Health Matters Today Episode 1: Back to School

In the first episode of our new podcast Health Matters Today, our experts talk about schools reopening during the COVID-19 pandemic and provide their advice for maintaining the physical and mental well-being of both kids and grown-ups.

Our panel includes:

• Dr. Edith Bracho-Sanchez, director of pediatric telemedicine at NewYork-Presbyterian’s Ambulatory Care Network
• Dr. Steven Kernie, chief of pediatric critical care and hospital medicine at NewYork-Presbyterian Morgan Stanley Children’s Hospital
• Dr. Christine Salvatore, chief of pediatric infectious diseases at NewYork-Presbyterian Komansky Children’s Hospital
• Dr. Mary Ward, child psychologist at NewYork-Presbyterian Komansky Children’s Hospital.

Sharon Cotliar: Welcome to Health Matters Today. I’m Sharon Cotliar, the editorial director at NewYork-Prebyterian. On today’s podcast, we’ll explore the topic of children returning to school amid the COVID-19 pandemic. We know it’s been an anxious few months for many parents, with so many unknowns about the school year and so many seemingly impossible decisions to make. To help answer some of your questions and hopefully provide some comfort in these challenging times, we’ve assembled a panel of four leading pediatric experts from NewYork-Presbyterian. We’ll ask our experts about the health risks of children returning to school. We’ll also ask them to address the social-emotional impact of remote learning versus attending school in person.

Thank you, everyone for joining us.

I’ll start by asking our panel to please briefly introduce yourselves to our listeners.

Dr. Steven Kernie: Sure. Steve Kernie. I’m the Chief of Critical Care and Hospital Medicine for the Morgan Stanley Children’s Hospital.

Dr. Edith Bracho-Sanchez: And I am Edith Bracho-Sanchez, a primary care pediatrician, assistant professor of pediatrics at Columbia and medical director of pediatric telemedicine in the Ambulatory Care Network at NewYork-Presbyterian.

Dr. Christine Salvatore: My name is Christine Salvatore. I am the chief of pediatric infectious diseases at the Weill Cornell campus. I’m associate professor of medical pediatrics and an associate attending at NewYork-Presbyterian.

Dr. Mary Ward: I’m Mary Ward on the pediatric faculty at NewYork-Presbyterian/Weill Cornell.

Sharon Cotliar: Thank you Dr. Ward. I’ll also add that you’re a child psychologist and specialize in developmental and behavioral pediatrics.

I want to start with Dr. Kernie, our critical care doctor. You treated children with COVID and COVID-related illnesses. With health being top of mind for parents, could you tell us what you saw? And what you think parents should know as their kids go back to school?

Dr. Steven Kernie: Thanks Sharon. Um. Yes. There are certainly a subset of kids who get infected with the SARS-CoV-2 virus who will get disease. You know, there’s two kinds of disease that we’ve seen. One is primary COVID-19 infection that’s more associated with adults and older people and it causes bad respiratory illness. We have seen very few children with that. Even at the height of the pandemic. There were very few otherwise normal or even children with some chronic medical disorders — it was rare to see either of those categories of kids with severe illness.

Now, the secondary illness that we saw and we saw a fair bit of, this multi-system inflammatory syndrome felt to be due to COVID-19, is an inflammatory disease that comes up after the primary infection. We saw many more children with this, but again, no children died from it, at least at our institution. We saw nearly 100 of them. It was pretty self-limited, responded well to treatment and those kids are doing well.

It’s rare that children get bad disease. It can happen, but it’s clearly quite treatable. I think more of the concern about children going to school is really about the potential to carry infection and potentially get infection and be asymptomatic and transmit it to other family members, particularly others who might be more susceptible to having severe disease. And that’s something we just don’t know a lot about yet, even though we know, I think, now a fair bit of how children themselves react to infection.

Sharon Cotliar: You raise a great point about that concern of transmission. I know New York City has maintained a low positivity rate for more than a month. So let me ask Dr. Salavtore, knowing the numbers in New York City, how are you viewing this school year and what are you advising parents?

Dr. Christine Salvatore: I have a 4-year-old. He is going to the playground and I let him go. Their development actually can be affected in my opinion if we really don’t let them play and be normal children.

So that’s why I make the comparison with my kid and I’m saying I want them to go in person in school, I want them to go to the playgrounds now. Of course you have to educate washing hands because that’s important at any stage. That is something that we have to try to implement and teach them the reason for doing that. And there are many studies, that show, especially from the Asian countries that they kept open or re-opened the schools much earlier than we did and especially there is a study from Australia that did actually show that there was one positive kid and none of the teachers and none of the other children got infected in the entire school. And this shows that really the incidence in this age group is minimal.

Even when we were at the peak, the incidence and the prevalence in the pediatric population of the infection was really relatively low, less susceptibility, less severe disease. So that, of course, has to be reassuring for parents.

The other important thing that I always tell them, that we have to distinguish a little bit between age groups. Kids probably less than 10, 12 are catching it way less instead of the other ones, probably above 12, they are comparable probably with the adults. Of course, now it depends what child you have, middle school and high school or one who is in pre-K or the elementary school.

I tell the parents you need to know what your school has implemented because that is very important. They have to have a plan in place that has to be flexible, things change. And so schools have to be prepared, also, to open their mind and say what we did last week is not right, then we have to change that.

Sharon Cotliar: And Dr. Kernie, I know you’re a parent and your wife is a preschool teacher, so you’re really in the throes of this. Could you share how you’re making these decisions in your family?

Dr. Steven Kernie: My personal history is I’ve got three children. Two of them are quasi-adults, but they’re not in school. Our youngest child who’s in high school who has special needs has been going to school, in-person school during the summer. His school district had three hours a day, five days a week. We were anxious to get him back in school because he really thrives in that environment and he was anxious to go back, so we really didn’t have a lot of reservations about sending him back for the summer and he’ll be going back full-time, kind of full school days. His situation is a little unique because there’s already good social distancing and things and the kids are older and really are in general pretty good about abiding by masking and things like that. And certainly our son is.

My wife’s situation is different. She’s a preschool teacher and her preschool is opening. But those — you know try to stick masks on a bunch of 3-year-olds. I mean, it’s just not going to happen, at least in an effective way. And it goes back to what Dr. Salvatore said, though, and I have been talking to both my wife and the other teachers at school. Those preschools need to be open if they possibly can and again, the risks if there are some, which we don’t know, there may be, but I think they’re really more attributed to the fact that those kids could transmit it to each other and potentially transmit it to the parents, grandparents and things like that.

We need to have a lot of mechanisms in place to prevent that if it does happen, but I do believe it’s important to get those kids back in school and going again back to Dr. Salvatore’s point, particularly in the New York area where there is so little endemic disease right now. I do believe it’s safe with, you know, monitoring and precautions and everything else we’ve been talking about.

Sharon Cotliar: That’s really reassuring to hear. Dr. Bracho-Sanchez, I’m curious to hear your perspective as a primary care pediatrician. You see so many families at your practice and I know you help them understand risks and make decisions based on the facts. What are the important factors you tell parents to consider?

Dr. Edith Bracho-Sanchez: Yeah, so I would say throughout this pandemic I have viewed my role as sort of supporting and listening to every family’s unique situation, while at the same time, providing them with whatever data we have. So I think the school decision and whether to send kids back to school in person is an extension of that, right?

For some families, they may live in a multigenerational household and have an elderly grandmother who has an underlying medical condition and if she gets COVID-19 could be at very high-risk. So for that family, that fear and that risk is real and so we can reassure them and say the current rates of circulating virus in New York City is very low. We can look into whatever precautions the school has put into place as layers of protection. But at the end of the day, I think each family’s circumstances are different and I think it’s our role and our responsibility to try to support them in whatever decision they make and help them feel good about whatever decision they make and see if we can help that child thrive in whatever environment the family has picked, right, because at this point in time, there’s no right or wrong answer.

I would say, which both Dr. Salvatore and Dr. Kernie mentioned already, there are important time-sensitive things that kids pick up from school that are not just education. And I call them time-sensitive because it really is time-sensitive. There are certain skills that go beyond learning math and reading, right? It’s, you know, waiting your turn and it’s socializing with everybody else and it’s following rules of a classroom. Those things that you can’t really — you can try and of course, parents have been trying their best to try to enact some of those rules and get kids, sort of, to sit for a while and to wait their turn and follow certain rules. But it’s not exactly the same and I also agree that for the youngest kids that’s the most important.

Sharon Cotliar: I know many parents would agree. Learning those skills is definitely important, but what about the people who might argue that going to school right now in this environment, with the distancing and precautions, is not really the same experience? Your child might not get to play with a big group of kids at recess, or do things in class that they might ordinarily do if we weren’t facing a pandemic. Dr. Bracho-Sanchez, do you feel that even with this changed school experience, it is still critical that they try to attend in person?

Dr. Edith Bracho-Sanchez: Yes. My answer is definitely yes. Really because of what we’re talking about with the sitting for a long period of time, the waiting your turn, the following the rules. Like, those skills kids don’t learn somewhere else. You know, a lot of parents, they’ve actually asked me the same question that you’re asking me. How are they going to socialize from six feet apart? Kids do socialize from six feet apart. We as adults wonder how are they going to interact and socialize? I mean, it’s distance, but it’s really not that much of a distance when you think about socializing, especially for small kids. And remember also, that I think a lot of schools are going to be implementing the cohorting with the pods as they call them. I’ve heard them called a number of things, but I think if you have a small enough classroom, if kids are really sticking to that classroom and you can enact it in that way, then it becomes safer if you’ve enacted all the other policies, of course, and if the virus that is circulating in the community is low, then I think it becomes safer and it allows kids some freedom within their little cohort of other kids.

Sharon Cotliar: Okay. So, this feels like a great opportunity to segue and talk a bit more about the social-emotional impact of the pandemic on children. Dr. Ward, as a child psychologist, how do you view this current crisis and the necessity of returning to an in-class experience, especially for the younger children?

Dr. Mary Ward: I think we are in the historical phase of this pandemic, whereas all of my colleagues have suggested, we’re beginning to recognize the unintended consequences of the isolation orders that went into place in March and from a clinical standpoint, I would say overall, I give families an enormous amount of credit for how well they’ve done in supporting their children through all of these changes and all of these stressors. In general, I plead with parents to be patient with themselves and patient with their children.

That said, there is a frightening level of mental health challenges that are basically unseen. The children that we all see are those who have ready access to care, who have no concerns about coming in for care and who can feel comfortable saying to a professional this is a stressor for our family. But that does not cover all kids. I think those of us who are advocates for children have to speak strongly and loudly about what is happening to children.

Kids are resilient. Kids can adapt to changes and eventually they will learn again, but I worry greatly about children whose parents don’t have the resources to assure they have a learning pod or a tutor or online resources and so forth.

And then finally, the family strife is significant. Parents being thrust into the role of doing the work that Dr. Kernie’s wife is expert in doing or my colleagues are expert in doing. Parents feel that they are not up to the task. They feel highly stressed. I strongly advocate and support the position of the American Academy of Pediatrics, saying that we should be doing everything humanly possible to get children back to school. As my colleagues have suggested, children belong with professional educators and they belong with their peers. That is the work of children and we have taken that away from them for the past almost six months and it’s our responsibility as adults to find a way to get them back where they belong.

Sharon Cotliar: Well, I know all parents are striving for that. Dr. Bracho-Sanchez, given your work with underserved communities, I imagine you share Dr. Ward’s concerns about the importance of getting kids back in school. What kind of challenges do at-risk populations face when it comes to whether or not to attend school in person?

Dr. Edith Bracho-Sanchez: I think an important thing to remember is that some of these parents truly have no choice. They need to work and if they don’t work, they don’t get paid for the day because there is no sick paid leave for some of our families. And so they are really scared. They’re terrified to send their kids to school. No matter how much I’ve reassured them, they’re really scared to send their kids to school and some of this has to do with they’ve seen COVID up and close, right? Sometimes in their household, sometimes in their communities. And so we also have to remember that these parents are scared, as we’re guiding them through some of these things.

Again, I think we’ve all alluded this, but the mental health aspect of things. Some of the kids in these vulnerable communities are coming to school and back to school potentially very likely behind from their peers because spring semester came to a very abrupt end and because the summer has been difficult for some of our families. And I think some of them may continue to struggle a little bit because their parents may not be able to provide the level of support that other parents are providing and they themselves may have witnessed some level of illness, some level of food insecurity in their household, even housing insecurity in their household that some of their peers may not have witnessed.

All of these things, we just have to remember that families are bringing with them and are taking into account when making decisions and the kids are bringing with them to school even if we can’t always see it.

Sharon Cotliar: I’m really glad you raised that. Dr. Ward, I want to stay on this topic of mental health and social-emotional well-being. This is obviously really important and as a child psychologist, I wonder, what advice can you offer parents about what they can do to try to combat the lack of normalcy and restore it to the best of their ability?

Dr. Mary Ward: Two major pieces of advice: The first is for adults to find support with other adults so that they can clearly maintain generational boundaries. It’s a little bit of a jargony term, so let me just emphasize what that means. It means that there are certain topics and certain ways of explaining things, certain expressions of experience that belong with other adults, are not the concerns of children and indeed are overly burdensome for children.

So if I, as a parent, if I am feeling anxious and uncertain and worried, I should not be sharing that with my young child. Children cannot process that information and the way all of my colleagues have spoken about their own children, that’s what they did. They made decisions based on the child’s need and they told the child this was what was going to happen. So I cannot emphasize enough the importance of assuring that adults are supported in sharing their fears and anxieties and upset with other adults.

The second of these issues is assuring, taking all possible measures to assure that there is peace within the family even at the expense of school, at the expense of activities, at the expense of neighbors and friends, assuring that peace reigns within the family. That often means cutting way back on other activities. It means setting priorities about what will maintain peace in the family that is at the core of children’s well-being. If there is peace within their home and they feel confident that their parents are in charge, children can withstand a lot. Children are resilient, children are strong and children are fine when they feel safe.

Sharon Cotliar: That’s such a good point. That feeling of security is so important for children, especially in such an uncertain time. Dr. Kernie, what guidance could you offer to other parents so that maybe they could feel a sense of peace?

Dr. Steven Kernie: You know, we’re all learning in this process. I really appreciate Dr. Ward’s point around keeping that family dynamic productive. In other words, having peace within the family, which to us has really meant keeping as many routines together that you can, but also, just realizing that we all need to be a little more flexible. I think we all need to be a little more kind and understanding than we might otherwise be.

The other point that I’d really like to make is I don’t believe this is the new normal. I believe we are going to get back to a time where kids just go to school and play with each other and they don’t wear masks and they don’t distance. And we need to keep it in perspective. It seems like we’ve been doing this for a long time and we have, but we’re not going to do this forever. And so I do believe people and families need to keep the perspective that we’ve gotten used to a new way of life, but it’s not permanent and we will get through this.

Sharon Cotliar: That is important to remember, to keep everything in perspective and remember that this won’t last forever. Of course, at the core of this is a real concern about health. So I want to turn to Dr. Salvatore. What counsel would you offer to parents?

Dr. Christine Salvatore: Try not to scare the kids, especially the younger ones. I think sometimes unconsciously they put some fear in these children, as well, and of course, that is something that I advise trying not to do. Try live the situation like Dr. Kernie said.

For example, for me, I have a 4-year-old. I didn’t tell him anything really. He seems the happiest thing in this world, has no idea what’s going on. And I heard some of the kids, they don’t want to go out. They want to stay home because they are scared. So I see the perspective from an infectious diseases doctor, but also, as a mom. And so that is one of the things that I would advise. Try to make the situation simple, especially now. Try to be as much natural as possible and try to encourage them to do the best instead in school.

Dr. Mary Ward: I think this is a good place to come back to a point that Christine made in the very beginning and that is you need to distinguish what you say based on the child’s age. She talked about distinguishing age groups from the standpoint of infectivity, but for very young children, very simple explanations are the best. And if they say why are we wearing masks? Because that’s what we’re told to do. That’s what we do. Why are we not hugging our friends? Because that’s what we’re told to do. For families who want to give a little bit more information, saying something very simple like “the virus was out there and we wanted to keep everyone safe, so we’re being very careful.”

I have a 3-year-old granddaughter and that’s what her mother told her without checking with me because I probably wouldn’t have said it. But when I tell you she is utterly unconcerned because she was not burdened with more information than she could manage. Again, for early school age children, the very basics is all they need. I’m advocating strongly for restricting children’s free access to the internet, letting parents decide what they’re allowed to read and they’re allowed to hear about and certainly for children under 12. And then the early teens perhaps giving them a bit more information that they’ll be able to only discuss with their parents and then with teenagers, offering them more balance, older teenagers 16 and up.

The last thing I want to say is a huge issue is the age-appropriate sense of invincibility that you see in adolescents. The sense that it’s never going to happen to me. I’m going to be fine. Throughout the country, we’re seeing spikes in college-age populations because they’re not following the rules. So rather than parents getting authoritarian and laying down the law, it’s best to discuss this in a rational way and to talk about the expectable consequences.

If you break the rules and don’t wear your mask and don’t maintain distance and people in your group start getting sick, they’re going to close school. So now you won’t have your school. If you take these measures, you can have it both ways.

Sharon Cotliar: Those are really excellent points, Dr. Ward. Thank you. I want to turn back to Dr. Kernie. I do wonder, given all that is happening, what do you think will happen with outbreaks? We’re already seeing outbreaks on college campuses, as Dr. Ward pointed out. For younger kids, what’s the likelihood of people testing positive and we find ourselves back dealing with at-home schooling regardless of our best efforts.

Dr. Steven Kernie: I think it’s something everybody needs to be prepared for. You know, I’ve said that one of the upsides about going through all this is there are no more snow days, right? Snow days become just learn at home virtual days and that’s probably going to be a permanent effect from the pandemic. And I think going forward at least for the next several months, you know, through the first of next year, I believe most schools will experience the equivalent of snow days, which are that there will be a cluster or there will be a single child or a teacher who tests positive and there needs to be some evaluation around having a break from in-person school, kind of doing the contact tracing, doing all of the things that need to occur to ensure it doesn’t become widespread.

It’s one of the challenges that all the schools will face, but at the same time, I think we know enough now, as opposed to last March and April that this is all very doable and it’s particularly doable in the New York area where there is so little disease. I at least, believe that we will be pretty nimble in our ability to both identify with those little outbreaks and mitigate it. Parents are going to have to be prepared because I think there will be starts and stops. And as best we can, hopefully the learning environment will continue throughout it. As schools have gotten better about being able to do these things virtually and I believe most schools are going to have a virtual component going on all of the time anyway, but the ability to flex between the two will be there. But yeah, everybody needs to be prepared. This is going to happen and it’s probably going to happen relatively soon after school starts. If we’re prepared for that, it won’t be a big surprise. If we get surprised and we don’t have to have those interruptions, that’s going to be great.

Sharon Cotliar: Thank you Dr. Kernie. Dr. Salvatore, what are you anticipating will happen? Do you think we’ll just have interruptions, or snow days, as Dr. Kernie describes them. Or do you think we’ll end up where we were last spring, where people don’t return to school?

Dr. Christine Salvatore: Hopefully nothing is going to happen. But one of the things that is extremely important is in medicine, there is never 100%, ever. We always have to keep in mind that even if we do everything correctly, the parents need to know that we are trying to mitigate as much as possible. It’s possible that we will never be able to completely eliminate.

So can it potentially happen that one child, two children, two adolescents will become positive? Yes. Then of course, we will have to see what is the next step. Is there going to be the need to close the entire school? Hopefully not. If the cohorting, for example, is done correctly, maybe just a couple of kids could be staying at home or maybe just one class.

I would love to anticipate that nothing is going to happen, we will be all happy, they are going to be going to school, they will be happy, we will be happy. But as I said, I do anticipate that there might be some cases in the schools, but I think containment is the best approach, not just canceling everything.

Sharon Cotliar: All the points you all made have been so helpful. And I want to try to end on a hopeful note. There is so much uncertainty and anxiety. Are there any positives? Dr. Kernie, let me start with you.

Dr. Steven Kernie: At this point, it’s a little hard to say enjoy the kind of time you’re getting with your kids because you’ll never quite get this. I have the advantage. I’ve got two young adult children who ended up spending an inordinate amount of time with us and that was really one of the unexpected true blessings of this is the ability to spend some time with your family that you otherwise couldn’t have. And I think keeping that in perspective that will probably never happen again, at least in that context, is something that even when it becomes frustrating and everybody’s tired of it to try to cherish some of those moments that have come about really as an unexpected consequence of all of this.

Sharon Cotliar: That’s great advice and a good reminder that good things can come out of times like these. All right, Dr. Ward, we’ve talked a lot about the mental health of children and their social-emotional well-being. But what advice would you give for parents and their well-being? What should they keep in mind as they approach the school year?

Dr. Mary Ward: I think what everyone has said is this, too, shall pass. That maybe there will be changes that are permanent, maybe not. Maybe we’ll just return to our lives. That’s my dearest hope is that we get our lives back. I think children are best characterized as resilient. That’s what the message has been about their physical health. That’s the message I’ll give you about their mental health. So long as children have their parents available to provide them with information and protection, they’re going to be fine. They’re going to miss their peers. They need peers, but if they live in a home where parents can exercise some kind of control to assure peace, kids are really going to be fine.

Final sort of plea I’ll make is for families who are afraid their children aren’t fine, please reach out to us. We are here to support you. Some very simple changes have seen very positive results with the distress reducing and everybody feeling better. Unless people come to us, we can’t help. And so that’s a really important thing.

Sharon Cotliar: Thank you for that important reminder for parents to seek out support, especially during such a challenging time. I hope you found this to be a conversation helpful and I want to thank our experts again for sharing their knowledge and perspective and for offering parents information as they navigate the beginning of the school year. Dr. Steven Kernie, Dr. Christine Salvatore, Dr. Edith Bracho-Sanchez and Dr. Mary Ward — thank you all so much.

And thanks to all our listeners. And if you’d like to read more of our experts’ recommendations be sure to check out healthmatters.nyp.org