- Four Seasons Pediatrics - http://www.fourseasonspediatrics.com -

Pass the Gravy and the Hand Sanitizer

Topics in this Newsletter:

COVID-19 Updates, Testing and School Notes

CHADIS

Safety during gatherings around Thanksgiving and Holidays

Tick Bites

COVID-19 Updates, Testing and School Notes

CHILDREN ARE LOW RISK

Children continue to be extremely low risk from the SARS-CoV-2 virus that causes COVID-19.  Again – let me emphasize that it does not mean there is no risk for children.  There are and will continue to be a small number of high risk children with immune problems, diabetes, hypertension and other medical conditions, who will have a bad outcome from COVID-19.  The risk is lower with good control (e.g. taking appropriate medications, diet etc.).  There are even a smaller number of healthy children who have had and will have a bad outcome from COVID-19, including death.  All the evidence continues to show that the flu is more deadly for children, while COVID-19 is more deadly for the Elderly with other medical conditions.   We believe that a vaccine will ultimately be the treatment that allows adults and children to return to more of the life as we know it.   Who should get the vaccine remains to be seen and we will comment more when there is more evidence available. 

RAPID TESTING

Four Seasons Pediatrics has started Rapid PCR Testing for COVID-19.  We will use these when available, though we may use them selectively as recommendations, amount of disease changes and depending on medical need. We made the decision to only use molecular PCR tests, as antigen tests are too prone to false negatives and require a back up PCR test anyway.   We currently use the Roche Liat PCR test. It tests for Flu A, Flu B and COVID-19. If you have not called in for symptoms, we would like you to be aware of several things.

OUR TESTING PROTOCOL

Any patients with ANY symptoms that could be COVID-19 do not enter our building and are not seen in our building.  We evaluate them outside in their car or in one of our two outdoor heated exam rooms (Medical Sheds).   If there is a possible need to be seen outside, you will be asked for the vehicle description and phone number of the person who will be physically present for the appointment.  At the time of the initial call, the person who will be coming should have their phone on and be ready to take a call from both our nurse and the doctor.   At the time of your appointment, you will be asked to drive around to the back side of our building (see the RED – COVID Testing Area Sign).  Park in one of the designated spots only (1, 2, 3 or 4).  Call in to the office and notify staff what spot you are in.  These spots are designated to maintain distancing from other cars that are being seen.  The provider will come out in PPE and be the only staff in contact with your child.  You may be directed to our Medical Shed at the discretion of the provider.  Your child’s temperature will be taken (do not keep the car too hot or too cold), oxygen measurement (try to keep the fingers under the shirt to keep them warm), and your child will be examined.  If you are directed to one of our Medical Sheds, we ask that you or your child not touch any items and to stay in the patient chairs or sit on the exam table.  After your examination, the provider will let you know if there are any findings (e.g. ear infection, chest infection etc).  If testing is performed, we perform it in your car or outside the Medical Shed. 

CLEARANCE NOTES

If you need clearance to return to daycare or school NYS requires that there is:

• A negative COVID PCR/Molecular test (some urgent cares are performing Antigen tests – these are not acceptable due to the high rate of false negatives)

• No fever for 24 hours without the use of fever reducing medication

• No vomiting or diarrhea for 12 hours

• Symptoms have improved.  We cannot write a note for clearance on the same day, even with a rapid PCR/Molecular test.  For example, if your child has a headache and the headache is better on the same day, we cannot be sure that other symptoms have not developed yet.  In addition, it is important that you child have an improvement in symptoms.  During the period of early onset, your child is most contagious, and even if the illness is not COVID-19, it may be another contagious virus.  Going back to school or daycare exposes other children to the virus.  Spread of another illness means time out of school, as well as getting test clearance for them as well. 

After a negative rapid test, we ask for a message through your portal account around 6 am. Verify that you have met clearance criteria.    Many parents ask us to send a clearance note directly to the school.  We are happy to do this for you, but please read all the instructions below.  You will need to know the nurse’s fax number or email. We do ask that you fill out a release found on our website under Forms or

• Click Here to download the form [1]

We recommend that you be proactive and fill this out now with all your children.  Again, you will need to know the fax number or email of the nurse or staff at each school for your child.  We can keep this on file for you.  Once you have the release form, you can fax to (518) 383-3255, drop off to us, or email to:

Exchange@fourseasonspediatrics.com 

If your PHI release is sent by email, you will need to put your child’s name and Patient ID in the subject line like this:

Release for John Smith 773447. 

Your Patient ID can be found in any of your Visit Summaries or through the Web Portal by clicking on Medical Records -> Visit Summary -> then click on a specific date.  We will not open an emails without this format. 

Once your PHI Release form is on file – a verbal request will allow us to send the note directly – saving you and us time.    Thank you for your cooperation.     

Holidays upcoming

As we head into the Holidays, we are all seeing a rise in number of COVID-19 cases.  We know many of you have put off group gatherings for over 7-8 months.   Many families continue to avoid gatherings, while others have decided to have a smaller gathering.  Each of you will make the decision that is appropriate for you.  Should you decide to have a gathering of loved ones, please remember to take safety measures proportionate to the level of risk.  As Dr. Fauci has stated: “I think people are going to have to evaluate the level of risk that they want to take, particularly in families in which you have grandpa and grandma and elderly individuals who are going to be vulnerable”.  There are countless examples of gatherings leading to outbreaks and this years Holidays are likely to be the greatest risk we have experienced since our lockdown.  We are all tired and have been deprived of the time with loved ones.  What should we consider for our upcoming plans:

Risk is higher for:

• Those traveling by air

• Larger gatherings

• Those traveling from areas with higher prevalence

• Those who have any of the COVID-19 symptoms

• Students returning home from school – they are no longer part of your family bubble

• Families from more than 1 household.  The higher number of families, the higher the risk.  EACH COLLEGE STUDENT COUNTS AS ONE FAMILY.

• Gatherings that include overnight stays from those outside your home

• The Elderly

• Those with strongest evidence of risk includes those with significant medical conditions including Cancer, COPD, High Blood Pressure, Diabetes, Heart Disease from Coronary Artery Disease and Heart Failure, Chronic Kidney Disease, Severe Obesity, Stroke, Sickle Cell, Pregnancy, Smoking and Organ Transplant. 

Strategies to reduce risk:

• The single most important strategy is hand washing.  The problem is most people do not wash their hands long enough.  We encourage you to have a pump bottle of hand sanitizer and insist all guests sanitize before touching serving spoons, going back for seconds and after clearing plates from the table. 

• Consider disposable plates and plasticware this year.

• If you have decided on getting together, consider getting together for only 1 Holiday in the coming months

• Consider getting together with relatives who have the same feeling about careful precautions.  If Uncle Frank thinks COVID to be a scam, many precautions will be erased.

• Do not attend a different household with ANY symptoms, however mild.  Do not write off your symptoms as allergies – allergens are not present in our area this time of year.  

• If you have a high risk loved one within your gathering, carefully think through the risk you are taking.   

Ticks are Back

TICKS:  We have had a high number of phone calls about ticks. Deer ticks can transmit Lyme Disease. The most important preventive measures are to use an insect repellent, shower and check the skin and remove ticks daily.  If your outside in the woods, raking leaves or playing in leaf piles, we recommend that you

• Consider using an insect repellent such as Sawyer Picaridin. This will protect your child from Ticks for up to 6-8 hours. Tick’s do not jump on the body, they require direct contact with leaves or brush at a level of up to 18 inches.

• Take a shower after being outside.  A shower will allow you to remove the clothes worn.  A tick may not have attached and the shower will wash off the repellant and it also washes off ticks that have not attached yet. 

• DO A TICK CHECK.  An infected deer tick requires an attachment and blood meal for at least 36-48 hours to transmit Lyme Disease. This means that you can prevent transmission by removing the ticks daily when going outside. Most ticks will be found at the edge of properties in wooded areas and in leaves.

The overall risk of Lyme Disease from a TICK is less than 1-3%. Our area is considered a moderate risk area for ticks.  For more information about Lyme Disease,  go to the Search section of our website and enter Lyme Disease.

Repellants we recommend for 1 application (use a repellent – 6-8 hour protection: Sawyer Picaridin 20%, Off Family Care Smooth and Dry. 7 hour protection: Repel Lemon Eucalyptus).  If you find a tick, do not panic see below.  Other preventive measures include: 1) wear light colored clothing and tuck pants into socks and shirts into pants 2) after removing a tick, disinfect the bite with soap, rubbing alcohol or hydrogen peroxide. See below for more information about ticks and lyme disease.

Patient information: What to do after a tick bite Authors: Anna R Thorner, MD – Deputy Editor — Infectious Diseases – Instructor in Medicine, Harvard Medical School. Allen C Steere, MD – Editor — Lyme Disease – Professor of Medicine, Harvard Medical School. Leah K Moynihan, RNC, MSN – Associate Editor — Patient Information. © UpToDate, Inc.a

TICK BITE OVERVIEW: While many people are concerned after being bitten by a tick, the risk of acquiring a tick-borne infection is quite low, even if the tick has been attached, fed, and is actually carrying an infectious agent. Ticks transmit infection only after they have attached and then taken a blood meal from their new host. A tick that has not attached (and therefore has not yet become engorged from its blood meal) has not passed any infection. The risk of acquiring Lyme disease from an observed tick bite, for example, is only 1.2 to 1.4 percent, even in an area where the disease is common. If a person is bitten by a deer tick (the type of tick that carries Lyme disease). Four Seasons Pediatrics follows recommendations from the American Academy of Pediatrics.   For children with a Tick Bite, we advise one of two approaches: Observe and treat if signs or symptoms of infection develop OR treat with a preventive antibiotic immediately – only under certain circumstances. There is no benefit of blood testing for Lyme disease at the time of the tick bite. The current test available is not reliable for diagnosis and prone to false results.  A false positive test can occur just from bacteria found in the mouth.  Even people who become infected will not have a positive blood test until approximately two to six weeks after the infection develops (post-tick bite), and again the test is not very accurate.  Before seeking medical attention, we recommend that you carefully remove the tick and make note of its appearance. Only the Ixodes species of deer tick causes Lyme disease.

HOW TO REMOVE A TICK:  The proper way to remove a tick is to use a set of fine tweezers and grip the tick as close to the skin as is possible. Do not use a smoldering match or cigarette, nail polish, petroleum jelly (eg, Vaseline), liquid soap, or kerosene because they may irritate the tick and cause it to behave like a syringe, injecting bodily fluids into the wound.   Pull the tick backwards gently but firmly, using an even, steady pressure. Do not jerk or twist. Do not squeeze, crush, or puncture the body of the tick, since its bodily fluids may contain infection-causing organisms. After removing the tick, wash the skin and hands thoroughly with soap and water. If any mouth parts of the tick remain in the skin, these should be left alone; they will be expelled on their own. Attempts to remove these parts may result in significant skin trauma AND THEY DO NOT TRANSMIT LYME DISEASE.

AFTER THE TICK IS REMOVED: Tick characteristics — It is helpful if the person can provide information about the size of the tick, whether it was actually attached to the skin, if it was engorged (that is, full of blood), and how long it was attached. The size and color of the tick help to determine what kind of tick it was; – Ticks that are brown and approximately the size of a poppy seed or pencil point are deer ticks (see pictures below). These can transmit Borrelia burgdorferi (the bacterium that causes Lyme disease) and a number of other tick-borne infections. Deer ticks live primarily in the northeast and mid-Atlantic region (Maine to Virginia) and in the midwest (Minnesota and Wisconsin) region of the United States, and less commonly in the western US (northern California). – Ticks that are brown with a white collar and about the size of a pencil eraser are more likely to be dog ticks (Dermacentor species). These ticks do not carry Lyme disease, but can rarely carry another tick-borne infection that can be serious or even fatal (Rocky Mountain spotted fever). – A brown to black tick with a white splotch on its back is likely an Amblyomma americanum (Lone Star tick; named after the white splotch). This species of tick has been reported to spread an illness called STARI (southern tick-associated rash illness). STARI causes a rash that is similar to the erythema migrans rash, but without the other features of Lyme disease. Although this rash is thought to be caused by an infection, a cause for the infection has not yet been identified. This type of tick can also carry and transmit another infection called human monocytic ehrlichiosis. A tick that was not attached, is still flat and tiny and is not full of blood, and was easy to remove or just walking on the skin, could not have transmitted Lyme disease or any other infection since it had not yet taken a blood meal.  If you were not sure of the duration of attachment, we can discuss the risks and benefits of treatment.  Only ticks that are attached and have finished feeding or are near the end of their meal can transmit Lyme disease. After arriving on the skin, the tick that spreads Lyme disease usually takes 24 hours before feeding begins.   Even if a tick is attached, it must have taken a blood meal to transmit Lyme disease. At least 36 to 72 hours of feeding is required for a tick to have fed and then transmit the bacterium that causes Lyme disease. After this amount of time, the tick will be engorged (full of blood). An engorged tick has a globular shape and is larger than an unengorged one. The organism that causes Lyme disease, B. burgdorferi, lies dormant in the inner aspect of the tick’s midgut. The organism becomes active only after exposure to the warm blood meal entering the tick’s gut. Once active, the organism enters the tick’s salivary glands. As the tick feeds, it must get rid of excess water through the salivary glands. Thus, the tick will literally salivate organisms into the wound, thereby passing the infection to the host.

Need for treatment — we will review the description of the tick, along with any physical symptoms, to decide upon a course of action. The American Academy of Pediatrics Infectious Diseases Red Book Committee (reviews studies on treatment of infections in children) recommends sharing decision making and preventive treatment with antibiotics only in people who meet ALL of the following criteria:

Attached tick identified as an adult or nymphal I. scapularis (deer) tick.

Tick is estimated to have been attached for great than or equal to 36 hours (based upon how engorged the tick appears or the amount of time since outdoor exposure).

Antibiotic treatment can begin within 72 hours of tick removal.

The person can take doxycycline (eg, the person is not pregnant or breastfeeding).

If the person meets ALL of the above criteria, we recommend that you call BEFORE the 72 hour period after tick removal.  We will review the risk benefit of treatment at an appointment for children under 8 years old.  The recommended dose of doxycycline is a single dose of 200 mg for adults and 4 mg/kg, up to a maximum dose of 200 mg. If the person cannot take doxycycline, we follow recommendations from the IDSA, the CDC and the AAP and do not recommend preventive treatment with an alternate antibiotic for several reasons: there are no data to support a short course of another antibiotic, a longer course of antibiotics may have side effects, antibiotic treatment is highly effective if Lyme disease were to develop, and the risk of developing a serious complication of Lyme disease after a recognized bite is extremely low.

MONITORING FOR LYME DISEASE: Many people have incorrect information about Lyme disease. For example, some people are concerned that Lyme disease is un-treatable if antibiotics are not given early (this is untrue; even later features of Lyme disease can be effectively treated with appropriate antibiotics). Many local Lyme disease networks and national organizations disseminate unproven information and should not be the sole source of education about Lyme disease. Reputable sources are listed below. Signs of Lyme disease — Whether or not a clinician is consulted after a tick bite, the person who was bitten (or the parents, if a child was bitten) should observe the area of the bite for expanding redness, which would suggest erythema migrans (EM), the characteristic rash of Lyme disease.  The EM rash is usually a salmon color.  Rarely, it can be an intense red, sometimes resembling a skin infection. The color may be almost uniform. The lesion typically expands over a few days or weeks and can reach over 20 cm (8 inches) in diameter. As the rash expands, it can become clear (skin-colored) in the center. The center of the rash can then appear a lighter color than its edges or the rash can develop into a series of concentric rings giving it a “bull’s eye” appearance. The rash usually causes no symptoms, although burning or itching has been reported. In people with early localized Lyme disease, EM occurs within one month of the tick bite, typically within a week of the tick bite, although only one-third of people recall the tick bite that gave them Lyme disease. Components of tick saliva can cause a short-lived (24 to 48 hours) rash that should not be confused with EM. This reaction usually does not expand to a size larger than a dime. Approximately 80 percent of people with Lyme disease will develop EM; 10 to 20 percent of people have multiple lesions. If EM or other signs or symptoms suggestive of Lyme disease develop, the person should see us for proper diagnosis and treatment.

Web Sites that are reputable:

National Library of Medicine: http://www.nlm.nih.gov/medlineplus/lymedisease.html [2]

National Center for Infectious Diseases: http://www.cdc.gov/ncidod/dvbid/lyme/ [3]

American Lyme Disease Foundation, Inc: http://www.aldf.com/lyme-disease/ [4]

Pictures of Deer Ticks showing approximate size compared to a dime: https://www.cdc.gov/lyme/transmission/index.html [5]

Thank you and have a Safe and Wonderful Thanksgiving,

The Providers of Four Seasons Pediatrics