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What Italian Pediatricians Can Tell Us What Italian Pediatricians Can Tell Us
(about 5 hours later)
Last week I took part in an online conversation in which a large group of American pediatricians listened as some of our colleagues from Italy talked about pediatrics in the coronavirus crisis, because what they are dealing with there is what we will be dealing with here very soon.Last week I took part in an online conversation in which a large group of American pediatricians listened as some of our colleagues from Italy talked about pediatrics in the coronavirus crisis, because what they are dealing with there is what we will be dealing with here very soon.
We Americans were hoping we could learn from our Italian colleagues, who are further along in handling this epidemic.We Americans were hoping we could learn from our Italian colleagues, who are further along in handling this epidemic.
On Feb. 23, several Italian towns were quarantined, with what then looked like fairly severe measures, and some large events — including Carnival in Venice — were canceled.On Feb. 23, several Italian towns were quarantined, with what then looked like fairly severe measures, and some large events — including Carnival in Venice — were canceled.
By March 4, schools and universities were closed, and by March 9, the whole country was on lockdown, which has grown progressively more stringent, with factories and “nonessential businesses” closing, with roadblocks stopping cars, and with many regions closing parks and outdoor areas as well.By March 4, schools and universities were closed, and by March 9, the whole country was on lockdown, which has grown progressively more stringent, with factories and “nonessential businesses” closing, with roadblocks stopping cars, and with many regions closing parks and outdoor areas as well.
“We are all facing something new and unknown, and also rapidly changing, for which we don’t have durable protocols,” Dr. Federica Zanetto, a family pediatrician who works near Milan, one of the areas where the pandemic is most severe, wrote in an email. “I went to reread the communications of three weeks ago,” she wrote, and the situation has changed so rapidly, “we seem to be catapulted into another world.”“We are all facing something new and unknown, and also rapidly changing, for which we don’t have durable protocols,” Dr. Federica Zanetto, a family pediatrician who works near Milan, one of the areas where the pandemic is most severe, wrote in an email. “I went to reread the communications of three weeks ago,” she wrote, and the situation has changed so rapidly, “we seem to be catapulted into another world.”
Dr. Giorgio Tamburlini, a friend who is a pediatrician and epidemiologist who directs the Centro per la Salute del Bambino Onlus (Center for Child Health and Development) in Trieste, sent me a piece he had written called, “The (precious) Time of the Coronavirus.” We have to find ways to answer children’s questions and address their fears, he wrote, but we also must make a virtue of necessity in how parents spend this time with their children.Dr. Giorgio Tamburlini, a friend who is a pediatrician and epidemiologist who directs the Centro per la Salute del Bambino Onlus (Center for Child Health and Development) in Trieste, sent me a piece he had written called, “The (precious) Time of the Coronavirus.” We have to find ways to answer children’s questions and address their fears, he wrote, but we also must make a virtue of necessity in how parents spend this time with their children.
In Italy, as everywhere, the coronavirus has been hardest by far on the elderly. Pediatric patients, for the most part, have not been terribly ill; in pediatrics there is no comparison medically to the acuity — and the danger — faced by those who are tending adults, managing ventilators on the front lines.In Italy, as everywhere, the coronavirus has been hardest by far on the elderly. Pediatric patients, for the most part, have not been terribly ill; in pediatrics there is no comparison medically to the acuity — and the danger — faced by those who are tending adults, managing ventilators on the front lines.
But pediatricians and parents are still worried, of course, about how the children are doing and about what kinds of dangers may loom even for this population which is — thank goodness — relatively safe from severe Covid-19 disease.But pediatricians and parents are still worried, of course, about how the children are doing and about what kinds of dangers may loom even for this population which is — thank goodness — relatively safe from severe Covid-19 disease.
So for three weeks now, these Italian colleagues have been trying to provide medical care for children while having a minimum of contact with them. As most pediatric practices are now doing here in the United States, they are trying to keep children out of medical offices and clinics. Essential vaccines are still being given (nobody wants to see one pandemic complicated by the emergence of other infections which could have been prevented).So for three weeks now, these Italian colleagues have been trying to provide medical care for children while having a minimum of contact with them. As most pediatric practices are now doing here in the United States, they are trying to keep children out of medical offices and clinics. Essential vaccines are still being given (nobody wants to see one pandemic complicated by the emergence of other infections which could have been prevented).
“Our main task at the moment is supporting families,” wrote Dr. Zanetto. “Every day more and more parents are infected or have relatives infected.” The pediatricians reinforce the importance of the government recommendation about staying home, and direct parents toward correct and authoritative information about the epidemic, and away from what she called “fake and disturbing news crowding social media.”“Our main task at the moment is supporting families,” wrote Dr. Zanetto. “Every day more and more parents are infected or have relatives infected.” The pediatricians reinforce the importance of the government recommendation about staying home, and direct parents toward correct and authoritative information about the epidemic, and away from what she called “fake and disturbing news crowding social media.”
My friend and colleague Dr. Stefania Manetti practices in Southern Italy as a family pediatrician, in a town not far from Naples, in a region of the country which has so far been relatively spared. The children she takes care of have been locked in at home for three weeks, with drones and the military deployed to make sure there are no gatherings.My friend and colleague Dr. Stefania Manetti practices in Southern Italy as a family pediatrician, in a town not far from Naples, in a region of the country which has so far been relatively spared. The children she takes care of have been locked in at home for three weeks, with drones and the military deployed to make sure there are no gatherings.
People can go out for health care, but that is meant to be a last resort; like many pediatricians in the United States now, Dr. Manetti is mostly attending to her patients by telephone and video conference; for vaccines, she can refer them to the public health office where vaccines are given — though some parents are afraid to take their children out.People can go out for health care, but that is meant to be a last resort; like many pediatricians in the United States now, Dr. Manetti is mostly attending to her patients by telephone and video conference; for vaccines, she can refer them to the public health office where vaccines are given — though some parents are afraid to take their children out.
Many parents are calling her, she said, because their children are having trouble sleeping — in fact, she switched from telephone visits to video conferencing because she wanted to be able to look people in the face while discussing the anxieties that are turning into sleep disturbances, loss of appetite, stomach aches and other physical symptoms.Many parents are calling her, she said, because their children are having trouble sleeping — in fact, she switched from telephone visits to video conferencing because she wanted to be able to look people in the face while discussing the anxieties that are turning into sleep disturbances, loss of appetite, stomach aches and other physical symptoms.
“We have a lot of somatization,” she said, using a term that usually means the emergence — or expression — of anxiety or depression as a physical symptom. “They keep going to the bathroom, they have abdominal pain, all these things.”
Updated June 22, 2020Updated June 22, 2020
A commentary published this month on the website of the British Journal of Sports Medicine points out that covering your face during exercise “comes with issues of potential breathing restriction and discomfort” and requires “balancing benefits versus possible adverse events.” Masks do alter exercise, says Cedric X. Bryant, the president and chief science officer of the American Council on Exercise, a nonprofit organization that funds exercise research and certifies fitness professionals. “In my personal experience,” he says, “heart rates are higher at the same relative intensity when you wear a mask.” Some people also could experience lightheadedness during familiar workouts while masked, says Len Kravitz, a professor of exercise science at the University of New Mexico.A commentary published this month on the website of the British Journal of Sports Medicine points out that covering your face during exercise “comes with issues of potential breathing restriction and discomfort” and requires “balancing benefits versus possible adverse events.” Masks do alter exercise, says Cedric X. Bryant, the president and chief science officer of the American Council on Exercise, a nonprofit organization that funds exercise research and certifies fitness professionals. “In my personal experience,” he says, “heart rates are higher at the same relative intensity when you wear a mask.” Some people also could experience lightheadedness during familiar workouts while masked, says Len Kravitz, a professor of exercise science at the University of New Mexico.
The steroid, dexamethasone, is the first treatment shown to reduce mortality in severely ill patients, according to scientists in Britain. The drug appears to reduce inflammation caused by the immune system, protecting the tissues. In the study, dexamethasone reduced deaths of patients on ventilators by one-third, and deaths of patients on oxygen by one-fifth.The steroid, dexamethasone, is the first treatment shown to reduce mortality in severely ill patients, according to scientists in Britain. The drug appears to reduce inflammation caused by the immune system, protecting the tissues. In the study, dexamethasone reduced deaths of patients on ventilators by one-third, and deaths of patients on oxygen by one-fifth.
The coronavirus emergency relief package gives many American workers paid leave if they need to take time off because of the virus. It gives qualified workers two weeks of paid sick leave if they are ill, quarantined or seeking diagnosis or preventive care for coronavirus, or if they are caring for sick family members. It gives 12 weeks of paid leave to people caring for children whose schools are closed or whose child care provider is unavailable because of the coronavirus. It is the first time the United States has had widespread federally mandated paid leave, and includes people who don’t typically get such benefits, like part-time and gig economy workers. But the measure excludes at least half of private-sector workers, including those at the country’s largest employers, and gives small employers significant leeway to deny leave.The coronavirus emergency relief package gives many American workers paid leave if they need to take time off because of the virus. It gives qualified workers two weeks of paid sick leave if they are ill, quarantined or seeking diagnosis or preventive care for coronavirus, or if they are caring for sick family members. It gives 12 weeks of paid leave to people caring for children whose schools are closed or whose child care provider is unavailable because of the coronavirus. It is the first time the United States has had widespread federally mandated paid leave, and includes people who don’t typically get such benefits, like part-time and gig economy workers. But the measure excludes at least half of private-sector workers, including those at the country’s largest employers, and gives small employers significant leeway to deny leave.
So far, the evidence seems to show it does. A widely cited paper published in April suggests that people are most infectious about two days before the onset of coronavirus symptoms and estimated that 44 percent of new infections were a result of transmission from people who were not yet showing symptoms. Recently, a top expert at the World Health Organization stated that transmission of the coronavirus by people who did not have symptoms was “very rare,” but she later walked back that statement.So far, the evidence seems to show it does. A widely cited paper published in April suggests that people are most infectious about two days before the onset of coronavirus symptoms and estimated that 44 percent of new infections were a result of transmission from people who were not yet showing symptoms. Recently, a top expert at the World Health Organization stated that transmission of the coronavirus by people who did not have symptoms was “very rare,” but she later walked back that statement.
Touching contaminated objects and then infecting ourselves with the germs is not typically how the virus spreads. But it can happen. A number of studies of flu, rhinovirus, coronavirus and other microbes have shown that respiratory illnesses, including the new coronavirus, can spread by touching contaminated surfaces, particularly in places like day care centers, offices and hospitals. But a long chain of events has to happen for the disease to spread that way. The best way to protect yourself from coronavirus — whether it’s surface transmission or close human contact — is still social distancing, washing your hands, not touching your face and wearing masks.Touching contaminated objects and then infecting ourselves with the germs is not typically how the virus spreads. But it can happen. A number of studies of flu, rhinovirus, coronavirus and other microbes have shown that respiratory illnesses, including the new coronavirus, can spread by touching contaminated surfaces, particularly in places like day care centers, offices and hospitals. But a long chain of events has to happen for the disease to spread that way. The best way to protect yourself from coronavirus — whether it’s surface transmission or close human contact — is still social distancing, washing your hands, not touching your face and wearing masks.
A study by European scientists is the first to document a strong statistical link between genetic variations and Covid-19, the illness caused by the coronavirus. Having Type A blood was linked to a 50 percent increase in the likelihood that a patient would need to get oxygen or to go on a ventilator, according to the new study.A study by European scientists is the first to document a strong statistical link between genetic variations and Covid-19, the illness caused by the coronavirus. Having Type A blood was linked to a 50 percent increase in the likelihood that a patient would need to get oxygen or to go on a ventilator, according to the new study.
The unemployment rate fell to 13.3 percent in May, the Labor Department said on June 5, an unexpected improvement in the nation’s job market as hiring rebounded faster than economists expected. Economists had forecast the unemployment rate to increase to as much as 20 percent, after it hit 14.7 percent in April, which was the highest since the government began keeping official statistics after World War II. But the unemployment rate dipped instead, with employers adding 2.5 million jobs, after more than 20 million jobs were lost in April.The unemployment rate fell to 13.3 percent in May, the Labor Department said on June 5, an unexpected improvement in the nation’s job market as hiring rebounded faster than economists expected. Economists had forecast the unemployment rate to increase to as much as 20 percent, after it hit 14.7 percent in April, which was the highest since the government began keeping official statistics after World War II. But the unemployment rate dipped instead, with employers adding 2.5 million jobs, after more than 20 million jobs were lost in April.
States are reopening bit by bit. This means that more public spaces are available for use and more and more businesses are being allowed to open again. The federal government is largely leaving the decision up to states, and some state leaders are leaving the decision up to local authorities. Even if you aren’t being told to stay at home, it’s still a good idea to limit trips outside and your interaction with other people.States are reopening bit by bit. This means that more public spaces are available for use and more and more businesses are being allowed to open again. The federal government is largely leaving the decision up to states, and some state leaders are leaving the decision up to local authorities. Even if you aren’t being told to stay at home, it’s still a good idea to limit trips outside and your interaction with other people.
Common symptoms include fever, a dry cough, fatigue and difficulty breathing or shortness of breath. Some of these symptoms overlap with those of the flu, making detection difficult, but runny noses and stuffy sinuses are less common. The C.D.C. has also added chills, muscle pain, sore throat, headache and a new loss of the sense of taste or smell as symptoms to look out for. Most people fall ill five to seven days after exposure, but symptoms may appear in as few as two days or as many as 14 days.Common symptoms include fever, a dry cough, fatigue and difficulty breathing or shortness of breath. Some of these symptoms overlap with those of the flu, making detection difficult, but runny noses and stuffy sinuses are less common. The C.D.C. has also added chills, muscle pain, sore throat, headache and a new loss of the sense of taste or smell as symptoms to look out for. Most people fall ill five to seven days after exposure, but symptoms may appear in as few as two days or as many as 14 days.
If air travel is unavoidable, there are some steps you can take to protect yourself. Most important: Wash your hands often, and stop touching your face. If possible, choose a window seat. A study from Emory University found that during flu season, the safest place to sit on a plane is by a window, as people sitting in window seats had less contact with potentially sick people. Disinfect hard surfaces. When you get to your seat and your hands are clean, use disinfecting wipes to clean the hard surfaces at your seat like the head and arm rest, the seatbelt buckle, the remote, screen, seat back pocket and the tray table. If the seat is hard and nonporous or leather or pleather, you can wipe that down, too. (Using wipes on upholstered seats could lead to a wet seat and spreading of germs rather than killing them.)If air travel is unavoidable, there are some steps you can take to protect yourself. Most important: Wash your hands often, and stop touching your face. If possible, choose a window seat. A study from Emory University found that during flu season, the safest place to sit on a plane is by a window, as people sitting in window seats had less contact with potentially sick people. Disinfect hard surfaces. When you get to your seat and your hands are clean, use disinfecting wipes to clean the hard surfaces at your seat like the head and arm rest, the seatbelt buckle, the remote, screen, seat back pocket and the tray table. If the seat is hard and nonporous or leather or pleather, you can wipe that down, too. (Using wipes on upholstered seats could lead to a wet seat and spreading of germs rather than killing them.)
If you’ve been exposed to the coronavirus or think you have, and have a fever or symptoms like a cough or difficulty breathing, call a doctor. They should give you advice on whether you should be tested, how to get tested, and how to seek medical treatment without potentially infecting or exposing others.If you’ve been exposed to the coronavirus or think you have, and have a fever or symptoms like a cough or difficulty breathing, call a doctor. They should give you advice on whether you should be tested, how to get tested, and how to seek medical treatment without potentially infecting or exposing others.
If you’re sick and you think you’ve been exposed to the new coronavirus, the C.D.C. recommends that you call your healthcare provider and explain your symptoms and fears. They will decide if you need to be tested. Keep in mind that there’s a chance — because of a lack of testing kits or because you’re asymptomatic, for instance — you won’t be able to get tested.If you’re sick and you think you’ve been exposed to the new coronavirus, the C.D.C. recommends that you call your healthcare provider and explain your symptoms and fears. They will decide if you need to be tested. Keep in mind that there’s a chance — because of a lack of testing kits or because you’re asymptomatic, for instance — you won’t be able to get tested.
“We have a lot of somatization,” she said, using a term that usually means the emergence — or expression — of anxiety or depression as a physical symptom. “They keep going to the bathroom, they have abdominal pain, all these things.”
The bedtime advice in Italy — as here — is to minimize the child’s exposure to news, to do quiet and pleasant activities for an hour or two before bedtime, reading books, listening to music, playing quiet games. “It must be a moment where the child has to be calm before going to sleep, a moment when he switches off,” Dr. Manetti said. “The children are afraid of switching off, they don’t know what will happen when they switch off.”The bedtime advice in Italy — as here — is to minimize the child’s exposure to news, to do quiet and pleasant activities for an hour or two before bedtime, reading books, listening to music, playing quiet games. “It must be a moment where the child has to be calm before going to sleep, a moment when he switches off,” Dr. Manetti said. “The children are afraid of switching off, they don’t know what will happen when they switch off.”
There are families, she said, who have found some positive aspects to being home together, but that’s much harder when parents are anxious about their jobs and their economic prospects. “If there’s a stressor in the family, it’s extremely difficult” to follow the advice about engaging children, distracting children, caring for children. “These families have to be economically sustained somehow.” These are also questions that American pediatricians are realizing we must address.There are families, she said, who have found some positive aspects to being home together, but that’s much harder when parents are anxious about their jobs and their economic prospects. “If there’s a stressor in the family, it’s extremely difficult” to follow the advice about engaging children, distracting children, caring for children. “These families have to be economically sustained somehow.” These are also questions that American pediatricians are realizing we must address.
How does she suggest that parents talk with their children about the coronavirus? “I tell them, as I do in other situations, that children need to know facts in a simple, clear way, and they also need to know that parents are there to support them,” Dr. Manetti said. And it’s not a one-time conversation, she said. “What you explain to a child has to be reinforced,” she said, comparing it to when a child asks questions about a book you read, and some days later you read the same book again, and the child asks the same questions.How does she suggest that parents talk with their children about the coronavirus? “I tell them, as I do in other situations, that children need to know facts in a simple, clear way, and they also need to know that parents are there to support them,” Dr. Manetti said. And it’s not a one-time conversation, she said. “What you explain to a child has to be reinforced,” she said, comparing it to when a child asks questions about a book you read, and some days later you read the same book again, and the child asks the same questions.
A couple of days ago, Dr. Tamburlini sent me another piece that he had written, about acknowledging the deaths of grandparents. In Italy, with a culture legendary for close family ties, the epidemic has devastated the grandparental and great-grandparental generations. “Ciao, Nonno,” the essay began — a phrase that can mean either “Hi, Grandpa” or “Goodbye, Grandpa.”A couple of days ago, Dr. Tamburlini sent me another piece that he had written, about acknowledging the deaths of grandparents. In Italy, with a culture legendary for close family ties, the epidemic has devastated the grandparental and great-grandparental generations. “Ciao, Nonno,” the essay began — a phrase that can mean either “Hi, Grandpa” or “Goodbye, Grandpa.”
“We have a double tragedy,” he said. “Most of the people who die are the elderly, and most of these people die without being assisted by the family, due to the absolute emergency in the hospital, and then can’t even have a funeral.” Families need to find ways to explain this to children, he said, and they need to find ways to acknowledge, salute and celebrate the people they are losing.“We have a double tragedy,” he said. “Most of the people who die are the elderly, and most of these people die without being assisted by the family, due to the absolute emergency in the hospital, and then can’t even have a funeral.” Families need to find ways to explain this to children, he said, and they need to find ways to acknowledge, salute and celebrate the people they are losing.
“You have to talk to children, you cannot leave children with their fears,” he said. “It’s better to talk rather than avoid talking.”“You have to talk to children, you cannot leave children with their fears,” he said. “It’s better to talk rather than avoid talking.”
“We will return, sooner or later, to the life of before,” Dr. Tamburlini wrote. “Or rather, it will no longer be the same as before. For many reasons — but also because we will have discovered a kind of time … time to fill, or to let flow by, more slowly than usual. With our children. That they will remember.”“We will return, sooner or later, to the life of before,” Dr. Tamburlini wrote. “Or rather, it will no longer be the same as before. For many reasons — but also because we will have discovered a kind of time … time to fill, or to let flow by, more slowly than usual. With our children. That they will remember.”