On March 23, the U.S. Surgeon General Dr. Jerome Adams issued this warning during an interview with NBC: "I want America to understand — this week, it's going to get bad.”
Frightened parents hardly need more cause for concern as they watch the number of cases surge across the U.S. amid news reports of critical supply shortages, leaving hospitals ill-equipped to handle the crisis.
Dr. Ronald Kleinman, Physician-in-Chief, Massachusetts General Hospital for Children, echoes Dr. Adams's forecast. “In some states like Washington, New York and California, the number of patients who are infected and sick will surge to levels that will challenge the health care systems in each of those areas over the next several weeks. The surge in other states will likely follow.”
But amid the dire predictions, Dr. Kleinman offers this calming reminder: We know all we need to know about how to keep ourselves and our children safe. The best thing we can do, he says, is to “follow the guidelines around physical distancing, wash our hands, keep our hands away from our faces, pay attention to the guidance of state agencies and hunker down.”
We’ve heard the symptoms of coronavirus can mimic those of a common cold. How do I know that my child doesn’t have it if he or she comes down with the sniffles?
DR. RONALD KLEINMAN: The challenge is that at this time of year, colds are very common. So our best advice is if your child hasn’t been exposed to someone with coronavirus and he or she is otherwise healthy, then take the same steps you would for any cold. Give your child fluids, and acetaminophen for a low-grade temperature, and keep an eye on them.
If your child has been exposed to someone with COVID-19, notify your pediatrician but keep your child home and observe. If the course is typical, it will pass, and the child should be fine. But if symptoms intensify — your child's breathing becomes labored, the fever goes up, or your child complains of muscle aches — it's time to see a doctor.
What are the symptoms of coronavirus in children? Are they the same as in adults?
DR. RONALD KLEINMAN: Coronavirus symptoms in most children seem to be significantly milder. Sometimes, children don’t have any symptoms and the virus doesn’t cause them to get sick. But we know that some children do get sick and may, unlike adults, develop gastrointestinal symptoms early in the illness, including tummy aches, diarrhea, a bad taste in the mouth or an inability to taste food.
So, again, it’s important to remember that, for the most part, children have a milder illness. And, just as it is with adults, those children most at risk for having serious forms of the illness are those whose immune systems are compromised either because they are on medicines to suppress their immune systems or they’ve got an underlying lung disease, such as cystic fibrosis.
A study published in the online journal Pediatrics made headlines with the warning that children can become seriously ill from coronavirus. Did it reveal anything we didn’t know before about COVID-19’s dangers for children?
DR. RONALD KLEINMAN: We’ve expected all along that some children will be seriously affected. There was one lone death in China of a child between the ages of 10 and 20, as far as we know. Of the others who have become seriously ill, for the most part, all of these children had an underlying illness that made them more vulnerable to this disease, which explains why they became seriously ill.
We expect there will be a whole spectrum of illness in children and we’re learning as we go from the countries that have more experience with the COVID-19 pandemic than we have. I mentioned some of the symptoms children may have that occur less often in adults, but all the information so far tells us that the spectrum of illness in children is very heavily weighted toward mild or no symptoms at all.
If my child does come down with a cold and is feverish, should I get my child tested?
DR. RONALD KLEINMAN: Take care of him or her just as you would if there was no COVID-19. You can expect those symptoms will very likely go away after a few days. But if they intensify and they turn into more serious flu-like symptoms — in particular, if your child has difficulty breathing — contact your pediatrician.
If my child has coronavirus, how do I care for her while protecting the rest of my family? Do I need to isolate her?
DR. RONALD KLEINMAN: By the time your child has symptoms, everyone in the family has likely been exposed to COVID-19, so there’s nothing special you need or can do to protect everyone. Remind everyone to practice good respiratory hygiene by sneezing or coughing into an elbow or tissue, continue to wash their hands frequently and resist the urge to touch their face. Clean the surfaces in your home regularly throughout the day.
What if my child gets sick and I live in a multigenerational household with a grandparent or a great uncle or aunt who has an underlying health condition?
DR. RONALD KLEINMAN: Protecting those most likely to become seriously ill is really important. If members of your core family are over the age of 60, and they have the opportunity to stay someplace else, where no one is sick, they should — especially if they have a higher risk for serious illness due to underlying medical conditions in addition to their advanced age.
What are the underlying health conditions that pose the highest risk?
DR. RONALD KLEINMAN: The risk for serious illness rises significantly over the age of 60 and peaks between the ages of 80 and 90. Any underlying lung condition that has already expressed itself as a difficulty to breathe, like COPD, cystic fibrosis or bronchiectasis, is another risk factor. People who are taking immunosuppressants used to treat such autoimmune diseases as rheumatoid arthritis, psoriasis or inflammatory bowel disease and those who have cancer or are undergoing organ transplants — they are also very vulnerable to becoming seriously ill from COVID-19.
Is there a treatment for coronavirus?
DR. RONALD KLEINMAN: There are no specific medicines at this time that have been proven to stop the virus from infecting humans or from causing injury once someone is infected. The supportive care for both children and adults who are infected with COVID-19 is the same. We provide fluids and medication for fever and any other infections that might coexist with COVID-19, like the flu or a strep throat or bacterial pneumonia. For patients with respiratory distress, oxygen — and in extreme cases, a respirator — is used.
We are testing one drug here called remdesivir, an antiviral that held promise as a treatment for Ebola. We, along with multiple centers across the U.S. and internationally, are now enrolling patients in a trial. Still, it will likely be several months before we have any sense of whether it works.
How far away are we from having a coronavirus vaccine?
DR. RONALD KLEINMAN: Most of those working on a vaccine feel we’ll have one in the next 12 to 18 months. There is a huge amount of work involved. Coming up with the active component of the vaccine that will protect someone is the first step. Significant progress has already been made in that regard. But then demonstrating its effectiveness, by testing it in animals first, then humans, takes time.
The March 13 issue of the Journal of Clinical Investigation reported on proposed efforts to use plasma (serum) from the blood of survivors for protection and treatment until a vaccine and antiviral medications are available. What is your reaction?
DR. RONALD KLEINMAN: The strategy of passive immunity, which means you take antibodies from someone who’s recovered from the infection to protect another, can be used in individual cases. But it’s not a strategy to protect the entire population. The reason it’s not is that you must take serum from multiple survivors, treat it so that it’s safe to inject into others, and then set up a distribution system for it. It’s much more effective to focus on building active immunity with vaccines.
Parents and kids who miss their friends and family might be tempted to try to find ways to meet up safely. Can families or friends who’ve been observing identical safety protocols meet in person?
DR. RONALD KLEINMAN: We need to wait until we are advised by our state or federal public health authorities that we can all come together again. Until that time, we should all follow the guidelines around what I prefer to call “physical distancing” rather than “social distancing.” Right now, we shouldn’t distance ourselves socially from one another. Instead, we should find ways to connect that don’t require us to be physically present with one another.
We should all follow the guidelines around what I prefer to call 'physical distancing' rather than 'social distancing.' Right now, we shouldn’t distance ourselves socially from one another. Instead, we should find ways to connect that don’t require us to be physically present with one another.
Whose advice around physical distancing should we follow?
DR. RONALD KLEINMAN: If you are listening at the federal level, Dr. Anthony Fauci, leader of the National Institute of Allergy and Infectious Diseases for three and a half decades, has been an excellent leader and spokesperson. On a local level, folks should look to their governors and those leading the public health effort within their states. The Centers for Disease Control (CDC) is an excellent source for overall guidance on the status of the epidemic in the U.S.
Should I take my child out to her scheduled well visit during this time?
DR. RONALD KLEINMAN: Here at MassGeneral Hospital for Children, we’ve canceled all well-child visits for all kids over the age of 2. We make an exception for children younger than that so we can initiate the immunizations that are given between birth and 2 years of age. Booster shots or the vaccines that come later in childhood can be put off for a month or two.
That doesn’t mean we are not available to see patients. We’ve converted the majority of our appointments here to virtual visits. So if that’s possible wherever you are, definitely take advantage of that. You can do so much in a virtual visit without overwhelming doctors’ offices and putting others at risk. Both phone visits or face-to-face doctor visits via a platform set up by your doctor’s office or hospital work very well in most circumstances.
How are you helping your own children and grandchildren through this difficult time?
DR. RONALD KLEINMAN: On the positive side, we see our grandchildren much more than usual because we FaceTime with them every day. We have two children (and “children-in-law”), all in their early 40s, and each family has two children, ranging from 2 to 11 years of age.
What’s working for them? For the older ones, their school system is set up for remote learning, so they have online classes for two to three hours every day. They do virtual playdates and one of my granddaughters Facetimes regularly with her soccer team. That’s terrific. They get exercise in the backyard, work on projects with their parents, and the older ones have started baking — so they’re learning new skills in the process.
Maintaining structure in a child’s day is really important. Sticking to a routine will support a child’s inherent resilience and help them transition from what they had before to what they will have again once this is over.
Maintaining structure in a child’s day is important. Get them up and dressed and ready for a full day of activities — meals, schoolwork, exercise and physical activity, virtual playdates, snacks — at scheduled times. Sticking to a routine will support a child’s inherent resilience and help them transition from what they had before to what they will have again once this is over.
What advice do you have for families who live in cities, for whom parks and playgrounds are essential to getting exercise and having fun?
DR. RONALD KLEINMAN: I would not take children to the park right now. In such a setting, where children are used to having free rein to run around, it’s very challenging to get them to maintain a physical distance of six feet from others. So, for now, it’s best to avoid parks and places where people congregate.
Of course, avoiding others on city sidewalks can make trips to the grocery store and pharmacy difficult too. My personal advice is that if you and your family need to get outside to run errands or go for a walk, one adult goes out with one child at a time. And stay together. Hold hands with younger children, walk shoulder to shoulder with older kids, and before you go out, make a pact to hang together and walk around other people. Then you should be fine.
The gloom and doom reporting about supply shortages is incredibly alarming. What’s your assessment of the pipeline at this point?
DR. RONALD KLEINMAN: It depends on where you are and on the number of infected sick patients. We are short of supplies in many places, but there’s a huge ramp-up in procurement and production happening right now and if that can continue over the next week or ten days we should be in pretty reasonable shape in most parts of the country.
At Massachusetts General, we are in good shape with respirators and scrubs and gowns. We have experienced shortages of masks, both N95 particulate respirator face masks and regular masks, but we are continuously getting shipments in. Concern about resources is understandable because many places are undersupplied, but those who are responsible for making sure we have enough supplies are working nonstop to bring them in.
What’s also encouraging is that there are all kinds of incredibly inventive things happening now to address the shortages, from 3D printing of masks to offers by manufacturers such as GM and Tesla to devote resources to help solve the nation's shortage of ventilators.
I certainly wish all of our efforts had started four to six weeks ago; that would have been the time to mobilize these resources. Having said that, it's very impressive that these resources are now coming together, and I think that the average citizen should let others worry about that at this moment.
Helping children stay social while maintaining physical distance will make it much easier for them to transition back into physical connection and friendship once this is over — and it will be over.
Can my child have playdates?
DR. RONALD KLEINMAN: Virtual playdates are the only kind that are safe. They are also essential. Staying connected is vital to the social, emotional and physical well-being of children on so many levels. Children are very social creatures, and you want to support their social development and allow them to see that their friends and other children are healthy and functioning during this time. Virtual playdates also enable children to see how everyone can use social media and other online programs to come together.
There are dozens of reasons to keep children socially active during this time. But perhaps one of the most important of all is that helping children stay social while maintaining physical distance will make it much easier for them to transition back into physical connection and friendship once this is over — and it will be over.
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In addition to his duties at Massachusetts General Hospital, Dr. Ronald Kleinman is Physician-in-Chief at MassGeneral Hospital for Children (MGHfC) and Partners Pediatrics, Charles Wilder Professor of Pediatrics at Harvard Medical School and a member of UNICEF USA’s New England Regional Board of Directors.
Top photo: Schools are closed across the U.S., and many people are now operating remotely, challenging kids like second-grader Luka and his mom, Sophia, to create new routines amid the coronavirus pandemic. Here, Sophia takes a break from her work to help Luka with a math assignment at their home in Connecticut. © UNICEF/UNI313395/McIlwaine