC’s doctors, which have come from articles, physician forums from providers around the world, conversations with front line COVID ICU/ER providers, and our personal experience of seeing patients with COVID for the last 4 months. We understand not everyone may agree with us, but during times like this when trustworthy information and guidance can be difficult to come by, we feel it is our duty as your healthcare providers to share our evidence and practice-based suggestions so that you can make the best choices to protect your family.
1. Is COVID-19 as bad as what has been presented in the press?
There’s a reason we’re calling it the beast! COVID-19 is scary, unpredictable, widespread and much worse than the flu. Every provider at TLC Pediatrics has had a physician friend in the ICU with COVID-19. These people have been young and had no known high-risk factors. We have had parents of patients in the ICU, and our patients’ family members die from this illness. We have also seen a significant increase in the positive rate of our testing - of our typical 30-60 swabs a week, about 20% come back positive, as opposed to less than 5% previously.
2. Do kids get this virus?
YES! We believe the early numbers were low because COVID can present differently in children, and children were not a significant part of the early waves of testing back in March and April. Each provider at TLC has taken care of symptomatic and asymptomatic children with COVID-19, and we can all confirm that children can also catch COVID-19.
3. How are kids doing with the virus?
Overall, our patients have done well recovering from COVID-19. To date, we have seen affected patients range from newborns to 21 years. We have had no hospital or ICU admissions, but we have heard from our physician friends that there has been a significant increase in pediatric ICU care and ventilator need in the past three weeks at Arizona's pediatric hospitals. Our experience has been that the presentation varies with age. Babies have congestion, mild cough and low-grade fevers. Toddlers appear to have runny noses, cough, fever and loss of appetite with loose stool. Younger school age kids appear to have more diarrhea, vomiting, fevers, and sore throats. The cough appears to get worse as you get older. The loss of smell and taste is far more common in teens and young adults. Some of our patients have been asymptomatic family contacts. Not every symptomatic patient has had a fever. Fatigue seems to be universal. We believe that we have seen families infected by children, and we have seen outbreaks now from family parties, daycares, sports teams, and camps. Again, we are fortunate that none of our pediatric patients have needed hospital care for COVID-19, and we aim every day to provide high-quality care and follow-up to continue that trend.
4. What are the high-risk factors for severe COVID-19?
This question seems to be a moving target. Below is our current opinion, which may change as more articles and research studies emerge. The most salient point is that it is very unlikely - though not impossible - for kids to end up in ICU. We do, however, worry that our patients will be bringing the infection home to their families and sending parents and grandparents to the hospital. A few particularly important factors we’d like to discuss are listed below:
-Asthma- Perhaps the trickiest of the risk factors, as different articles have presented different relative risks. Initially, it appeared that treated asthma may actually lower your risk of ICU admission; however, more recent studies are less clear. What we do believe is that it is important to stay on your medication and manage your asthma aggressively during this COVID season. People with well-controlled asthma do better than those who are uncontrolled.
-Diabetes- It is our belief based on the current research that both children and adults are at higher risk if they are diabetic, whether it is type 1 or type 2. We have had a type 1 diabetic do well after contracting COVID, but it is our recommendation that our diabetic patients and family members do everything possible to avoid getting the disease. Like asthma, we also recommend that you adhere to your medication regimen to keep your diabetes well-controlled.
-Cancer- Both current and past chemotherapy in both children in adults may put you at higher risk for serious COVID-19.
-High blood pressure, kidney disease, and autoimmune disease- For these scenarios, we are basing our recommendation on adult research, but it appears that all three may lead to a higher risk of serious infection.
-Obesity- We understand how sensitive a subject this is to bring up, but we care about our families enough to let them know that this is a risk factor for both children and adults.
-Pregnant moms- This particular situation is a bit tricky to work out the true risk based on current research, but our main concern centers on the increased risk of clotting with COVID-19.
-Babies- We have been fortunate our infants have done well, but as with most of our pediatric infections, there does seem to be a higher risk for young infants to severe outcomes.
5. So why are masks a big deal?
Everything that we are learning now seems to point to respiratory spread being the cause of getting the virus (which includes talking and breathing). Some things seem to make it worse like coughing, singing, yelling and sneezing. For some as-yet unknown reason, some people are super spreaders capable of spreading to large numbers of people undetected. The problem is we just don’t know why yet. In addition, it isn’t clear that 6 feet is enough to prevent person to person spread. The virus has been found hanging around rooms for hours after a person with COVID leaves (which is why we are asking everyone to keep their masks on at all times in our office). While masking does help to protect you from getting the infection, its best work is actually to prevent you from spreading to other people. Thus, if we can all wear masks out in public, we can help to keep each other safe.
P.S. - If you haven’t had a chance to check out our recent blog post on masks, head on over to see a great simulation on how masks help to prevent spread.
6. Are all masks equal?
No. You will notice that all our doctors and medical staff are wearing N-95s or KN-95s. These are medical grade masks that prevent the spread of viral particles, which we wear due to seeing a diverse array of patients all day. Most non-healthcare providers do not need a N-95 or KN-95 mask. If you are in a high-risk family, consider purchasing a KN95 mask as they become more available.
7. So what if I get exposed to someone with known COVID?
Per the CDC, you need to quarantine (which means stay home for 14 days). Please no restaurants, sport teams, hair appointments, family get together etc.! If you come in for a doctor’s appointment, please be sure to let us know that you’ve been exposed. This helps to protect our staff and doctors, so that we can continue to be there for our families.
8. What about school?
This is the current million-dollar question. There is no easy way or one-size-fits-all way to approach this, but based on what we’ve seen with COVID-19, here are our current recommendations:
-If homeschooling is your superpower, we envy you greatly. Keep your kids at home, it is the safest for both them and you.
-If you are like the rest of us, we believe every family’s situation is unique and we cannot make that decision for you. If you have a high-risk person in your family, please try to distance learn until the current Arizona pandemic calms down. We support in-class learning, but we are not sure if it will be possible by August, based on current numbers. If and when schools do open, please teach your children to wear masks and emphasize to them how important it is to keep them on all day. Practice with them over the summer - we promise it does get easier to keep them on!
9. What about divorced situations?
This is another situation where every family is different. Please note, TLC Peds will not be able to make any judgement about what is best for your family. Please consider who has been already exposed and where the high-risk people live. Please be flexible and open with each other and consider modifying custody arrangements for a few weeks.
10. What about sports teams?
If you had asked us a few weeks ago, our answer to this question would’ve been masks and social distancing. But the quickly changing nature of this pandemic has caused us to change and upgrade many of our recommendations, and this is also one of those. We love you all and have amazing athletes in our practice but right now we are recommending that you take a few weeks off, at least until the pandemic stabilizes. We have seen soccer, volleyball, swim, football, hockey, and gymnastic teams affected by the virus, and the close contact in many sports is the perfect petri dish right now for COVID-19. Practice and keep your skills sharp at home as best you can. Staying safe right now in the present means that you’ll be there to play in the future.
11. What about travel?
We recommend putting off non-essential airline travel at this point. If you do go, wear your masks at all times in the airplane and airport, pass on eating and drinking to keep your mask on, and wipe down your surroundings on the plane. It is a great time to drive to see the US, but it gets tricky with eating and hotels. Consider camping. If you do go on the road picnics are great, masks and hand sanitizer are essential for all rest stops and consider outdoor dining for dinner. Many hotels are doing a great job with sanitation; check out their policies before arrival. Also be sure to check if your destination requires you to quarantine - Arizona has been placed on several states’ lists for a 14-day quarantine upon arrival.
12. What about testing?
We continue to believe in the importance of testing. Unfortunately, we continue to struggle with lab turnaround times, which are unpredictable and can be anywhere from a few days to two weeks. We anticipate in-office tests for this winter but are cautious to make sure we weigh important factors such as accuracy and cost to the patient. Right now, we are offering both the nasal test and the oral test (which is 3-5 percent less accurate but more comfortable).
13. Is it safe to use Ibuprofen?
Yes. The initial reports of ibuprofen making Covid-19 worse appear to be inaccurate.
14. Good grief, is there any good news out there?
YES! Overall, the death rate is down. We have some new treatments for severe illness such as Decadron, convalescent plasma and Remdesivir. We still have a ways to go but it is a good start, and some of the best minds in the world are hard at work on continuing the progress. We can all help by holding off the virus until we get more effective treatments or a vaccine.
15. Is there a silver lining for this epidemic?
This answer will be different for every family, but at TLC Pediatrics we say yes. This has been a hard reset for our practice. We have gotten to slow down and reexamine why we all went into medicine. We have recommitted ourselves to providing excellent care, even when the going got tough. We decided to face the virus head on, diagnosing it in the office and standing by families fighting it. The pandemic also helped us to realize that it is time to face our own challenges. We are committed to trying to keep our wait times down, limiting our patients in our waiting room, and innovating new ways of practicing medicine, such as virtual and curbside visits. We will never be the same after this, but our hope is that we will be much better.
Thank you all for standing with us during this difficult time! As always, we are proud and privileged to be your providers. Stay healthy and stay safe!
Your TLC Family