YOUR HOME FOR QUALITY PEDIATRIC CARE • SUMMER 2020 Welcome to The PediaMag.............. 2 BACK TO SCHOOL Back To School 2020 Into The Unknown........................... 3 Back To School? Not So Fast........... 4 Five Steps to Wash Your Hands the Right Way.................................. 5 COVID-19 Child face mask tips and tricks........ 6 How to keep your kids active in the summer of COVID19.............. 7 COVID-19 Frequently Asked Questions............................. 8 PARENTING Free Zoom Classes for New and Expectant Parents..................... 9 TELEHEALTH AHN Pediatrics After-Hours Telehealth Services......................... 9 SEASONAL It’s Tick Season............................... 10 ALLERGIES Summer Allergy Update................... 11 YOUTH SPORTS Sports Nutrition- Fueling Optimal Performance....................... 13 The Future Of Youth Sports.............. 15 PATIENT PORTAL Helpful Tips for Patient Portal Users......................... 16 Publication Provided by:
Chelsea Raffa CRNP
Welcome
Welcome to The PediaMag Welcome to the Summer 2020 issue of The PediaMag! The providers and staff at AHN Pediatrics - Pediatric Alliance are back at full-strength after the spring COVID lockdown that kept our children home from school and parents home from work, and their pediatricians learning new skills with virtual telehealth technology. We are still here for you performing routine well child care exams and acute care visits in-person or virtually. If the pandemic has set your child’s immunization schedule back a few months, it is important to give the office a call today so we can schedule a visit and get them caught up on their shots. The last thing we want to see is a disease outbreak of a vaccine-preventable disease like measles or whooping cough on top of a global pandemic of coronavirus! Which reminds us: We will have plenty of flu vaccine in stock for your kids this fall, so watch your inbox and social media pages and The PediaBlog and get ready to sign up for one of our annual flu clinics! All of us at The PediaMag wish your family good health during these difficult times. We hope you enjoy reading The PediaMag. Onward!
About Us: Pediatric Alliance was formed in 1996 when eight individual practices joined together to provide quality health care throughout Southwestern Pennsylvania. Over the years, Pediatric Alliance grew to be the largest physician-owned group pediatric practice in the area. In 2019, Pediatric Alliance joined with Allegheny Health Network to allow expansion of resources in order to stay abreast of the latest technology and advances in health care. Our board-certified pediatricians offer primary care to children and adolescents in 16 different office locations including two specialty care offices for allergy, asthma, and immunology and pediatric endocrinology. We are proud to offer personalized, patient-centered care to patients from birth to 21 years of age. We strive to meet your family’s pediatric needs, provide convenient access to care, and build strong relationships with families to maximize your child’s health. To learn more about AHN PediatricsPediatric Alliance, visit our website at www.ahnpediatrics.org.
AHN Pediatrics-Pediatric Alliance 1100 Washington Ave., Suite 219 Carnegie, PA 15106 www.ahnpediatrics.org
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The PediaMag is published semiannually, copyright 2018. All rights reserved. Publisher AHN PediatricsPediatric Alliance
Editor Rebecca Scalise
AHN Pediatrics-Pediatric Alliance • Summer 2020 • www.ahnpediatrics.org
Art Director Brent Cashman
Back to School
Back To School 2020 Into The Unknown By Dr. Bethany Ziss
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Developmental Pediatrics, AHN Pediatrics Bloomfield
In my work as a developmental pediatrician, I have conversations with families every day about challenges relating to school. Many now are wondering how best to prepare children to return to school in the fall, after the abrupt change to remote learning in March. Districts are still working out what school will look like in the fall, and plans made now may change very quickly later. So instead, we are preparing children for uncertainty. School at home was tough for many, but resuming school in a building brings additional challenges. When we talk about going back to school, children may picture school the way it was in the past. The difference between school before COVID-19 and after COVID-19 may actually be harder for some children because they will be in the same place, with the same people, doing many things differently. As always, children do best when they know what to expect, even if they may have to expect changes. It may help to tell children before the year starts that we are making a “for now” plan. If more people get sick nearby, the plan may change. We are all changing plans together.
Older children and teens: As with younger children, prepare students for the changes that we know are expected. Teens may want to read some articles about the different ways school districts are preparing. Expect to field questions about why classmates may be going to events that they are not permitted to attend. You may hear the word “unfair” a lot – this is to be expected. The conversation that “different families have different rules” applies here, just as it does around bedtimes, electronics use and allowances. Touch is often an important part of social relationships for tweens and teens. It may be hard to see friends for the first time in months while having to keep a distance.
Younger children: If children will be attending school in person some days and by remote other days, make a calendar. Use pictures and color-coding younger children. What will school be like? > Students will be wearing masks except for when they are eating. > Everyone may have a temperature checked every day. > Desks will be kept further apart and facing forward rather than in groups. > Children will not be sharing supplies as much. > Classmates will greet each other with waves rather than hugs or high-fives. > You might want to look together at pictures from areas that have started socially distanced classrooms. The wonderful Daniel Tiger’s Neighborhood has an episode where Jodi moves to the neighborhood and joins school. Unlike Daniel’s own “first day at school” episode, Jodi has been to school before. At first, she notices all the things that are different. Her teacher and family help her look for things that are the same. “Daniel’s Very Different Day” also addresses plans changing at home and school.
Older students often have increased expectations for independent work and time management. This may be a good time to experiment with systems to keep track of assignments. Try a paper journal or datebook. Kids and teens who have a phone or tablet might try a free organization app (with adult oversight). Teens may be missing out on independence milestones – driving, working, dating. Be creative and collaborative in finding ways to balance your teen’s growing need for independence with your expectations for safety and social distancing. If students are attending school in person some days and doing independent work by remote other days, try to keep a somewhat
AHN Pediatrics-Pediatric Alliance • Summer 2020 • www.ahnpediatrics.org
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Back to School
consistent sleep and wake time. Kids don’t have to be up at 6 if they don’t have a bus to catch. But staying up late and sleeping late on some days can make it harder to get up and out on the days they do have school in person.
possible. This means that many students with IEPs spend part of their day in the regular education class and part of the day in a special education setting. Families and schools may need to make some creative changes to meet both IEP and public health requirements. Remote school has been extra-hard on many children with special educational needs, but the new expectations may also be extra-hard. Children with ADHD, autism and other developmental disabilities may have more difficulty following social distancing expectations to stay in one place and keep their hands to themselves. Pictures and visual reminders may be especially useful. Talk to your pediatrician or specialist team if your child has a medical condition that places them at increased risk for COVID-19 about the safest way to participate in school this year.
Children with special educational or health care needs: If your child has an IEP, remember that the “I” stands for “Individualized.” our meeting may be held by remote, and evaluations may be delayed due to the pandemic, but your child’s plan should still be made by both you and the school team together. One public health recommendation is that students stay together in the same room as much as possible. However, special education law requires students to be in the “least restrictive environment”
Back To School? Not So Fast By Dr. Ned Ketyer
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Originally posted at www.ThePediaBlog.com
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Will schools open up on time next month? That is the question on everyone’s mind on a hot Monday in July. The answer is… complicated. Everyone would like this pandemic to end. We would like all kids to be back in school, all parents back at work, and all athletes back on the field. Unfortunately, viruses don’t respond to our wishes and hopes. They do respond, however, to our behaviors and to the decisions we make. In a joint statement with teacher groups last week, the American Academy of Pediatrics announced that having students physically present in schools this fall is a goal that can be achieved if decisions are based on evidence and the word of public health experts, not politicians. (Of course, the statement calls for federal funding of new protocols and resources, so political meddling is essentially guaranteed.) Kids lost a lot when schools around the country closed last March due to the pandemic: We recognize that children learn best when physically present in the classroom. But children get much more than academics at school. They also learn social and emotional skills at school, get healthy meals and exercise, mental health support and other services that cannot be easily replicated online. Schools also play a critical role in addressing racial and social inequity. Our nation’s response to COVID-19 has laid bare inequities and consequences for children that must be addressed. This pandemic is especially hard on families who rely on school lunches, have children with disabilities, or lack access to Internet or health care.
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July 13, 2020
That last part is important because while we are “all in this together,” we are not all in this equally. We’ve all noticed how much states have differed in their public health responses to COVID-19, and we know that funding of public education differs significantly between states as well. Even within individual states, schools and school districts have different capabilities for providing a good-quality education to students. Some school districts are funded and staffed better than others, and schools can vary widely in regard to infrastructure (class size, room size, ventilation, etc.) and technology. Children’s academic needs also vary widely. While the majority of students might fall in the average range of scholastic abilities, there are a good number who struggle with learning differences (as many as 14% according to the CDC) and others who thrive as “gifted” students.
AHN Pediatrics-Pediatric Alliance • Summer 2020 • www.ahnpediatrics.org
Not all families have the same access to computers and highspeed Internet services. If online learning becomes a necessary part of schooling this year, will every kid be guaranteed the access and tech support they need so they don’t fall through the cracks? Of course, the most important determinant of whether or not schools open on time — and stay open throughout the year — is how safe students, teachers, and school staff will be from coronavirus. And a lot of that depends on how well viral transmission is controlled in each community: Local school leaders, public health experts, educators and parents must be at the center of decisions about how and when to reopen schools, taking into account the spread of COVID-19 in their communities and the capacities of school districts to adapt safety protocols to make in-person learning safe and feasible. For instance, schools in areas with high levels of COVID-19 community spread should not be compelled to reopen against the judgment of local experts. A one-size-fits-all approach is not appropriate for return to school decisions. The good news in all this is that young children appear to show very few (if any at all) symptoms when they are found to be infected with coronavirus. Older children and teenagers don’t appear to be bothered much either. The bad news is children are notorious germ dispensers, not likely to cover their coughs and sneezes, wash their hands, or wear face masks properly unless (constantly) reminded. And we know that classmates, teachers and school staff, coaches and teammates,
siblings, parents, grandparents and others may be at risk of suffering poor health outcomes if they are inadvertently infected by kids spreading the virus around. The worst news might be that in the United States, COVID-19 is outof-control at the moment. Here are some statistics as of July 12: > Total cases in U.S. — more than 3.2 million confirmed > Total deaths in U.S. — more than 134,000 > # of states with increasing cases — 37 plus the District of Columbia > # of states with decreasing cases — 2 (New Hampshire and Maine) > # of states with increasing deaths — 21 Cases of COVID-19 are rising in Pennsylvania, including “significant increases” in people between the ages of 19-24. Counties in southwestern Pennsylvania, including Allegheny County and others, that didn’t experience a surge early in the course of the pandemic are seeing worrisome increases in cases now. Schools located in states that succeeded in “flattening the curve” and controlling the outbreak may well be ready to open their doors to students again a few short weeks from now. But for other parts of the country reeling from what is still the “first wave” of COVID-19, it will take extraordinary action now (beyond just wearing a face covering in public) to slow transmission, sickness, and death. Until that happens, don’t expect schools in those areas to reopen anytime soon.
Five Steps to Wash Your Hands the Right Way www.cdc.gov/handwashing/when-how-handwashing.html Washing your hands is easy, and it’s one of the most effective ways to prevent the spread of germs. Clean hands can stop germs from spreading from one person to another and throughout an entire community—from your home and workplace to childcare facilities and hospitals. Follow these five steps every time. 1. Wet your hands with clean, running water (warm or cold), turn off the tap, and apply soap. 2. Lather your hands by rubbing them together with the soap. Lather the backs of your hands, between your fingers, and under your nails. 3. Scrub your hands for at least 20 seconds. Need a timer? Hum the “Happy Birthday” song from beginning to end twice. 4. Rinse your hands well under clean, running water. 5. Dry your hands using a clean towel or air dry them.
AHN Pediatrics-Pediatric Alliance • Summer 2020 • www.ahnpediatrics.org
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COVID-19
Child face mask tips and tricks Your child is getting used to a lot of new rules because of coronavirus – including wearing a face mask. It can be an uncomfortable, or even scary, adjustment to make. To help, we’ve compiled a few best practices to consider. Take a look and reach out to your pediatrician if you have any questions. Your doc is always there to help.
Your child should always wear a face mask: • If the child is age 2 or older and is out in public • Anytime the child is within 6 feet of others
Your child doesn’t need to wear a face mask: • While inside you home • Outside, if they’re at least 6 feet away from others • When eating or drinking
Putting on a face mask. A cloth face mask will provide the proper level of protection for you child. The adult versions may be too big, so try to find one that’s child-sized or has adjustable straps. When it’s time to go outside:
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Place the mask across your child’s face, covering the ears and mouth. Make sure it’s a snug fit.
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Encourage your child to avoid touching the face mask or any area of the face when outside.
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When you get home, carefully remove the face mask by the straps and have everyone thoroughly was their hands.
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Wash the cloth face mask between uses – in the washing machine or by hand.
Answering The Tough Questions As your child adjusts to this new normal, questions are sure to come up. Do your best to stay calm and reassure your little one that wearing a mask is what’s best for everyone’s safety. Here are a few responses to consider.
“What’s Coronavirus?”
“Why do I have to wear a mask?”
Coronavirus is a new type of sickness – like an ear infection or cold. But, because it’s so new, doctors and scientists don’t know a whole lot about it. They think most people will be okay, especially kids, but we all have to be extra careful to keep everyone safe and feeling their best.
Remember when we talked about covering your mouth when you cough or sneeze? How that helps to not spread germs? Well, right now we have to be extra careful – so wearing a mask slows down the spread of germs. Some people may get really sick because of this new virus, so when you put your mask on, you’re becoming a special helper – you’re helping everyone stay safe.
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AHN Pediatrics-Pediatric Alliance • Summer 2020 • www.ahnpediatrics.org
“But it’s scary. I don’t want to wear it.” I know, it can feel a little scary, but I promise you’re doing something really nice to help other people. And remember, Mom, Dad and your friends are wearing masks. Why don’t you go get your favorite toy and we’ll put a mask on it, too?
How to keep your kids active in the summer of COVID19 By Marco A. Alcala, MD
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Director of Sports Medicine, Pediatric Orthopedic Institute
This year has brought on so many changes and challenges for all of us, but it has been especially difficult for our children. The recent coronavirus pandemic has made it too easy for kids to sit on the couch all day watching TikTok. Despite social distancing orders, kids can still be active this summer. Respecting social distancing has been key in reducing transmission of the coronavirus and can still be applied when being outdoors. Jogging, hiking and bicycling have been very popular and successful as an activity and helps keep distances with others while participating together. Several other activities can also be performed, especially with familiar people that also have the same respect for social distancing. Washing hands or using hand sanitizers before and after activities can also help minimize spread of COVID19. If these precautions are taken, then activities can range from baseball, soccer, frisbee, etc. Decreasing large groups is important, as well as not allowing the kids to gather in a dugout for example. Minimizing contact with others is very important, at least for now. The use of masks has also been very helpful in decreasing the spread of COVID19. The combination of social distancing, regular use of hand washing or sanitizers and wearing masks, can provide the best approach to avoid becoming infected with COVID19. Staying up to date with the current CDC guidelines is also very important during this pandemic. If your child can carry out these safety precautions, then he or she can enjoy a summer of activities with very minimal exposure. Sitting at home does
Pediatric Orthopaedic Institute 12620 Perry Highway, 2nd Floor Wexford, PA 15090 724-933-6699 Hours: Summer hours (Adjusted due to COVID-19): Monday to Friday - 8:00am to 4:30pm Beginning in September: Monday and Tuesday 8:00am to 6:00pm Wednesday thru Friday – 8:00am to 4:30pm
not have to be the only option if your child is someone that loves to be outdoors. There is always something that they can do safely. Some basic rules to follow if there is any contact with a known infected person are to self-quarantine for 14 days. If starting to develop any symptoms such as cough, muscle aches, chills, fevers, fatigue, not feeling right, etc. then testing for COVID19 would be recommended at that time. If there is any doubt, then quarantine will be the safest and next best step and of course call your pediatrician at AHN Pediatrics for any further recommendations or for an evaluation.
Providers: > Dr. Mark J Sangimino, Pediatric Orthopaedic Surgeon > Dr. Stephanie Schneck, Pediatric Orthopaedic Surgeon > Dr. Ryan Sauber, Orthopaedic Surgeon – Specializing in Spine
> Dr. Marco Alcala, Sports Medicine – sports injuries and concussion > Dr. Ed Snell, Sports Medicine – sports injuries and concussion > Brittany Paterniti, Physician Assistant > Justine Dutcher, Physician Assistant > Rebecca Zill, Neuropsychology Fellow > Kaitlin Striker, Child Life Specialist
Services: Behavioral Health Integration X-ray and EOS on site Therapy Services (physical, occupational, speech) Custom and Generic Bracing
AHN Pediatrics-Pediatric Alliance • Summer 2020 • www.ahnpediatrics.org
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COVID-19
COVID-19 Frequently Asked Questions There is a lot of frequently changing information regarding COVID and we want our patients to stay informed. The best sources of information are your primary care physician, the CDC (www.cdc.gov/ coronavirus/2019-nCoV/index.html), and the PA Health Department (www.health.pa.gov/topics/disease/coronavirus/Pages/Coronavirus.aspx). Always follow the advice of your healthcare provider and remember people with chronic conditions may need to take special precautions. Below is a summary of some frequently asked questions and current guidelines: > What is the difference between quarantine and isolation? > Isolation is used to separate people infected with the virus (those who are sick with COVID-19 and those with no symptoms) from people who are not infected. People who are in isolation should stay home until it’s safe for them to be around others. In the home, anyone sick or infected should separate themselves from others by staying in a specific “sick room” or area and using a separate bathroom (if available). > Quarantine is used to keep someone who might have been exposed to COVID-19 away from others. Quarantine helps prevent spread of disease that can occur before a person knows they are sick or if they are infected with the virus without feeling symptoms. People in quarantine should stay home, separate themselves from others, monitor their health, and follow directions from their physician or local health department > Who needs to isolate? > People who have symptoms of COVID-19 and are able to recover at home > People who have no symptoms (are asymptomatic) but have tested positive for COVID-19 > I think or know I had COVID and had symptoms, when can I be with others? > Follow healthcare provider instructions. > 3 days with no fever and > Respiratory symptoms have improved and > 10 days since symptoms first appeared > I tested positive for COVID-19 but had no symptoms, when can I be around others: > If you continue to have no symptoms, you can be with others after 10 days have passed since test > Who needs to quarantine? > Anyone who has been in close contact with someone who has COVID-19.
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> What counts as close contact? > You were within 6 feet of someone who has COVID-19 for at least 15 minutes > You provided care at home to someone who is sick with COVID-19 > You had direct physical contact with the person (touched, hugged, or kissed them) > You shared eating or drinking utensils > They sneezed, coughed, or somehow got respiratory droplets on you > Steps to take during quarantine: > Stay home for 14 days after your last contact with a person who has COVID-19 > Watch for fever (100.4ºF), cough, shortness of breath, or other symptoms of COVID-19 > If possible, stay away others, especially people who are at higher risk for getting very sick from COVID-19 > When to start and end quarantine > Follow health care provider advice > You should stay home for 14 days after your last contact with a person who has COVID-19. > Even if you test negative for COVID-19 or feel healthy, you should stay home (quarantine) since symptoms may appear 2 to 14 days after exposure to the virus. > See https://www.cdc.gov/coronavirus/2019-ncov/if-you-aresick/quarantine.html for common scenarios and proper response > When should I be tested for COVID? > At this time, there is limited testing supply in Western Pennsylvania, so many places will only test if there are active symptoms present. > Many testing sites require a physician order > Many testing sites that do not require a physician order will not test patients under the age of 18 and/or have a screening process to determine eligibility and/or still require an appointment. > If you have had close contact with a confirmed case of COVID-19, you may want to seek testing. Please note that if you are not symptomatic, you may not be able to be tested. The recommendation is to selfquarantine and monitor for symptoms. If you are able to get testing, it should be done 5-7 days after exposure, but even if there is a negative result, you should still quarantine for the 14 days. > When can I expect testing results? > Typically at results can be expected in 2-3 days, but at this time, many labs are overwhelmed and it can take over 7 days to get results.
AHN Pediatrics-Pediatric Alliance • Summer 2020 • www.ahnpediatrics.org
Parenting
Free Zoom Classes for New and Expectant Parents AHN Pediatrics offers complementary newborn, breastfeeding, and nutrition classes to new and expectant parents. Due to the COVID-19 pandemic, all of our classes are currently being offered virtually through Zoom rather than in person. Parents can join these interactive sessions and meet one of our pediatric providers from the safety and comfort of home. Online registration is required for these free classes. Visit www.growinguphappyandhealthy.com for class information and registration. Once you have completed this step, you will receive an email with addition-
al information to register through Zoom and receive your login information. Our virtual class offerings include: Baby Basics, Breastfeeding, and Transitioning to Table Foods. We are also currently offering our Nursing Café virtually where moms can get together via Zoom and receive group support from other nursing moms with guidance from one of our Certified Lactation Consultants. We’re excited to continue meeting new and expectant parents and answer their questions in a supportive environment during this challenging time. We look forward to meeting you!!
Telehealth
AHN Pediatrics After-Hours Telehealth Services AHN Pediatrics now offers a limited number of telehealth visits with our Pediatric Nurse Practitioners and Physician Assistants for patients calling after hours with urgent, acute symptoms that don’t require an emergency room visit, but that cannot wait until the next day. When a patient calls their AHN Pediatrics office after hours, one of our pediatric triage staff review their symptoms and determines the appropriate course of action. Some concerns can be addressed by the nurse over the phone. Other non-urgent concerns may be sent to the patient’s regular AHN Pediatrics office for follow-up the next business day. After hours telehealth appointments are being scheduled as follows: Monday through Friday from 5:00 PM to 9:00 PM; Saturday from 12:00 PM to 4:00 PM and Sunday from 8:00 AM to 12:00 PM. Our staffing is limited during these hours, so we ask that you call your regular AHN Pediatrics office during normal business hours regarding any non-urgent issues or symptoms or that arise earlier in the day. These hours are subject to change. As always, we will keep you updated should any changes arise. We are also working to change the way we get important screening information from patients scheduled for telehealth visits. We typically hand out forms in the office at the time of a patient’s in-person appointment to assess things such as infant development, asthma management, ADHD, depression, and anxiety. Many of these important screening tools are now available on our website as fillable PDF forms
that patient can complete, save on their computers or mobile devices at home and email to the email address for the patient’s specific AHN Pediatrics office prior to telehealth visits. This new process improves the ability of our providers to document important information when providing telehealth services. When scheduling telehealth appointments, you may be asked by our staff to go to http://pediatricalliance.com/ links-resources/forms to complete one or more forms and send them to the office at the email they provide for you.
AHN Pediatrics-Pediatric Alliance • Summer 2020 • www.ahnpediatrics.org
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Seasonal
It’s Tick Season By Dr. Ned Ketyer
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Originally posted at www.ThePediaBlog.com
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The Pennsylvania Department of Health issued an email advisory to health providers last week regarding the rising number of tick bite-related emergency department visits and tickborne illnesses in the state: The Pennsylvania Department of Health (PADOH) has identified recent sustained increases in tick bite-related emergency department visits in nearly all regions of the state. This trend is expected, as tick exposures in Pennsylvania generally increase during spring and summer months and serves as an important reminder that tickborne diseases occur annually in Pennsylvania. In addition, due to the stay at home orders, residents may be spending more time outdoors. Seeking medical care for tickborne illness should not be delayed due to the COVID-19 pandemic. From April through September, health care providers should have a heightened clinical suspicion for tickborne diseases.
Reported Cases of Lyme Disease — United States, 2018 (CDC) As seen in the map above, the range of Ixodes scapularis (the blacklegged tick) extends from northeastern and mid-Atlantic states through Pennsylvania to the upper midwest. The best-known illness it transmits by biting people (and dogs too) is Lyme disease, which is caused by the bacterium Borrelia burgdorferi. Anaplasmosis, babesiosis, and Powassan disease are much rarer diseases transmitted by blacklegged ticks (also called deer ticks). The Pennsylvania Department of Environmental Protection has collected blacklegged ticks and documented Lyme disease in every one of Pennsylvania’s 67 counties. Other species of ticks can cause other diseases in humans. For example, a bite from either the American dog tick, the brown dog tick, or the Rocky Mountain wood tick can cause Rocky Mountain Spotted Fever (a very serious infection in which the greatest
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June 11, 2020 numbers are seen in North Carolina, Oklahoma, Arkansas, Tennessee, and Missouri — states far away from the Rocky Mountains). The lone star tick (Amblyomma americanum) causes ehrlichiosis, tularemia, STARI, the Heartland and Bourbon viruses, and the sudden onset of a life-threatening (anaphylactic) beef allergy. (The irony of this unusual malady should not be missed: Cows belch methane which contributes to climate change, which in turn is believed to be responsible for expanding the tick’s range beyond the U.S. Southwest and the Lone Star State, Texas.) In Pennsylvania, Lyme disease is the most commonly reported tickborne infection. Pennsylvania ranks fourth nationally in Lyme disease incidence (79.7 per 100,000) and number one in total cases (10,208) in 2018. Transmission via tick bites occurs more frequently during the summer, from May through September. (Year-long transmission is possible where blacklegged ticks are present in areas that don’t receive subfreezing temperatures and snowfall in winter — another consequence of climate change. In such places ticks really don’t have a season.) Previously on The PediaBlog, we’ve examined the clinical symptoms and treatment of Lyme disease… Typical symptoms are not specific: fever, headache, muscle aches, and fatigue. The rash that can accompany a tick bite — erythema migrans or bullseye rash — is not present in all cases. If the diagnosis is made at this early stage, treatment with antibiotics (amoxicillin or cefuroxime under eight years old and doxycycline for those who are older) for 2-4 weeks is usually curative. If this early stage of Lyme disease is not identified and treated, the bacteria can spread to the joints (arthritis), the nervous system (meningitis, bell’s palsy), heart (arrhythmias), and cause severe symptoms of debilitating and chronic fatigue and muscle pain. In people with these symptoms, treatment options and recovery without residual health problems are variable, less than certain, and frequently a simple matter of opinion. This can be frustrating for people who suffer as well as doctors who treat them. … and strategies to prevent tick bites: T icks live in areas that are grassy, bushy, leafy, or wooded. Spending time outdoors walking in tall grass, gardening in the yard, hiking, camping or hunting in the woods invites ticks to latch onto your clothing and skin. Pretreating clothing and gear
AHN Pediatrics-Pediatric Alliance • Summer 2020 • www.ahnpediatrics.org
with permathrin and carefully applying DEET-containing insect repellent [at least 20%] have been shown to be effective in preventing tick bites. Closely examining your skin — and the skin of your loved ones, including your canine pals — when returning from an outdoor excursion is always a good habit to get into when living in regions that are home to ticks. Remember that ticks can’t jump or fly. They climb on tall grasses and shrubs and wait for someone to brush against them. Once they hitch a ride, ticks like to hide in and around the hairline, behind the ears, under the arms, inside the belly button, around the waist, between the legs, and behind the knees. Immediately removing an attached tick as soon as it is found is hugely important because after 36 hours, transmission of tickborne diseases becomes more likely. The CDC suggests not waiting for the tick to detach by using “folklore remedies such as ‘painting’ the tick with nail polish or petroleum jelly, or using heat.” Instead: 1. Use fine-tipped tweezers to grasp the tick as close to the skin’s surface as possible. 2. Pull upward with steady, even pressure. Don’t twist or jerk the tick; this can cause the mouth-parts to break off and remain in the skin. If this happens, remove the mouth-parts with twee-
zers. If you are unable to remove the mouth easily with clean tweezers, leave it alone and let the skin heal. 3. After removing the tick, thoroughly clean the bite area and your hands with rubbing alcohol or soap and water. 4. Never crush a tick with your fingers. Dispose of a live tick by putting it in alcohol, placing it in a sealed bag/container, wrapping it tightly in tape, or flushing it down the toilet.
Read the CDC’s outstanding reference manual on “Tickborne Diseases of the United States” here. Read more about Lyme disease and tickborne illnesses on The PediaBlog here.
Allergies
Summer Allergy Update Sergei Belenky, MD, PhD
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Allergy, Asthma, Immunology.
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AHN Pediatric Institute
As the COVID-19 pandemic has been dominating social and medical discourse for quite some time now both globally and locally, we in the healthcare community and the public in general have been particularly strained with ‘run of the mill’ human disease, both chronic and acute. I’d like to give a brief perspective of what to expect this summer and fall from seemingly unending allergy season looming large in our region and geographies across the country. I am writing this on July 24th which, in our area, puts the community in the midst of a pretty significant outdoor MOLD season - ALTERNARIA. Alternaria thrives in the hot and humid conditions generously provided by the summer time. It is an important cause of allergic rhinitis and asthma and keeps allergists busy through the summer, some years more than others. The GRASS pollen season as such should be considered over at this point, but more sensitive sufferers of allergy may still be feeling its effect.
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Allergies
The outdoor allergen everyone is primarily concerned about in North America, however, is RAGWEED. Its generic name is Ambrosia, which in translation from Latin means ‘food of the Gods’. There are 17 species of ragweed, common ragweed being a chief allergen producer. It starts blooming between 10th and 15th of August and continues its spewing rampage through mid-September. With climate change, even after defusing the political charge of the term, ragweed season can linger until frost and sets the tone for the fall allergy season. Ragweed is a fairly tall weed (up to 18 feet high) with hairy stem, long leaves, and yellow flowers. But don’t mix it up with ‘yellow rods’, which are totally harmless from an allergy standpoint. Ragweed is an unimposing free space taker and roadside grower. But its impact is substantial and lasting. One ragweed plant is estimated to be able to produce up to 1 billion pollen grains per season.
that ragweed season inflicts on the ones who don’t take up this action plan. For ragweed allergic patients of all ages, combination therapy of intranasal steroids/antihistamines, oral antihistamines, and ocular antihistamines is commonly applied and, to varying degrees, effective. Some therapy is continued for at least 6 weeks from the onset of the season. Intra-nasal steroid sprays are available over the counter with such well-known brands as FLONASE, NASACORT, RHINOCORT, SENSIMIST. And there are prescription options of both steroid and antihistamine nasal sprays, as well as generic versions of almost all of the brands. PATADAY is an over-the-counter anti-allergic eye drop which is both safe and effective. Bear in mind that almost ALL eye drops and nasal steroid sprays are FDA approved to 2 or 3 years of age. Please, do not use VISINE. It will make your eyes look good, but Visine does not address underlying allergic inflammation. Oral antihistamines are widely represented on any pharmacy shelf in the allergy section. Well-known brands are ZYRTEC, CLARITIN, ALLEGRA, XYZAL. All of them are available in doses and formulations appropriate for adults and children of different ages. Generic equivalents are also available. All of these medicines are over the counter, however, can also be prescribed, and quite possibly will be less expensive that way. As a first line choice for severe allergic reaction like hives, BENADRYL is absolutely safe, but avoid using it on a regular, ongoing basis because of a heavier load of side effects. For allergic symptoms of the nose and eyes second generation anti-histamines as outlined above are the choice.
How to prevent
Symptoms of ragweed seasonal allergic rhinitis are similar to any other seasonal allergy of the nose and the eyes. It usually presents as congestion, runny nose, sinus pressure, sneezing, and once well established in the inflammatory cascade, post-nasal drip. During the peak of the season, usually early September, we see a lot of ocular allergic complaints requiring the use of anti-allergic eye drops. Itchy mouth, itchy ears, ‘itchy everything’ are not uncommon. We should be prepared to see a surge in sudden onset of hives attributed to a heavy pollen season.
Allergy immunotherapy is the ultimate answer. Confirmation should be obtained by either skin test or blood test, preferably outside the season, allowing for the time to start immunotherapy in advance. Immunotherapy is very effective and well tolerated. Its efficacy is superior in children and adolescents. It entails 2 main forms: allergen injections (notorious ‘allergy shots’) and oral administration (‘allergy drops’). Specifically for RAGWEED allergy, a third alternative exists for ages 18 years and older - SLIT (sublingual immunotherapy). It is FDA approved, effective and also well tolerated. The brand name is RAGWITEK, and it should be started in the middle of May, three months before the ragweed season and continued through November. Only the 1st dose has to be given in the allergist’s office, and once it is found to be well tolerated, it should be continued DAILY at home. This is an allergy product and NOT a medication - a big winner with young people and their parents who don’t like medications. As any other immunotherapy, if deemed effective SLIT is done for three years - 6 to 8 months each year.
How to be ready. The most effective recommendation is to initiate an intranasal steroid spray during the 1st week of August at the very latest. Patients who follow this annual advice are usually protected against the misery
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Seasonal asthma Let’s not forget that asthma is an allergic disease that can be triggered by pollen, including RAGWEED. It also temporally overlaps with the
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onset of respiratory viral season in early September, notwithstanding an unending coronavirus. So, asthma alert should never be dropped, and patients and their parents are emphatically reminded of preventive anti-inflammatory therapy, i.e. inhaled corticosteroids, which in patients with known, even mild persistent asthma should be initiated (if ever stopped) at the same time as their allergy medications in advance of the season onset. Continuous use of inhaled steroids in the fall is also recommended for asthmatics in order to prevent severe asthma flares. There are five steroid compounds available in the US for inhaled use in asthma, all by prescription ONLY. Familiar brands include PULMICORT in dry powder form (FLEXHALER), ASMANEX, in both dry powder form (TWISTHALER) and pressurized metered-dose inhaler, FLOVENT, QVAR, ALVESCO. None of these medications is yet available in generic form. Most of those are FDA approved down to age of 4 years. Don’t mix these allergy medications up with ALBUTEROL which is a rescue or reliever inhaler that should be used only as needed for wheezing, chest tightness, shortness of breath and 15 min before exercise for exercise induced asthma patients.
Thunderstorm asthma This asthma variant was first described in Australia and is recognized as a very severe form of allergic asthma when hypothetically explosive release of pollen grains, ragweed included, leads to acute asthma attacks requiring urgent care. There is a correlation found worldwide between a heavy thunderstorm season and emergency room visits and hospital admissions for asthma flares. This is something to keep in mind when working with your pediatrician or allergist to create the best treatment strategy for asthma in summer.
In summary Pollen.com has a National Allergy Map that gives us pretty accurate allergy pollen counts and allergy forecast in any area of interest in the US. Allergy Alert app provides an in-depth 5-day forecast of most specific allergens in the area. I hope this review of summer allergies proves to be helpful to you in your tireless pursuit of your children’s health and wellness in which allergy and asthma can play a significant role.
Youth Sports
Sports Nutrition- Fueling Optimal Performance Jennifer Yoon RDN, LDN, IBCLC For kids and teens involved in athletic activities, good nutrition is crucial for appropriate growth, development, and sports performance. A healthy balanced diet that includes all the food groups provides the energy, protein, vitamins, and minerals needed to help athletes perform at their best. > Grains – Bread, Cereal, Rice, Pasta- are an important source of carbohydrates needed for energy. Whole grains like wheat and bran provide B vitamins, minerals, and fiber. Athletes who choose to limit grain intake may not get enough calories for endurance and replenishing or building muscle stores. > Fruits and vegetables are high in vitamins and minerals to ensure proper growth, development, and overall body functioning. Fruits also provide carbohydrates for energy. > Dairy – milk, cheese, and yogurt – provides carbohydrates and is an excellent source of protein. Dairy is rich in Calcium and vitamin D which are very important for athletes because they build strong bones and are involved in muscle contraction. > Proteins – lean meat, poultry, fish, eggs, dry beans, and legumes group – provide protein needed for energy and
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Youth Sports
healthy muscles. Meats, eggs, and beans are also rich in Iron which transports oxygen through the blood. > Fats and oils – especially olive, canola, sunflower and safflower- are used for energy, cell function, hormone production, and healthy skin and hair. Certain fats are essential therefore should not be avoided. Healthy fats are in nuts, seeds, nut butters, and avocado. High fat fried foods and snacks, however, contain saturated fat which is not easily used for energy and should be limited in the athlete’s diet. > Sweets contribute calories but very little vitamins and minerals. It is okay to enjoy sweets and drinks, such as cakes, candies, and soft drinks sometimes, but these foods will not help you prepare for your sport.
Hydration – fluids lost through sweat and respiration must be replaced. Proper hydration involves drinking the right amount of fluid before, during, and after physical activity, as well as throughout the day. Water is the best choice. In general, 60-80 ounces of fluid a day is recommended. To ensure individual fluid needs are being met, urine should be light in color and low in odor. Urine that is bright or dark yellow or has a strong smell indicates the need for more water. If the competition lasts greater than an hour, or a lot of fluid is lost through sweat, 8-12 ounces of a sports drink is plenty to replace electrolytes. Refueling – is giving back what your body used during activity. To refuel properly, a meal or snack should be consumed within thirty minutes of ending athletic activity. The best refueling meals and snacks contain both carbohydrates and protein. Some good examples are peanut butter and crackers, string cheese and a piece of fruit, or a cup of milk or yogurt. Each time you refuel properly, you are preparing your body better for future activities. Caution should be used with the use of protein drinks and supplements to ensure they do not contain ephedra, or herbal sources of ephedra, as these raise the heart rate and can be dangerous for young athletes. Energy drinks should be avoided completely. Athletes who want to perform at their best should think of food as fuel. A variety of healthy foods and fluids are required to properly fuel the athlete’s body.
Sports Nutrition is about Timing, Hydration, and Refueling Meal timing plays an important role in preparing for competition. Five to six small meals per day – or three meals plus two to three snacks – is recommended. Each meal and snack should contain foods and drinks that contain both carbohydrates and protein. A good “pre-game meal” provides quick energy, is easy to digest, and won’t weigh the athlete down. Fruit, bread, cereal, rice, or pasta with a lean source of protein such as chicken or turkey, low fat milk or yogurt gives the athlete carbohydrates and protein to fuel them during their competition.
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Chan Y., Age 14
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The Future Of Youth Sports By Dr. Ned Ketyer
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Originally posted at www.ThePediaBlog.com
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Author and founder of Changing the Game Project, John O’Sullivan, reimagines youth sports in a post-COVID-19 world. He says a major rethink is in order, especially for kids 12 years old and under: Do we really want to return to the exact same youth sports system we just had to shut down? T he existing model is dysfunctional at best and broken at worst. Parents and kids have rediscovered free play, family activities, and outdoor sports. Will they just want to go back to the old way with no adjustments?
The pandemic has created hardship for everyone, especially children who may be super-eager to return to their sports programs. O’Sullivan expects these thoughts will be running through parent’s minds the closer we get to the “new normal”: 1. We just had family dinners night after night for the first time in years. I want my kids to go back to playing sports, but do we really want to be running around with our heads cut off 7 nights a week? 2. My child is feeling healthy and well rested for the first time in years because he/she had some time off. Perhaps we should cut back a bit on the number of sports practices and training load. 3. My child is enjoying the time-off and pursuing other passions. He/she is also getting better practicing on his/her own for the first time, or playing unorganized sports with siblings.. 4. This has been a tough hit financially for our family. Perhaps there is a better, less expensive local sports option. 5. We already live in an area with millions of people, why do we need to travel by bus and plane to get games when we can get plenty of games close by? 6. The virus has settled down in our area, but not in other places. I am not sending my child to play games against teams where the virus is not under control.
June 29, 2020 While parents may have rediscovered the preciousness of quality family time, deteriorating economic conditions are likely to play a huge factor in the future of youth sports: This Wall Street Journal article highlights concerns that we may lose 20-40% of our youth sports clubs to insolvency, and result in a huge drop in participation. After the 2008 recession, participation of US children dropped from 45% in 2008 to 38% in 2014, and the financial impact of this event will be far worse. It is unlikely many families are looking forward to high-priced, travel heavy youth sports experiences, especially for children still in elementary school. This system had already created a huge socio-economic participation imbalance, with more than twice as many children participating in sports in families with incomes over $100,000 than in the lowest income brackets. Is this what we want to return to? O’Sullivan believes that “every youth sports organization that wants to thrive in a post-pandemic world must put character and personal development at the forefront of their mission.” That responsibility, he says, is on coaches who volunteer their time to teach skills and develop young athletes. They will need to be educated and their coaching skills developed first: We must train every single coach not simply on the Xs and Os, but on connecting with kids, winning the relationship game, and understanding the social, emotional and cognitive development of the children they are coaching. Involving parents more is also mandatory: Our parents can be our biggest assets, so connect with them, teach them how they can help their children and support them on and off the field. Maybe when activities are allowed to commence again, families will want a little more balance in their lives: Families have just spent a few months having free time, game night, and family dinners, and watched their family connections grow. I am not saying that they won’t want any sports, but will they want a full sports takeover of their lives again? Full time? I am not so sure. It should be clear to practically everyone that “back to normal” is not the direction we are currently headed. Our kids need to stay active and fit, and physically interact with their peers. While sports are an effective and fun avenue for athletic development, it is character development that coaches and parents would be wise to emphasize in a post-pandemic world.
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Patient Portal
Helpful Tips for Patient Portal Users Patient Portal gives patients a secure way to connect with our office and access their medical information at home and on the road. — Please ensure your email address is current in our system.
Patient Portal Tips under the Patient Tools section of our website. www.pediatricalliance.com/patient-portal/
• How to Renew Medications • How to Request an Appointment • How to Send Messages via Patient Portal • What to do if you forget your Username/Password In addition to these helpful tip sheets, you can also email or call our portal line if you need assistance. portal@pediatricalliance.com or (412) 278-5102
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