Four Seasons Pediatrics

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COVID Omicron Booster and Update on Sick Visits

COVID Booster Vaccine Update

The COVID Vaccine has finally received an update to include the Omicron Mutation.  COVID-19 booster vaccines targeting the Omicron BA.4 and BA.5 subvariants currently dominating in the United States have been approved by the FDA and CDC.   We expect to have the new Booster by sometime Tuesday.  This has been approved as a booster dose for those 12 years and older.  It is approved to be given 2 months after completing your primary series OR 2 months after a booster dose.  As best we know, other ages will be approved in the coming weeks to month.   Up until now, the current COVID vaccine has had the original virus surface proteins since it was first developed.  We knew that the virus would mutate and it will continue to do so.  This vaccine showed excellent protection for almost a year until the Delta mutation came along.  This eroded the protection for infection, but it still worked well and continues to work well to prevent serious infection and MIS-C (reducing it by 90% in children).  After the Omicron variant came along last January, the original vaccine has provided protection from most infections, but it is limited to about 10-12 weeks.  The new booster will restore more prolonged protection from infections UNTIL significant mutations occur again.  We feel it is a better way to prolong protection from COVID infections as we head into the fall.  

Was this studied enough?

You may be hearing news stories about this being tested only in mice.  Let’s clarify some of that information.  This transition to updating vaccines for COVID-19 is being done much like the US updates its flu vaccine annually, tweaking the formula of an established vaccine platform.  Earlier this year, vaccine makers submitted data to the FDA on an updated vaccine that targeted BA.1 (the first Omicron Mutation and the previously predominant Omicron variant). But then the FDA asked the companies to update their vaccines to add an Omicron BA.4/5 component, to create a vaccine that is a bivalent booster — meaning it will cover both the original strain of the virus that emerged from China and the newer BA.4 and BA.5 subvariants.  The BA.1 vaccine did show protection but not as much antibody protection for BA.4/5.  With BA.4/5 added, antibody levels are higher for the circulating mutations.

Dr. Miller comment: By the time the data was being submitted, the Omicron mutations to BA. 4/5 had occurred.  The vaccine is only changed in the sense that the new surface proteins include BA.4/5 in the vaccine.  IF we perform lengthy studies every time we include a new variant, we will wind up with a product that is not as effective.  It took 5 months from Omicron in January – until we had the data in June.  This virus will not wait for us to overthink our approach.  The virus will mutate again, making the vaccine less effective over time.

If the infection is mild in children, why not let them get the infection instead?

In many cases, infection is inevitable.  At the present time, the average person will be infected every 9 months.  Even if you had an infection, the booster vaccine offers more prolonged protection from the mutations that are currently circulating.   It is still better to have just the surface proteins of the virus (through the vaccine), then to get the entire virus.

What is in it for your child?

Your child will get immediate protection and greatly decrease the chance of getting an infection.  For most children, this will provide more prolonged protection until a significant mutation(s) has occurred.   As noted above, it greatly reduces the chance of MIS-C.  As of August 29th, 2022; 8,862 children have had MIS-C in the United States, and New York is one of the four states with the highest number of cases.

What is in it for my family?

In addition to reducing risk for your child, reducing infection reduces spreading to a family member who is at higher risk.  It will also reduce exposure to family members without known risk.

What is in it for society?

Mutations are a mistake that occurs when the virus inserts itself into our cells.  Our cells become virus maker machines and make millions of copies of the virus.  When a mistake occurs in the copies, we get mutations.  The number of copies is inversely proportional to the number of infections (i.e. the more the infections, the more the mutations).   If we are to live with this virus and how contagious it is, and we want to do more together with school, families and friends, we need a strategy to minimize the number of infections.  We will not eliminate infections.   Simply put, vaccinations reduce infections which reduce mutations.  They are not perfect, but provide a much better alternative than getting the virus.   

Sick Visits Update

We continue to be overwhelmed with sick visits.  This is true of all healthcare workers.  As has been documented, there continues to be a shortage of those who want to work in healthcare.  A Mayo Clinic Survey of 20,000 physicians found that 1 in 5 healthcare providers have stated that they will retire early, and another 1 in 3 state that they are going to cut back their hours.  At Four Seasons Pediatrics, we have always been proactive in making changes that provide the best care for our patients in a constantly changing environment.  With that it mind, we need to look at current need.  Many parents who have had a child during the pandemic have not experienced a sick child until the last 6 months.  Compared to other practices, our practice has one of the highest percentage of young children under 3 years of age.  In order to meet the demands of our staff and our patients, we will be making steps towards a pre-pandemic approach of sick visits. 

For many patients, we will begin indoor visits.  We have reviewed the charts of all patients who tested positive in our practice for the last 6 months.  66% of the positives have had a positive contact or a family member has had a positive contact.  As they represent the highest chance of having COVID, these patients will continue to be seen outside.  If you have not had a COVID contact, doing a home test before your appointment, will help us reduce our risk if you have COVID (healthcare staff still have to isolate for 10 days at this time).  We recognize that the home COVID test can sometimes miss a positive and we may still recommend a PCR test at times. 

For sick visits, we will focus more on those who have a need to be seen.  Many parents have requested appointments in the first few days of symptoms.  Understandingly, there has been great anxiety over illness and a need for more reassurance.  To better serve both those who really need our medical expertise, and to preserve and protect burn out of our staff, you may be asked to observe your child in the early course of fevers and viral illnesses.  Below you will find excerpts of an earlier newsletter.  These will help you to determine whether you need to be seen.  We will always listen to parents who still state they are uncomfortable observing their sick child without an evaluation by us.  We hope parents will also be open to our comfort when we suggest that observation is recommended in the appropriate situations.  We will also follow that up with advice about what might lead to a recommended visit.  

The advice we will most likely recommend is also available in an American Academy of Pediatrics app you can download on your phone:

Kidsdoc on the Apple Store

Kidsdoc on the Google Store

What are the most common situations that my child needs to be seen?

Fever is one of the most common reasons we get a phone call.  Which fevers are most likely to need evaluation?  

Fever in the beginning of an illness

First decide if your child is uncomfortable.  If they are, treat with acetaminophen.  If you used the appropriate dose (found on our website), and your child is comfortable – that is very reassuring. The onset of fever, the height of fever and the duration of fever can vary by virus and by child.  If your child just started a fever, other symptoms may start right away or take a day or two to show up.  Sometimes patience will allow the other symptoms to show up.  The same is true for the timing of a fever when cold symptoms have begun.  The fever may take a day or two to begin.  In general, a fever that starts in the first 2-3 days, (with cold symptoms such as a runny nose or cough) can be observed.  The goal is comfort.  If your child is comfortable and is drinking, alert and appropriate, you can observe at home.  If the fever is over 105 degrees F, lasts more than 3-5 days, or your child is not drinking and acting appropriate, we would like to have you call us.  You should also call if they are having difficulty breathing or they do not look well despite acetaminophen.  

Fever late in an illness

A fever that occurs late in the illness (generally more than 3 days into cold symptoms) may still be viral, but we would recommend that you call us.

Fever comes back after going away

Once a fever is gone and 24-48 hours have passed, a return in fever should be evaluated.  This type of situation can represent a new viral infection, but is also a reason for us to search for a secondary infection (examine your child, check the ears, listen to the chest)

Sore throat

Not all children with sore throats need to be seen or need a throat culture.  Strep throat does not cause a runny nose, cough or hoarseness.  If any of these symptoms occur within days of the sore throat, a throat culture is not necessary and in most situations, your child does not need to be evaluated.  If your child is unable to drink, you should give us a call. 

Frequent Infections in Your Child

We continue to see frequent infections.  Your child gets over one infection and another one starts.  In many cases, the symptoms continue with new symptoms starting before the other symptoms went away.   You go to the doctor and your child has been diagnosed with another viral infection.  Is something wrong with the immune system? 

Why does this keep happening?

This is a scenario we frequently see at Four Seasons Pediatrics.  Many parents are frustrated with the frequent illnesses.  Let’s go through some of the factors that are leading to this, and give you direction about when it is ok, and when it might represent an immune problem.  

Prior to the pandemic, surveys show that the average 1-3 year old gets up to 9 upper respiratory infections per year.  For ages 4-10 years, up to 6 viruses or upper respiratory infections (URI) per year.  Children just starting school or daycare are more likely to have more infections in the very first year than in the second year.   The pandemic has resulted in a setback to exposure of illness, which is a glass half full and a glass half empty.  It has been wonderful (half full) to see less illness during the pandemic, however each illness is an education to the immune system – and that education simply has not been occurring (half empty).  For some pandemic children, they have never been exposed to illness outside the home.  Now that we have a much needed return to school, families and social circles, the small pockets of illness have exploded.  As families explore the want and the need for more human interaction, there is more spread of illness.  

What other factors make this so apparent?

Pre-pandemic – your child experienced these same illnesses.  They were more spread out through the year, though concentrated in the winter.  Currently they are compressed and many are making an unseasonal surge.  This includes illnesses like RSV  – which usually occurs from November to March in our area and has been occurring from July on; Coxsackie virus which usually occurs in the summer, was occurring over the winter.  Croup usually peaks in the fall and we are seeing a prolonged and higher level of this illness – usually caused by parainfluenza virus.  In MOST cases, children would either carry on in daycare or school, or stay home for a few days and then return.  During previous protocols, children were immediately pulled from school, or sent home to be tested.  This has been placing a greater burden on parents, schools and doctors – as every illness was “in your face” on day 1, demanding more of everyone’s time, loss of school and loss of work.  To add to the burden, later in the illness – there may be concerning symptoms that lead to another visit to check it out.  

My child has been sick continuously – don’t I need an antibiotic?

Let’s do the math on these illnesses.  There are over 200 cold viruses. The rate of illnesses triples in the fall and winter when we are indoors and closer together.   Most illnesses last 9-10 days and some can last for weeks with symptoms slowly improving, but still lingering.  A typical viral upper respiratory illness will ramp up for the first 3 days, peak in the middle 3 days and start winding down in the last 3-4 days.   If there are 9 illnesses for 10 days – that will be 90 days of symptoms.  If most children are now getting back to daycare or school and exposed to more children and adults, it would seem like your child is constantly sick.  You would be correct about that!  The time off from work, from school and general loss of your time is very frustrating to parents.

Here is the good news.  Studies previously done have shown that a child in daycare will have less infections in the SECOND year of daycare.  Children in daycare will have less sick time when they get to school.  

How do I know it is not a problem with my child’s immune system?

Most parents worry that a child who is ill repeatedly has some serious underlying disease. Children with immune system disease (inadequate antibody or white blood cell production) do not get more colds than the average child. Instead, they often have two or more bouts per year of unusual pneumonias, sinus infections that don’t clear up, draining lymph nodes, or boils and recover slowly from these infections. Moreover, children with serious disease do not gain weight adequately.

When your child gets sick, you have not neglected your child.  Viruses are an unavoidable part of growing up.  To put the problem in perspective, consider the findings of a pre-pandemic survey: On any given day 10% of children have colds, 8% have fevers, 5% have diarrhea, and 3% have ear infections.  Although you can reduce some of the symptoms, you cannot shorten the course of a cold.  Your child has to work through it and keep up the hydration.  A runny nose is natures way of washing out the virus.  

When to return to activities?

Most protocols allow a child to return when there is no fever and the symptoms are not excessively noisy or distracting for classmates.  Sports may need to be postponed until your child feels well enough to play.   Some illnesses such as RSV and Coxsackie virus have a contagious period for up to 6 weeks.   Most of the spread occurs in the first few days, while there is fever and or drooling in a young child.   It is just not practical or helpful to keep children out of daycare and school for the entire time a child might be contagious.  Daycares have sometimes asked us to write notes that state – “this child is no longer contagious”.  Such a note would not be truthful, so we instead focus on what is appropriate from a contagious point of view.  (e.g.  May return when fever free and symptoms not distracting).  The pandemic has created some well intentioned approaches that lead to frustration.  When appropriate, we will help you navigate these situations.   

There are no instant cures for recurrent colds and other viral illnesses. Antibiotics don’t help unless your child develops complications caused by a bacterial infection, such as an ear infection, sinus infection, or pneumonia. Having your child’s tonsils removed doesn’t help because colds are not caused by infected tonsils. Nor are they caused by poor diet. lack of vitamins, bad weather, air conditioners, or wet feet. Remember, the best time to have these inevitable infections and develop immunity is during childhood.

About sinus infections

It is mostly about duration of symptoms AND not improving.  We start to consider the possibility of a sinus infection when a child has a runny nose and cough for 10-14 days AND not improving.  Color does not matter.  You can have a clear runny nose with a sinus infection and a yellow green runny nose with a viral infection.  Sometimes this can seem like a sinus infection when a few illness are running back to back.  Look for the subtle clues.  (e.g. runny nose stopped for a few days, then seemed to come down with new symptoms and less eating or activity).  Certain infections need antibiotics immediately (e.g. pneumonia).  You can be patient with concerns over a runny nose signifying a sinus infection.  Some will get better and and not need antibiotics.      

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