Just a few days ago, Dr. Wendy Glaberson, one of our favorite pediatricians in Miami, took the time to answer our long list of concerns about the new Omicron variant—ironically while she was in isolation with her husband and two daughters. There’s so much good information here, including ways to help kids who have tested positive.
A longtime Miami resident, Dr. Glaberson received her doctorate at the University of Miami and went on to complete her pediatric residency at Holtz Children’s Hospital. In addition to being a board-certified pediatrician, Dr. Glaberson recently finished a sub-specialty fellowship in Nephrology. You can find her at Vicente Roger and Associates in Bay Harbour.
Kids are back to school and Omicron is everywhere. We are seeing classes shut down or teachers and students under quarantine. What should we expect for the next few weeks?
Omicron is certainly surging here in Florida, and the next few weeks may be bumpy for local families. Many statisticians have suggested that this current surge in the United States may peak in late January-early February, followed by a recession in virus for some time. That said, there is another variant of COVID-19 being detected in the UK. It is unclear if this variant will be infective as the Omicron variant.
We are hearing that Omicron is less severe. But what about kids? How are they reacting to this new strain?
In general, Omicron is a less severe variant, meaning that fewer patients are requiring advanced ICU care, intubations and extracorporeal membrane oxygenation (ECMO) or heart and lung machines. This is likely due in part to mass vaccination strategies and due to virus mutations, which infect the upper respiratory system more than the lungs. However, because this variant is extremely contagious, more people are becoming infected. By virtue of statistics, if more people become infected, then more people will likely require hospital treatment. It is true that more young children than ever before are being admitted into the hospitals. This is generally due to respiratory symptoms, such as severe croup or wheezing (bronchiolitis), and inability to maintain their hydration by mouth. Right now, children, especially those under five years old, are one of our most vulnerable populations as they are not yet eligible for vaccination. Despite this limitation, most otherwise healthy children will develop cold or flu-like symptoms, fever, runny noses, croupy coughs. Some will not even know that they’re carrying the virus.
What are the best ways to protect kids during this surge?
The best way to protect anyone during the surge is to use a multilayered approach, which means to ensure isolation of those who are infected and quarantine of those who are exposed, vaccination (and boosters), and effective masking, now thought to be best with an N95 or KN95 mask, which thankfully are significantly more available than at the beginning of this pandemic. Parents should themselves get vaccinated and model appropriate masking in front of their children, similar to wearing your seatbelt or a bicycle helmet; children will follow a strong example. Children also need support–especially emotionally. They pick up on adults who are anxious or frightened. Parents should attempt to minimize discussion of the pandemic around their youngest children. With school-aged kids, it’s okay to discuss the pandemic and answer questions in a non-threatening way. With adolescents, having family “check-ins” or one-on-one conversations are appropriate.
Is it too late to vaccinate kids for this particular surge?
It is never “too late” to be vaccinated provided that you do not treat vaccines as your only barrier against the virus. Just as you should not drive a car without seatbelts, airbags and headlights, you should not treat the vaccine as your only mitigation strategy. For children to develop a robust immune response against the Pfizer vaccine (the only one currently approved), they require at least two doses set apart by three weeks. Full immunity is generally seen approximately 10-14 days after the second dose, but partial immunity is seen seven days after the first dose. So, while your child may still become infected during this surge, any immune boost should help to decrease symptoms and severity of the illness. It is also important to remind parents that vaccination offers more robust and long-lasting protection against COVID-19 than wild-type infection and we also know that vaccination lowers the risk of hospitalization and severe effects of this virus including death.
What about kids under five, who can’t be vaccinated? What’s the best protocol for them?
Children under five years old should be considered vulnerable to COVID-19, similar to those with underlying medical conditions. To protect vulnerable populations, large numbers of vaccine-eligible people need to choose to take the vaccine. Children over two years old should be taught how to wear a mask. This can start in small steps: associate mask wearing with something fun, such as a favorite game or screen time (gasp!). While the child keeps his or her mask on, the fun activity can continue. If the mask is pulled off, don’t get upset, just stop the activity, reset and begin again. Start slow and in small doses. Additionally, children under five years old should be taught how to wash their hands effectively. Kids are gross! They constantly spread germs in their mouths, eyes, and noses–this is made more obvious by a global pandemic. I would recommend that young children (and unvaccinated people) avoid crowded public places as much as possible while the positivity rate in the community is so high.
What if a child tests positive for COVID-19? Aside from isolating, what are the best ways to keep them healthy during their illness?
In general, children need appropriate rest and hydration. Their appetites may drop and that’s okay for a short illness, as long as they are well hydrated. Consider popsicles or placing some fruit, such as watermelon and cantaloupe, in your freezer to become excellent snacks that also offer hydration. A little juice is perfectly fine if that’s all your child will take. Remember that most of our vitamins come from our diet, so continue to offer a well-rounded diet. Offer favorite foods and remember that COVID-19 may affect their sense of smell or taste. Children may need symptomatic care as well. Keep a thermometer on hand and Tylenol (or Motrin if over 6 months old) if they are experiencing discomfort from fever, sore throats or body aches. Sore throats can also be managed with saltwater gargles, decaffeinated tea with honey and lemon (if over 1 year old), or “sore throat lollipops,” which are basically cough drops on a stick. Congestion and runny noses should be managed with nasal saline and suctioning in young children or rinses/blowing in older children. Steaming up the bathroom and using a cool-mist humidifier in the bedroom can be helpful. Non-sedating antihistamines, such as Cetrizine (Zyrtec) or loratadine (Claritin), may be appropriate to help dry out a runny nose. Keep children occupied while they’re in quarantine, especially if they are not symptomatic. New games or activities, movies and socially distanced walks outside are all important parts to healing and passing the time. If they are symptomatic and can communicate, be sure to answer their questions about what is happening and what they can expect (it’s okay to turn to your pediatrician for the answers). If their friends are also sick, it’s okay to let children know it and potentially to allow them to talk to their friends so they know that they’re not alone.
When should parents bring their positive kids to their pediatrician or the emergency room?
Parents should bring their child to the pediatrician if they are uncertain about the diagnosis or worried about their symptoms. Pediatricians know your child’s medical history, so they are the best people to discuss your child’s risk of severe illness. Some pediatricians do testing for COVID-19 in their offices. Be sure to warn your pediatrician that you’re worried about the possibility of COVID-19, so that they can wear appropriate personal protective equipment during the visit. It’s time to take your child to the emergency room if he or she is confused or lethargic (very sleepy), communicates feelings of chest pain or shortness of breath, is dizzy, is cold or clammy in the skin, has prolonged or very high fever more than a few days, has severe abdominal pain (including nausea and repeated vomiting or diarrhea). Signs of difficulty breathing in children are changes of color in their lips (i.e. bluish-purplish), rapid breathing, shallow breathing, muscles pulling above their collarbones or between their ribs and nostrils flaring with each breath.
There’s so much confusion over the CDC rules, vaccination status, even the reliability of Rapid Tests. What are some rules of thumb or best advice you are giving patients about this moment?
The CDC rules (and terminology) are confusing even to physicians. We are constantly going back to the data, but they are designed to react to the current phase of the pandemic and that is why they have changed over time. A word about terminology, which to me is mostly semantics. Isolation is the separation of those who are currently sick with COVID-19 and those who are not. If you test positive for COVID-19, you should isolate. People who were exposed to COVID-19 but have not yet tested positive or developed symptoms fall into the “quarantine” category. Currently, we believe that people are most infectious with the Omicron variant in the 48 hours preceding symptoms and the first 3-4 days after developing symptoms. This is for the vast majority of cases, but certainly not all, which is why we need to be vigilant with protecting our community even after that first five days of illness.
Isolation should be for a minimum of five days, ideally 10 days, to protect the community. You can end isolation after five days if you are healthy (not-immunocompromised or high risk) and fever-free for 24 hours without Tylenol or Motrin, and your other symptoms have improved. For the next five days, you should be in a well-fitting KN95 or N95 mask when around others. The CDC also suggests that you do not go to places where you are unable to wear a mask, such as restaurants, and avoid eating around others until a full 10 days after your first day of symptoms. As a pediatrician, I recommend that families keep their children home a full 10 days to prevent the potential spread of COVID-19 to others, since most children unmask at lunchtime in an indoor (usually poorly ventilated) setting. In the state of Florida where masking is not required in schools, there is a potential for significant spread of the Omicron variant. When it comes to quarantine, the rules get more complicated, but the bottom line is that if you are recently vaccinated or boosted (or recovered from COVID within 90 days) AND asymptomatic, you are considered immune and do not require quarantine as long as you can wear a tight fitting N95 or KN95 mask consistently for 10 days. You should be tested for COVID-19 around day 4-5 post-exposure. I’ll reiterate that this is extremely difficult to do well in the school setting. If you can keep your child home, do so. If you are partially vaccinated, unvaccinated, or not boosted, you should quarantine at home for at least five days, monitor for symptoms, test for COVID-19 on day 4-5, and continue to wear a tight-fitting mask for the next five days.
It’s early, but do we know if kids who test positive for Omicron/COVID-19 now have strong antibodies?
This is a supposition, because we truly don’t know how long native immunity lasts with COVID-19. But it is not forever, as has been demonstrated in the medical literature and likely in your everyday lives by people testing positive multiple times in the same year during the pandemic with multiple variants. At this time, the CDC believes that native immunity lasts at least 90 days, therefore if you test positive at one point, you can expect to be significantly more protected for the next three months. Again, you should not rely on native immunity alone to protect you from COVID-19, you should still get vaccinated (or boosted), mask, practice smart social distancing and test if you become symptomatic. Another thing to mention is that the numerical level of antibodies found in the blood does not directly correlate to your “immunity,” as long as you are above a minimum threshold, you can consider yourself “immune,” at least temporarily.
If so, is there a silver lining here? That we may reach natural herd immunity?
Yes, despite Omicron being extremely contagious, the silver lining is that vaccinations are working and people are surviving COVID with more mild symptoms. Fewer people are requiring advanced ICU care. We have anti-viral therapies and monoclonal antibody treatments that are significantly more effective against COVID-19 then at the beginning of the pandemic. Herd immunity is still a question, as there has not been enough vaccination in the general community to support herd immunity and the native immune response appears to wane significantly sooner than that of vaccines and memory cells.
How are you handling the pandemic with your own family? Any parenting strategies you can share?
This question is certainly timely, as I am in isolation with my young daughters. My three-year-old tested positive for COVID-19 right before the return to school and she infected the rest of us. Thankfully, we found out before she returned to school and did not spread the virus outside of our family. As both my daughters are theoretically vaccinated (I say theoretically as my youngest is in the Moderna trial) and I am boosted, we all have mild symptoms. So, we are thinking of this isolation as a “forced” family bonding time. We have been doing puzzles, board games, craft kits (bouncy balls, glycerin soap, stained glass), recipes (we made bagels and cake pops so far), movies and yoga. We found a very isolated park to bicycle in where we could stay distant from others. And the best part to come out of this time is that we’re effectively potty training my youngest. She’s been eating A LOT of M&Ms for her efforts.
What is your best advice for telling children they tested positive for Covid? For example, my 6-year-old was distraught when I told her she tested positive.
For children who can communicate, it’s appropriate to be honest with children. Children pick up way more subtext than we give them credit for, so I would sit my child down and let them know they tested positive, and their symptoms would likely be similar to when they’ve had a cold or flu. Allow them time to ask any questions they might have about what to expect. My older daughter asked me straight out if COVID would make her very sick like some of the people in the news. Let them know that you will be there to support them through their illness and that you have been in touch with their doctor and know how to help them recover. You might mention some of their friends who also are isolating and going through a similar situation. This is where FaceTime and other virtual connections truly serve a purpose to allow children to remain connected to their peers and loved ones.
How have these last (almost) two years affected our children? Mentally? Spiritually? Physically? What trends are you seeing with kids today?
Children have certainly been affected by this global pandemic. As a pediatrician, I have seen changes in eating habits–increased obesity for one. When you’re constantly home with access to the refrigerator and suddenly your extracurricular sports are on hold, it’s a recipe for disaster when it comes to weight gain. It’s hard to then return to an active lifestyle after being sedentary. On the other hand, early in the pandemic, I had some toddlers drop significant weight after a COVID infection. As they were non-verbal, I could not prove it, but I suspected that they may have had a change in their sense of smell or taste. I have also seen increased situational anxiety, depression and adjustment disorder, increased behavioral difficulties and acting out, and somatic symptoms (i.e. stomach pain) related to these feelings. I recommend that parents seek out guidance from their pediatrician when it comes to mental health. I also recommend books on anxiety and coping, applications such as Calm, and doing some meditation or yoga. In young toddlers, there has been some mild developmental delays, especially when it comes to speech. With fewer children in daycares and spending more time at home, it is important to remember that you are your child’s teacher, and you should be modeling complex speech patterns throughout your day. Try not to rely on passive learning from a screen such as an iPad or television and, instead, engage your child by reading to them and asking them simple questions. Finally, some children have fallen behind in school, especially those in extended virtual school without parents at home who have the ability to support their learning. If your child is struggling with learning, now is the time to reach out to your child’s teacher and express what is happening. Thankfully, children are very resilient and most tend to take each new challenge (including a global pandemic) in stride.