Four Seasons Pediatrics

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Coronavirus – COVID-19

March 22, 2020 UPDATE

We enter a new day with new challenges.   With limited travel and the New York Order to stay at home, we are here for you.   The office was very quiet last week and we anticipate it to be so this week.  Again we feel confident about our policies and procedures to do social distancing and to keep you safe in the office.   We have a much greater need to serve people through telephone support and Tele-Visits over the next 4-8 weeks.  Many pediatric offices have found it challenging to maintain staff and some have considered closing.  Insurance companies have partnered with us.  They recognize that we have less office visits and will need to give more telephone support.  Most insurers are now covering both Tele-Visits and Telephone calls.   As we stated with the March 20 update,  the American Academy of Pediatrics has advocated we continue well visits if we can balance risk and benefit.  With that said, here is what we want you to know:

Well Visits:   We will continue well visits and immunizations.  We ask that you limit who you arrive with and only bring those who need to be in the office.  We also ask that you call and reschedule your visit if anyone coming is sick with cold symptoms such as runny nose, sneezing, cough, sore throat or fever.    For the next 4-8 weeks, no patients who are sick are allowed upstairs on the well floor.  All well visits will not check out at the desk, they will be discharged from the room directly.   To schedule follow ups, we will ask you to do so by telephone.   Please continue social distancing in the office.

Sick Visits: We are having very few sick visits.  All sick patients are seen downstairs.  We have office sick visits ONLY for those we need to see (e.g. we cannot do a Tele-Visit to diagnosis Strep throat as it requires a test to do so).    Having said that, we can do a lot more with Tele-Visits during this crisis.  If you are coming in for a sick visit and anyone with you has cold symptoms (again runny nose, sneezing, cough, sore throat or fever), please have someone without symptoms come in the building FIRST to obtain a mask for anyone with these symptoms.  If you are unable to leave the car to do this, please call our office and let us know how many masks you need.  We will bring them out to your car.  Please wear the mask throughout the visit and do not remove it until you are back in your car.   If your child cannot or will not wear a mask, please be sure to carry tissues to cover the mouth and nose for all coughs, and sneezes.  All sick visits will will be discharged from the room directly.   Please continue social distancing in the office.

Tele-Visits:  We will be doing more visits by Tele-Visits.   During this crisis there will be no cost share for these visits (no copay, deductible etc regardless of insurance or no insurance).  A list below shows you what type of visits we are considering.  In order to do so, we recommend that you download the following apps: Healow and Google DuoHealow is the app that is the most secure and is the best app to use while we are open in the office.  During after hours and weekends, if we decide that a Tele-Visit would be most appropriate, the doctor on call cannot use the Healow app at home at the present time.  Instead, we may elect (if you consent) to connect by Face-time, or if you have an Android device, we can connect by Google Duo.  In Preparation please immediately make sure you can sign in to Healow  and try out the Duo App with friends/family to get comfortable with it.   For Healow instructions, see our home page and click on Online Bill Pay and Portal Login on the top left.

Visits we can consider for Tele-Visits include:

  • Acne
  • ADHD follow ups
  • Allergies
  • Anxiety
  • Asthma reviews
  • Asthma except if shortness of breath
  • Behavioral Problems
  • Cold  symptoms
  • Concussion follow ups
  • Conjunctivitis (Pink Eye)
  • Coxsackie virus
  • Croup
  • Diaper Rash
  • Diarrhea
  • Earache for children over 2 with pain relieved with Tylenol (Acetaminophen)
  • Eating Problems
  • Eye Allergy, Discharge, Redness
  • Food reactions without breathing difficulty
  • Hair loss
  • Hand, Foot and Mouth Disease
  • Headache
  • Hives without difficulty breathing
  • Nasal allergies
  • Prolonged cold symptoms
  • Rash
  • Sleep issues
  • Sore throat (with runny nose, cough, or hoarseness)
  • Thrush
  • Tick bite
  • Toenail ingrown
  • Umbilical cord discharge or redness
  • Vomiting with diarrhea
  • Vomiting on medication
  • Warts

Telephone Calls:  During this crisis, most insurance companies again recognize the stress offices are experiencing.  Most are allowing insurance coverage for telephone calls.  As such, we will bill for these services.  Again, there will be no cost share for these services (no copay, co-insurance or deductible regardless of whether your insurance covers this service, or if you have no insurance).

Office Staff:  We want to recognize the absolute commitment our staff (from the front staff, the nurses and our doctors) have shown to care for all of you.    No staff have shown symptoms to date, but we have tight policies and procedures to isolate and test any staff who show symptoms of COVID-19.    Our goal is to keep you informed, slow down and reduce the number of people infected, monitor for new treatments and to be ready to implement more testing and treatment when Personal Protection Equipment AND testing supplies are available to use beyond just the hospitalized patients.  Thank you for being so understanding and for honoring our explanations regarding testing.

March 20, 2020 UPDATE

Increase in number of diagnosed cases – as we stated in our March 15th update, we predicted we would see an increase in the number of cases as more tests become available.   Although uncommon, there have been children with more severe symptoms.  Please know, if children in our practice develop the symptoms (severe shortness of breath) which require hospitalization, they will be tested.    Meanwhile, the federal government has stepped in and will manufacture Personal Protective Equipment (PPE).  Until this is in the hands of hospital and healthcare workers, who need protection, we are not testing at this time.

Well Visits – we have very strict policies and procedures to protect you and our staff.  Yesterday the American Academy of Pediatrics, advocated we continue the important benefit of well visits, but asked us to balance the benefit of immunizations and screenings with the risk of exposures.  In the balance, we are also to consider modifications to the structure of our schedule and physical space.  We have done that and continue to put policies and procedures in place to give confidence to your safety.    Again, we feel confident in those policies and procedures and will continue to monitor and respond to recommendations as they come out.  With that in mind here are some modifications to be aware of:

  • We have waived all late cancel and no show fees.  We still plead with you to cancel with 24 hour notice, so that we can offer appointments to those who need them (e.g. Tele-Visits and Children who are due for Immunizations).   We do not want an outbreak of a preventive disease while we deal with this crisis.    An outbreak of Pertussis, Meningitis, Rotavirus, Pneumonia etc, will not be beneficial if resulting in hospitalization or lowered immune protection.    Insurance companies that operate in the state of New York have waived all patient responsibility for Tele-Health visits.  We are working to develop emergency criteria for visits by Tele-Health (called a Tele-Visit by our Electronic Record) for types of visits that we required an office visit for.
  • Many are also covering telephone calls during this crisis, so that we can support the high volume of concerns, and calls that do not require a Tele-Visit.  We will send this criteria out over the weekend.   We are not having many sick visits in the office, and we feel this criteria will reduce this even more.  What you can do right now: recover your password and user name for your portal account.  Download the Healow App (click here) on your phone, make sure you can log in.  This way, we can have a smoother Tele-Visit.
  • As of Monday, 3/22/20 – IF you have a well visit, where the patient, the parent OR a child who you cannot leave at home, is having cold symptoms (runny nose, sneezing, coughing) or fever (100.4 or higher), please CANCEL the well visit.  We can reschedule, when symptoms have resolved.

Sick Visits – If we advise you of the NEED to have an office visit, it is because we feel we NEED to assess you.   You will be safe in the office.   Upon arrival, please have a person without symptoms come into the office and obtain a mask for the parent or patient if having runny nose, sneezing coughing or fever.  Please mask them in the car and then enter.  If you cannot leave your child in the car due to age or lack of another person to stay in the car, please call us and ask for a staff to bring out a mask.  (tell us who needs it: e.g. 8 year old or adult – so we know what type of mask to bring to you).     If it is not possible to mask (e.g. an 18 month old who just will not wear a mask), please be sure to have tissues with you to cover sneezes and coughs.    Thank you in advance for your help.

March 18, 2020 UPDATE

Tele-Visit Video Calls:  We had our first Tele-Visit Yesterday.  Staff training will occur at noon today and we will have appointments starting this afternoon.  In preparation, we encourage everyone to go to our home page and click on Web Portal on the top left – link is below.

You will see instructions on counting breathing rate, heart rate as well as detailed instructions about setting up and getting ready for a Tele-Visit.  If you forgot your password or User Name, click on Need Help to recover these.  Please note, we prefer you use a computer rather than a phone (unless your phone is the only option) due to movement of the phone.

Social Distancing:  As we look around, we do see some concerns about social distancing.  Young adults want to carry on with normal movement.  We see families outside more, but also see families walking with other families in groups and are hearing about sleep overs.  We encourage you to be outside.  Please do this with your family, not with others.  This might be a time where screen time would be a better way to socialize for the young adults (I know this is a different message than we usually encourage- more personal interaction in normal times).   On the evening of 3/16, local pediatricians joined a conference call to share good ideas and make each other aware of how we are approaching this crisis.  We are having calls once to twice a week to do so.   We discussed a study about children published in our journal “Pediatrics”.  This study from China had some significant flaws, as two thirds of the children were not tested to confirm COVID-19.  There was some testing of children without symptoms and 12.9% of those who tested positive had no symptoms.  Another 43% had mild symptoms.  This confirms our concern that children may be an important source of spreading this infection.  This is very important for the children with no symptoms.  Sneezing and coughing are the important symptoms that can spread droplets to others.  Lack of symptoms does not change this.  At home, think of the different ways children might spread infection; than occurs outside the home.  Sharing drinks, sharing food, cleaning dishes, pacifiers, toys, etc. represent everyday activities that can spread disease.   We feel that this is an important consideration in keeping your children away from those at risk (grandparents, elderly).

Office Social Distancing – we are staying open.  It is quiet in the office for office visits, but our phones have been very busy.  We will maintain our staffing through what is likely to be a long haul of social distancing (based on reviewing information available at this time – social distancing will be most effective if it occurs for 8 weeks).  We have social distancing in our office.  People are not in waiting rooms and we have removed objects from the waiting area that children would want to touch on the way in and out.  You will likely not see other patients during any visits.   In the meantime, it is rewarding to see steps taken to bring us together.  “Shopping Angels”: a student who is shopping and delivering groceries to seniors.  Grocery stores are creating “Shopping Hours for Seniors” so that they can have a dedicated time to get what they need.  Congratulations to Market 32 for joining this approach to protect the most vulnerable group.


March 16, 2020 UPDATE

As an update – this message is from Dr. Elmer, Dr. Miller:

Process changes in the office – what you need to know:

1. Tele-medicine – we are testing and prepping for tele-medicine (also called tele-health) video calls.  To have a tele-health call, you will need to have a portal account and a computer with a camera.   We will announce when we are ready to implement this technology.

2. Well visits – we are continuing well visits but with some limitations.  We ask that you only come upstairs if everyone in your group is well.  If anyone is sick, we recommend that you reschedule or head downstairs.   Anyone with cold symptoms  will be asked to mask during your entire visit and leave the building with the mask.  If your child will not wear a mask, please hold them in your lap with tissues to cover coughs and sneezes.  After check in, you will be moved directly to the exam room.   During your visit, well children will be cared for by our well staff.   Visit summaries will be given in the room without returning back to the front desk for check out.  We are sanitizing all surfaces in sick and well rooms with Clorox.  This includes our exam tables, door handles, cabinet handles, baby scales, eye and ear instruments, keyboards, mice, and stethoscopes.  Use your judgement about keeping your well visits.   Parents have informed us that they appreciate the opportunity to still have these visits during this time.  We are having very few sick visits, as people have respected our recommendation to stay at home unless we medically need to see them.  We believe that our policies and procedures will result in a much lower chance of getting COVID-19 in our office than any other activities that you have to carry on with (groceries, gas for the car etc).   We are constantly re-evaluating this approach and will change our process if appropriate.

3. Testing – we have the ability to do testing, but are reserving testing for those who need to be hospitalized at this moment.  With consultation of the local county health department, we are experiencing a critical shortage of personal protective equipment (also called PPE).   Every-time we test, we are required to mask, wear eye protection, a gown and gloves.   Every time we use these, it is one less doctor and nurse who can be protected in the hospital setting.  Hospital need will become more critical in the coming weeks to months.  Please know that we want to test, we want to know and we need more information.   We also want to be responsible in our approach.   We have heard stories about other doctors taking different approaches and we understand how this can be confusing.  Please note that testing will not change how we treat your child unless they are needing hospital care or we develop a medication that can treat this infection.

4.  Asthma – we are getting a high volume of calls for asthma medication, specifically albuterol.  Please only call for your albuterol if you are having symptoms and need the medication.   We are already seeing pharmacies running out of albuterol.  Secondly, we recommend that you avoid the use of the nebulizer unless necessary.  One study showed that nebulizing medication when you have COVID-19 may suspend the virus in the air for up to 3 hours.  If you need to nebulize, do so in one room.

5. Low risk to children – COVID-19 studies continue to show low risk to children, young and middle age adults.  This does not mean no risk, but is very reassuring to the population we serve.

March 15, 2020 UPDATE:

Diagnosed COVID-19 cases continue to rise.  We are seeing dramatic changes in approaches to social distancing.   We will see a very big growth in number of cases, even as we take these important measures.  A very significant increase will occur as a direct result of more tests becoming available.  A greater percent of cases will be those that are not as sick. Unfortunately, there will be more lives claimed as well.   As these tests become more available, we will test responsibly.  We do want to test more, but there is still a very significant downside of this approach.   1) We don’t have a treatment for this infection 2) the risk for poor outcomes is extremely low for children, young and middle age adults 3) we do not want to run out of supplies and staff for those who need medical support.  Each test now requires that we mask, gown, wear eye protection and glove up to protect health care providers, supplies that we do not have enough of.   New York State and the County Health Departments are working hard to help us secure supplies.  Many supplies were purchased by the public as they do not require a license.  In addition, the supply chain has relied on China, which was shut down during their crisis.   We have been adapting and will continue to adapt to do the best we can for you.

You have been hearing us and all the experts talking about risk to the elderly over age 60 with certain medical conditions (Heart Disease, Diabetes, Hypertension and Chronic Lung Disease).  These are the people who need hospitalization.  They need to have tests available, they also need to have isolation supplies (the same masks, eye protection, gowns and gloves) and they need the health care people who care for them to stay healthy (some of which are also at high risk).

Every day, our staff and other medical offices are struggling with what to do today.  We spend our days and nights planning for any changes to implement.  We are trying to care for you while being responsible with how we approach this crisis.  We have been and always will be evidence based providers of healthcare.  We are careful with prescriptions for antibiotics.  We wait until the appropriate time to prescribe.  We offer non antibiotic approaches for ear infections.  We have only given tamiflu and test for flu, when it really changes our treatment approach.   We will not panic.  We will follow what the recommendations and evidence based medicine points us to.  We are following guidance from the NYS Department of Health as found here:

In the meantime, what can we do to minimize the effects on children?:

1. If your children are sick, keep them home if possible.  For example, the previous article that we wrote about fevers and when to worry about them applies to how to handle fevers now.  This is on the home page of our website and is found below:

2. We will be offering Tele-Visit with video visits for some visits that we feel are appropriate in the very near future.  We will announce when our capability is available, after further testing.  Please bear in mind that we cannot diagnose strep throat, ear infections, and pneumonia by a video visit.   Video Tele-Visit give us an opportunity to view your child and view you.  When we implement this process, we may ask some things of you.  We may ask you to try to count the breathing rate in a minute, take a temperature, or check the heart rate.

Breathing Rate: Set a timer for 30 seconds and count the number of times your child’s chest rises. Double that number to get his respiratory rate.

Heart Rate: To check your child’s heart rate, place two fingers on their wrist, below their thumb. Apply gentle pressure until you can feel a slight beat against your fingertips. Count how many beats you feel in 15 seconds. Then multiply that number by 4 to determine your child’s heart rate, which is measured in beats per minute.

In addition, it will be most helpful to talk to you first and then ask you to bring your child in front of the camera at the appropriate time.   It won’t help you or us to see your child throughout the video visit.  As you can imagine, some children will cry for your attention when you are busy speaking with us.  Some children will be more focused on seeing themselves on the screen.  If we are unable to communicate and ask questions, the visit will be un-rewarding.   In some cases, we will need to examine a child and that will not change.

3. News cycle and Anxiety – having your child home with a 24 hour focus on COVID-19 will lead to anxiety for some children.  We suggest that you not leave the news on.  Speculation about what could happen, pictures of adults fighting for groceries and showing the number of  cases and the number of deaths will only serve to add to more difficulty for you.  Keep your children busy with schoolwork, chores, helping with dinner, games and going outside.  Show your children confidence about illness not affecting them or you.  Only talk about risk for the elderly when you need to explain that you are doing a good thing by not visiting Grandma so you do not spread other germs.    Remember, children will excel in your confidence but struggle if they see you worry.   Set good examples.  When they ask about how the elderly are at risk of disease, think about someone (neighbor, friend, relative) who is older and at risk.  Demonstrate by calling, texting, emailing that person.  Ask if they need any groceries, supplies, medications.  Tell them you will put supplies at the front door and ring the doorbell.  Have your child go with you to see what you are doing.  These are not only ways to support the elderly, they show your child the positive messages of how we pull together.

Keep the faith – Dr. Miller

March 12, 2020

As an update – this message is from Dr. Miller:

Please note that there is a lot of panic.  Please remember that there have been no deaths for children under 9 years and 0.2% for those between age 10-39.  Please note these are ONLY the sickest patients.  Testing was only done on the sickest patients and we feel the actual incidence of fatality is much lower.  We feel that this is VERY reassuring to our pediatric patients and their parents.   Does this mean we will not see a child die from the disease – no I think we have to prepare for that.  There is something very different about how the lung is behaving for the young.  They are not getting the severe changes that the elderly are.   They seem to be protected from this virus as compared with the flu.  Have said that, please remember that as of today, 136 children have already passed from the flu.  We still feel that the flu is definitely more of a concern for children.  Children and Young Adults seem to have some protective effect from how this virus inflames the lung.  As a parent, you will know if there is a problem.   (e.g. my child can’t catch their breath).  This risk looks really small.  I cannot say that enough.   Importantly, getting tested with less than concerning symptoms, will not be helpful as there is no early treatment.  There is treatment, but it is at the point of needing hospitalization.    In the meantime I will remind everyone of the following:

1. Stay out of the office, hospital, urgent care UNLESS necessary.  This is also true for those with Chronic Medical Conditions.

2. If we recommend that you care for an illness at home, please consider following our advice.  If you feel you must come in, we will respect that as always.   We know that your instinct about something being wrong HAS to be listened to.  All we ask, is that you listen to your instinct about when that is really the case, as opposed to letting the fear of this virus get the best of your judgement.    If we can tamp down the fear, talk ourselves through the next month or so, we can prevent over-whelming the medical system as it struggles to keep up with a society that is minutes away from another update.  There will be more cases.  There will be unfortunate bad outcomes.  Let’s focus on what we can do.  Wash the hands.  Cover the mouths.  Keep with the social distancing.  Avoid crowds.  And most of all, protect our elderly.    The statistics for risk of the elderly is the part that is not reassuring.  Try not to visit grandparents – especially those with high blood pressure, heart disease, diabetes, COPD and cancer.  Drop off groceries to them so that they don’t have to go out. Make sure that they have their medicine at home.

3. We are here for you.  We believe strongly that we have your best interest in mind.  We will always have your back.

Warm regards – Dr. Miller


The Capital Area has had our first three cases of Coronavirus confirmed with one in Clifton Park. The three cases are from Saratoga County.  The providers at Four Seasons Pediatrics would like to update you with our views about the Novel Coronavirus – COVID-19.   Behind the scenes, we have been reviewing all the information that is coming in about this virus.   Some of the information from the press has resulted in panic in the public.  We have had Preparedness meetings with our staff.  We are working with Pediatricians in the Capital Area and have a preparedness meeting this week at our office.  We are working with public health officials from the counties we serve and have invited them to participate in our meeting.   Many of these suggestions should begin now, as we have our first cases of COVID-19.  Here are some key points (but please review this entire newsletter carefully):

1. COVID-19: based on best available data from  China, Italy and South Korea, this virus is extremely low risk to children.   While there is always a possibility of poor outcomes with any respiratory virus, those at highest risk appear to be the elderly over age 60 and especially those over 80 years old as well as the elderly with medical conditions including Heart Disease, Diabetes, COPD, High Blood Pressure.

2. There are three confirmed cases in the Saratoga County, but risk at the present time is extremely low.  We do feel there will likely be more cases in the near future, and there is potential for widespread infection.   There is no vaccine, and as you may have heard we do not anticipate one for approximately a year.  There is no anti-viral medication available at present.

3. The most effective strategies: hand-washing, covering a cough or sneeze with a tissue (throw away immediately), and keeping sick children away from others when possible (especially the elderly).  Please observe your children’s habits and teach them how to limit spread.

4. Flu Vaccine – we PLEAD with you to get the flu vaccine for you and your children if you have not already done so.  We still have a limited supply.  Fevers that occur in the coming weeks will be suspect for COVID-19.  Prevention of any fevers and cold symptoms  can reduce consideration of COVID-19.  This can reduce un-necessary visits to the doctor and can reduce fever and illness to others who also might have to be evaluated.   We are most concerned that panic about this virus may lead to over-whelming the health care system in offices and emergency rooms.

5. For many people who did get infected with COVID-19, they can and should be cared for at home.  Of course we can and will always see children, whose parents insist that they be seen, BUT we ask you to consider not being seen if our evaluation results in a recommendation to provide care at home.  We can always revisit the need to be seen if symptoms change or you are concerned about your child.   You will see us implement special strategies for those who are under-investigation for COVID-19 including any of the following: having parents text from the car upon arrival, masking in the car if masks are available, going directly into a room downstairs and being discharged directly from a room without entering the waiting area.

6. Well visits – we will continue to have well visit appointments.   We ask that 1) if your child or anyone accompanying your child is sick with any cold like symptoms (cough, sore throat, fever, runny nose, sneezing) to call us BEFORE your appointment so that we can give advice and not put you in the well area. 2) If you have a sick sibling, please do not bring them to the office.  We have to insist on this approach so that everyone can feel safe about coming to the office for well visits without sick symptoms

Again, please remember that COVID-19 will result in taxing the healthcare setting in all areas (Medical Offices, Emergency Rooms, Urgent Cares, Hospitals).   We are working hard to make sure that your healthcare experience is safer than your everyday contacts in school, work and in the public.   We are implementing strategies to only come in for illnesses that are likely to require evaluation and treatments you cannot do at home.   We recommend staying out of urgent cares and emergency rooms unless medically necessary.  To reduce fevers and illnesses that can be confused with COVID-19, we will continue to vaccinate children for the flu in our office for as long as we have vaccine.  We highly recommend that you vaccinate as soon as possible, if you have not already done so.  This virus is NOT airborne like Measles or Pertussis.  It is spread by droplets related to coughing, sneezing, touching the face and then contaminating surfaces.  We feel it is likely easily killed by cleaning with a disinfectant and will not remain on surfaces that are cleaned.  Hard surfaces are more important than soft surfaces.  That is why wiping down often-touched surfaces with disinfectants or a household cleaning spray, are a good idea.

TIP 1: Prevent Infection: The predominant way that respiratory illnesses are spread is from person to person in respiratory droplets from coughs and sneezes. Germs can also spread when a person touches something contaminated and then touches their eyes, nose or mouth. Some viruses and bacteria can live up to 48 hours or longer on surfaces like tables, doorknobs and desks that are not cleaned.  We are implementing strategies to disinfect more potential surfaces to help stop the spread of germs:

  • Avoid touching eyes, nose, or mouth.
  • Greet with a nod rather than a handshake
  • Avoid close contact with people who are sick. When you are sick, keep your distance (e.g. 1 meter/3 feet or more) from others to protect them from getting sick.
  • Stay away from crowds when you have a choice
  • Clean surfaces with a disinfectant.  This can be made by mixing 2 ounces of bleach with 1 gallon of water.  For a list of disinfectants listed by the EPA to disinfect surfaces, Click Here

TIP 2: Hand washing: Hand washing is a simple habit most people do without thinking.  Hand washing, when done properly, is one of the best ways to avoid getting sick and was a very effective strategy for other Coronaviruses including SARS and MERS. This simple habit requires only soap and warm water or an alcohol-based hand sanitizer — a cleanser that doesn’t require water.  Hand sanitizers have disappeared as people have been buying them.  Soap and water will be readily available if sanitizer is not.   In general, regular soap is fine.  Wash before eating or preparing food, after coughing, sneezing or blowing your nose, after using the restroom, or after touching another person.

Follow these instructions for washing with soap and water:

  • Wet your hands with warm, running water and apply liquid soap or use clean bar soap. Lather well.
  • Rub your hands vigorously together for at least 20 seconds. (Sing the ABC song slowly)
  • Use a towel to turn off the faucet.

TIP 3: Cough Etiquette: Cover your mouth and nose when coughing or sneezing, using tissues and disposing of them in a trash receptacle immediately. If tissues are not available, cough or sneeze into your sleeve (make sure to smother the sound or it does no good). Then wash your hands.  Again observe your family for cough etiquette and hand-washing.

TIP 4: Boosting Your Immune System: Your immune system responds to how you treat your body.  Reducing stress, getting consistent rest, and eating plenty of fruits and vegetables are important in this regard.  Maintain your hydration

When to Call the Office:

· Not waking up or interacting
· Sounds like a life-threatening emergency to the triager
· Being so irritable that a young child will not be held
Go to ED NOW (or to Office With PCP Approval)
· Child sounds very sick or weak to the triager (R/O sepsis)
Go To Office NOW
· Difficulty breathing, not relieved by cleaning out the nose (R/O bacterial pneumonia)
· Fever >105°F, rectal or oral (R/O serious bacterial infection).
See Today in Office
· Parent wants child seen
· Yellow scabs around the nasal openings (R/O impetigo)
· Fever present >3 days (R/O secondary infection usually otitis)
· Fever returns after going away for 24-48 hours (R/O secondary infection)
· Symptoms have been present for 48 hours or less AND (REASON – Provider to determine if anti-virals are indicated)
– Child is younger than 2 years OR
– Has certain chronic medical conditions (pulmonary, cardiac, renal, hepatic, hematologic or metabolic including diabetes) OR
– Has conditions that can compromise respirtory function (cognitive dysfunction, spinal cord injuries, seizures, neuromuscular) OR
– Immunosuppressed by medications or HIV OR
– On long term aspirin therapy
See Within 3 days in Office
· Nasal discharge present for greater than 10 days
· Cough present for greater than 3 weeks
· Influenza lasts greater than 10 days
Home Care
· Probable influenza with no complications
1. Reassure the Caller:  For most people, influenza is just a bad cold.  The treatment of influenza is based on the symptoms.  Bedrest is not necessary, but helpful for some.
2. For a runny nose with profuse discharge, blow or suction the nose:
· Reassure the parent that the nasal discharge is natures way of washing out the virus.
· Blowing the nose is all that is needed.
· Apply petroleum jelly to the nasal openings to protect them from irritation.  Clean the skin first
3. For a Blocked Nose, Use Nasal Washes
· Importance: A young infant cannot nurse or drink from a bottle, unless the nose is open
· Use warm water or saline nose drops to loosen up the mucous followed by suctioning or blowing.  Repeat until clear.  Most stuffy noses are blocked by dried mucous.  Suctioning alone or blowing will not remove it.  Neither can medicines.  Do nasal washes especially to help with eating or sleeping
· Saline Nose Drops: 1/2 teaspoon to 8 ounces (1 cup) of warm water.
· Humidifier: Use if the air is dry to sooth the air passages.
4. Fever Medicine:  For fever over 102 degrees F, use acetaminophen or ibuprofen (buffer with some food).  The goal is comfort, fever does not need to be eliminated.  Do not use aspirin for fever due to the risk of Reyes Syndrome.
5. Cough Medicine: For mild cough or hoarseness use 2-5 ml of corn syrup or buckwheat honey for younger children > 1 year old, or cough drops for children > 4 years.  We want to encourage a productive cough, not suppress it.
6. Sore Throat Relief:  For mild sore throat, give warm chicken broth for children > 1 year old, or cough drops for children > 4 years.
7. Contagiousness:  Spread can be rapid because the incubation period is only 24-36 hours, and the virus is very contagious.
8. Expected Course:  The fever lasts 2-3 days, the runny nose 5-10 days, and the cough 2-3 weeks.
9. Call back if
· Fever lasts > 3 days
· Fever returns after going away for 24-48 hours
· Nasal Discharge last > 10 days
· Your child becomes worse.

When should I call 911?

  • If you see severe difficulty breathing (struggling for each breath, making grunting noises with each breath, unable to speak or cry because of difficulty breathing, severe retractions/sucking in between the ribs)
  • Bluish lips or face
  • Not waking up or interacting
  • Your young child is so irritable that they will not be held

When should I take my child to the Emergency Room?

  • Under our advice if your child appears very sick or weak

You should call us to be seen now (if the office is open) if:

  • There is difficulty breathing, not relieved by cleaning out the nose
  • Fever >105°F, rectal or oral

We should see you today in the office if:

  • Yellow scabs are around the nasal openings (possible impetigo)
  • Your child is not able to get comfort with use of an appropriate dose of acetaminophen (tylenol) or ibuprofen (Motrin or Advil)
  • Fever is present for 5 days or longer – check in with us to make sure there is not a secondary infection like an ear infection
  • Fever returns after going away for 24-48 hours – to make sure there is no secondary infection

Other considerations for an office appointment – we expect a higher volume of office visits when COVID-19 is occurring.  Some symptoms do require an office visit.  There are also some symptoms listed below which could potentially wait longer if you feel your child is starting to improve.  We will see most patients on a same day basis, but we may need to limit some patients with these symptoms from same day appointments.  This may be to accommodate patients who may need more immediate care, as well as allowing some patients to improve on their own without being see.

Call to be seen within 3 days if:

  • there is a daily nasal discharge present for greater than 10-14 days and it is not improving (possible sinusitis)
  • there is a cough present for greater than 3 weeks

What can I do to help treat symptoms at home?


For most people, the medical evaluation and symptomatic treatment of COVID-19 is based on the symptoms.

  1. Bedrest is not necessary, but helpful for some.
  2. For a runny nose with profuse discharge, blow or suction the nose.  The nasal discharge is natures way of washing out the virus.  Blowing the nose is all that is needed.
  3. Apply petroleum jelly to the nasal openings to protect them from irritation.  Clean the skin first
  4. For a Blocked Nose, Use Nasal Washes.  A young infant cannot nurse or drink from a bottle, unless the nose is open.  Use warm water or saline nose drops to loosen up the mucous followed by suctioning or blowing.  Repeat until clear.  Most stuffy noses are blocked by dried mucous.  Suctioning alone or blowing will not remove it.  Neither can medicines.  Suction the nose for a runny nose that is preventing eating or sleeping.  We usually don’t advise suctioning for more than 3-5 days.    For Saline Nose Drops: 1/2 teaspoon salt to 8 ounces (1 cup) of warm water.
  5. Humidifier: Use if the air is dry to sooth the air passages.
  6. Fever Medicine:  For fever over 102 degrees F, use acetaminophen or ibuprofen (buffer with some food).  See the medication dosing area of our website or click here.  The goal is comfort, fever does not need to be eliminated.  Do not use aspirin for fever due to the risk of Reyes Syndrome.
  7. Cough Medicine: For mild cough or hoarseness use 2-5 ml of honey for younger children > 1 year old, or cough drops for children > 4 years.  We want to encourage a productive cough, not suppress it.
  8. Sore Throat Relief:  For mild sore throat, give warm chicken broth for children > 1 year old, or cough drops for children > 4 years.
  9. Expected Course:  As best we can tell, like most respiratory infections, we anticipate that the fever lasts 2-3 days, the runny nose 5-10 days, and the cough 2-3 weeks.   This may change as we get more experience
  10. Call back if:  the fever lasts 5 days or more, the fever returns after going away for 24-48 hours, the nasal discharge lasts > 10 days, or you feel your child becomes worse.
  11. If you are asked to come to the office and mask for ill symptoms, you can make your own mask at home using supplies that most people have.  See this link.  Please note, do not buy up staples, rubber bands to stock up.  This is a consideration because all the masks have been removed from availability and health care offices are not able to get them for best care in offices.
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