When is someone contagious?

 

When is someone contagious? Some of the most common questions that I get as an advice nurse revolve around when kids are contagious and at what point are they ready to go back to school, daycare or nanny-share. Wouldn’t it be nice if there was a little human equivalent of the butterball turkey pop up timer that could easily signal if someone is contagious or not? Alas that doesn’t exist, so we have to do the best we can. Covid adds a whole extra layer of stress into this discussion. I need to remind everyone that MOST of the illnesses that we are seeing are the same ones that we have been dealing with for generations. Kids who are around other kids get sick. That’s simply the way it is. Of course, we want to be responsible parents and not expose others to our sick child. We also want to protect our own recovering child from going back into the 'germ pool' too quickly. If they are just getting over something, their immune system may be a bit diminished and they are vulnerable to coming down with something new. What makes it even more challenging is that kids aren’t always accurate reporters about how they are feeling. For older kids, some are reluctant to miss school and will put on a brave face. Maybe they have a test that they don’t want to miss, or really want to be with their friends. These kids will push themselves to return as quickly as possible. Others will earn an academy award convincing you that they really need to stay home in bed. Another consideration is that some parents can take time off to stay home with their little sick child and others simply can't afford to. It is naive to think that these aren't real factors.  Early warning signs Many kids may be a little fussier than usual. Perhaps they don't eat quite as much. Most savvy parents know enough to be suspicious when their 5 year old who fights naps with a vengeance announces that they are going up to have a daytime snooze. Your antenna might be up that something is brewing, but are those reasons to miss work and keep your child at home??? It isn’t always an easy answer. Figuring out if someone is contagious or not is almost never clear cut. What makes it all so tricky is that most viral syndromes can be spread a day or two before the kids show clear signs that they are ill. Also, as discussed below, tests for illnesses like covid are not always accurate at the beginning of an illness. The fact is, if your child comes home from school in the afternoon and is sick that evening, most likely everyone they were with earlier that day has already been exposed and I am going to take that into consideration when we try to come up with the most sensible plan on when they can return. Lets address Covid first According to the CDC, the incubation period for Covid-19 is thought to extend up to 14 days, although the average is 5-6 days. This means that if 2 weeks go by after an exposure, you are most likely in the clear. Some young children may catch covid and become infectious without ever exhibiting any symptoms. For those that do develop symptoms, they usually show signs of illness long before that 14 day mark. Testing for Covid There are 2 kinds of tests for Covid. The PCR/NAAT is a very sensitive test that looks for any genetic material on a surface (such as a nostril). You would likely get this test from a doctor's office or lab. These are great to find out if you have COVID or not, but because the DNA fragments can remain in the nostrils for days to weeks, they will still show up as positive even after someone is no longer contagious. This makes them somewhat useless if you are trying to figure out if you can stop your isolation.  The rapid antigen tests are the ones many folks have at home. These tests look for large chunks of virus pieces that are signatures of Covid (the “spike” protein). A negative antigen test in the first day or two is not necessarily accurate because the virus can replicate in other parts of the body (i.e. the throat or bloodstream) without leaving accessible spike proteins in the nose. So if you have been exposed and have symptoms, retest in a couple of days or check with the PCR options before you take that negative test to heart. On the other hand, after the infection if you test negative with the home tests it means you are likely no longer contagious Quarantine versus isolation. Quarantine means staying home after an exposure but before symptoms start. It was common practice at the beginning of the pandemic but is no longer recommended as a strategy for controlling COVID-19. Isolation means staying home and away from others in your household if you have symptoms or you test positive. If you test positive, contact your doctor to see if you should receive treatment. There is no need to isolate from family members who are also testing positive. Here are the 2023 CDC exposure and isolation guidelines If you were exposed but have no symptoms Regardless of your vaccination status: Get tested immediately and 3-5 days after last exposure* Wear a good mask when around others for 10 days after exposure, even at home if other people are present If you test positive, isolate *If you had COVID-19 within the last 30 days: You don’t need to test after exposure unless symptoms start If symptoms start, isolate and get tested If you test positive, whether you have symptoms or not Regardless of your vaccination status or infection history: Isolate for at least 5 days Sleep and stay in a separate room from those not infected Use a separate bathroom if you can Wear a mask around others, even at home You can end isolation early, after Day 5, if: You have no fever for 24 hours without taking fever-reducing medication, AND Your other symptoms are gone or improving If you still have a fever, continue to isolate until the fever is gone for at least 24 hours If other symptoms are not improving, continue to isolate through Day 10 If after Day 10 you still have mild symptoms (runny nose, cough, fatigue) that are improving and no fever, you can end isolation no matter what. After you end isolation: Wear a mask around others for 10 full days after the start of symptoms. If you have no symptoms, wear a mask for 10 full days after your positive test. You may remove your mask sooner than Day 10 if you have two negative tests in a row, at least one day apart.(remember the PCR test will probably still be positive, so use the at home antigen tests) For children who test positive: Children under 2 years can end isolation after Day 5 Children 2 years and older should follow the steps above for ending isolation Okay…Thank you to the CDC for their guidance, but how realistic is it to actually successfully avoid contact with family members? It is very difficult to isolate siblings. Of course be scrupulous with your hand washing, avoid sharing utensils and sloppy wet kisses, but in many cases it is hard to avoid catching each other’s cooties. They were also likely to have been exposed to each other before you knew anyone was sick. If you have a newborn, keeping the sick toddler away from the baby is a worthy goal, but don’t beat yourself up if it is simply not possible. Breastfeeding moms, sorry to say that by the time you realize you are ill, it is too late to prevent an exposure. Hopefully the magic of breast milk will protect your baby, but we would generally suggest that you continue nursing while masked. As an aside, breastfeeding moms, if you are sick, it is especially important to make sure that you are getting plenty of fluids. Also, if you are given medication, check with your nurse or doctor’s office to see if it is compatible with breastfeeding. (spoiler alert: Paxlovid has not been cleared for nursing moms. Tamiflu is probably fine) So how important is it to get an actual diagnosis in the first place/ In other words, is it worth sticking a swab up your toddler’s nose? These days, some doctors rely on symptoms and don’t always bother to test. If you are a candidate for taking Paxlovid then it is worthwhile finding out if you have Covid or not, but some folks don’t bother. If you have an infant or vulnerable family member it is nice to know what you are dealing with. However if you aren’t inclined to test and treat make sure you monitor and if symptoms warrant, make sure you go and get checked.  Coughs, colds and other viruses Most of the illnesses are NOT covid. As far as common colds go, the average child under 2 years of age has EIGHT symptomatic colds a year. Frankly, if you plan on keeping your child at home until your little toddler is free from a runny nose, you will be waiting a very long time before you leave the house. Remember that some clear runny noses are not contagious. Teething as well as some allergies can be the cause. (There is debate about whether or not teething is associated with congestion. Nurse Judy votes yes.) While I would strive to keep my youngest and most vulnerable patients free from viral syndromes and colds as long as possible, exposure to these common viruses is in fact developing the immune system. At some point they are going to have to deal with the myriad of illnesses that make the rounds. During the first couple of years of the pandemic, kids were kept in a bit of a bubble and did not get the normal amount of coughs and colds. Guess what, the minute we got back to being with others and loosened the mask wearing, most families got overwhelmed with all of the respiratory infections. Hand Foot Mouth questions come up a lot.  I respect that schools want to keep this yucky virus from getting spread around. Unless you have been on a break, there is a reasonable chance that the infected kids likely got it from school in the first place and/or were contagious before they were identified and segregated. Patients can actually shed that virus in their stool for several weeks. Since I don’t think schools are able to genuinely keep children out until they are completely clear, I suggest common sense guidelines.  If they have a fever, keep them home. If they are fussy and miserable, they will be much happier at home with mom or dad. If they seem to be feeling okay and are fever free, for the above reasons, I don’t think it is reasonable to exclude them from daycare/school until all the blisters are completely cleared.   I know that the name alone makes parents shudder, but this is one of those illnesses that most kids end up getting. Think of it as a rite of passage. It is actually better to get some of the childhood illnesses out of the way. Unfortunate adults that lack immunity and catch these illnesses are pretty miserable. The American Academy of Pediatrics says that kids can go back when they’re fever free, feel up to participating, and don’t have many open weepy blisters (dry ones are okay). With most viral syndromes time is the ultimate healer. However, If you suspect the flu, it might be worth getting seen and tested. As opposed to most viruses, influenza hits quickly and hard with a ‘hit by a truck’ feeling. Once you get a positive flu test there are treatment options that can be useful if started within the first few days of symptoms. Bacterial infections  If your child has an infection that is being treated with antibiotics, we generally consider them no longer contagious after they have been on the medication for at least 24 hours. Bacterial conjunctivitis is also usually given the all clear after 24 hours of eye drops (of course you need to finish the course.)   So can you go on that play date? Regardless of the illness you are dealing with, if you are questioning whether or not to go on an upcoming play date, explain your situation to the other parents. They may be perfectly fine hanging out with you and your snotty nosed child, or perhaps they have an important event or vacation coming up and want to be more cautious. Maybe someone is pregnant and hasn’t told people. We never know exactly what other families are dealing with. Let them decide. Full disclosure ahead of time is the best practice. If you are in a small share-care situation It is essential to have a talk with the nanny and the other families involved to make sure you are all on the same page. I would suggest that you agree that the kids will have a "sibling" relationship. This simply means that you all accept that the kids are most likely going to get each other’s mild illnesses. Typically if I have a child with a fever over 101, a new case of diarrhea, or a brand new cold that has them spewing green mucus it is worth keeping them home for at least a day or so to see what is coming next. Just this week one of Dr. Ted’s patients asked him, “I was dropping my kid off at daycare and saw all these kids with crazy snotty noses. How can you tell me they aren’t contagious?” He reminds parents of two things: First, what are you going to do about it? Kids under five essentially live their entire winters with runny noses, and kids who are kept in a bubble without exposure to the community germ pool will do the whole process when they start kindergarten. After a virus, the body’s mucous membranes have been damaged, and the virus has left behind plenty of inflammation. As the immune system clears the debris, there is a lot of swelling and leaky fluid membranes. This is where that persistent runny nose and lingering cough come from. It is not necessarily an active infectious virus that causes these symptoms.  We wish there was a magic light that signaled the "all clear." Alas, there isn't. Use your best common sense. When in doubt avoid contact with anyone who is vulnerable. This would include newborns, or someone with a compromised immune system.  Thanks to Dr. Ted for his valuable wisdom and input! Thanks to Sylvie’s mom Leah (just getting over covid) for helping me identify some of the questions that needed to be addressed

Creating a healthy sleep routine/instructions for making a 'bedtime'book

 

Some people celebrated an extra hour of sleep this week. Likely NONE of them are parents of young children or pets. My post this week will hopefully help you move forward with a clean routine.

Creating a healthy bedtime ritual No families sleep routine is exactly the same. When I was growing up my mom was early to bed and early to rise. She loved getting up at dawn and having the quiet house to herself while the rest of us slept. My dad was a night owl and was delighted if I stayed up with him to keep him company. I remember doing some odd projects together including translating physics from Russian to English or building a ‘heath kit’ color TV. Sometimes it was just watching the late news. I typically called it a night long before he did. So when Sandy and I had kids, creating a firm bedtime was not at the top of my list. It was right up there for Sandy though; he was (and still is) a data hound. He had read how important sleep was. He was the one who did most of the sleep training when the kids were young and he was certainly the enforcer when it came to bedtime. One evening, the kids may have been 3 and 6, Sandy was out of town on business. It turned out that several of my good friends were also playing single mom that week. We gathered at one of their homes with all the kids and ordered in chinese food. The kids were running around and the moms were chatting. I wasn’t keeping close track of the time, but it was late and the kids were starting to get cranky. “Hey girls, don’t get whiney, This was a special treat and I let you stay up” “No, we are tired! It is past our bedtime. Daddy would have made sure we were home and in bed!” Uh…way to throw me under the bus, I was NOT expecting this response. But even when they don’t tell you as clearly as mine told me, kids do thrive from routine. Have you ever noticed how some kids go down for a nap like clockwork at daycare but fight it at home? If the schedule is wishy-washy, kids will push to see what kind of power they can exert. That’s their job! Your job is to make sure that the rules are clear and the enforcement is consistent. Kids will ultimately follow them and thrive. Have a set bedtime and try hard to stick to it. Block out a reasonable amount of time for the process. It might vary from child to child but count on at least 30 minutes. Be present for this. Ideally this means keeping laptops and phones out of the room. Blink and your child will have outgrown these magic moments. Savor the sweetness. The goal is for bedtime to be the perfect time for deep connection rather than a battle. Sandy brought his guitar in and had a repertoire of oldies that he would sing. Make your own memories. When you are establishing a firm, new routine, talking about it for the first time during the actual bedtime when your little one is tired is NOT the time to learn about new rules. This will work best if they are part of the team. Have a conversation about this earlier in the day. Let them help create a routine that feels comfortable. Let them help negotiate how many songs/books etc. Discuss some rewards that they can earn for going right to sleep and not trying delay tactics My grandson Elliot, who is the grand master of bedtime delays and shenanigans is actually doing very well with a simple sticker chart. He earns stickers for easy bedtimes and a certain amount of stickers can turn into specific rewards.  I would rather focus on rewards, but discuss consequences for not cooperating. These can range from not going on a special outing, or cutting the allotment of screen time. Problem Solve some common issues before they happen. I am thirsty: okay to have a sippy cup or water bottle near the bed I want an extra yogurt pouch: Be clear on a reasonable window for getting a last minute snack. Once the teeth are brushed there is no more eating. I know it breaks your heart to hear the “but I’m hungry”. Try not to cave. “Tomorrow we will make sure to have a snack before you brush your teeth.” I am afraid there is a monster under my bed: This house is safe. There are no monsters. If you like we can put a nightlight in here. (Do not search for monsters. This would indicate that the possibility of a monster in the closet exists.) I have to poop: This is a tough one, I would take them to the potty but do NOT engage or talk to them. Make it very businesslike. Other considerations Avoid sugary foods and screen time in the period before bed. If possible make sure kids are exposed to natural daylight during the day. Start dimming lights and lowering the noise and energy level about 45 minutes before the actual bedtime. This is very impactful! A cooler room is more conducive to good sleep. Keep the bed for sleeping and napping. Do not use it for ‘time outs’ or playing. I have no issues with using a white noise machine. Model good behavior (sorry daddy, you were not such a good example in this one instance.) Try to keep the schedule the same every night. Weekends shouldn’t be different from school days. If you or your child are having consistent issues falling asleep, it is worth checking iron and Vitamin D levels. Low levels can be associated with insomnia. If you are feeling more ambitious and have the bandwidth, another way to have a really clear routine is to make a Bedtime Book with your kids. Children love ritual and will enjoy reading their special book night after night. You will tire of it long before they do. Here is a step by step guide to making your own. Many children love helping you make the book by posing for the appropriate pictures. Of course this means you actually have to print some, rather than having them live exclusively on your phone. Make your Bedtime book: Get a binder. Bonus if it has an insert on the front so you can slide in a photo. This should not be too hard to find. Put the pages into clear page protectors for a waterproof book that you can tweak over time by adding or subtracting pages. You may want to update it yearly with current photos and rituals. Call it what you want; MY BEDTIME BOOK or add your child's name and age. Start the book with photos of important people and introduce them. Here is (parent) and if there are two of you, here is (parent), Here is (sibling) Here is (pet) This is Me (or us if there is more than one child sharing the book) For young kids, I would keep it to your immediate family members and pets, but you can be as inclusive as you want but keep in mind that unless you want to be reading for hours, this is not the time for the entire family tree Next add a picture of your house with street sign and address: This is where my family lives (great way for kids to learn their address) Picture of bed. Picture of special blanket. This is the safe comfy place where I sleep. These are my special stuffed animals. If your child has two homes you can take a picture of each room and make 2 copies of the book so there is one at each house. It is nice to have a ritual that is consistent in both places. Take pictures of your nighttime rituals such as: I get into Pajamas Picture of a toothy smile - Before I go to sleep I brush my teeth. It is important to have clean and healthy teeth. We get into bed and the lights get a little darker (picture of snuggling). You can add some open-ended pages that allow the story to vary each night. Options include things like: Pick several from this list: We have read our (number that you have agreed on) stories/books We have sung our (number that you have agreed on) songs Let's talk about something I did today that I am proud of Let's talk about something I did today that was kind Let's talk about something I learned today What was the silliest thing that happened today Let's talk about something special that we can look forward to tomorrow We send special goodnight "thought kisses" to people that we love Finally, end with pages appropriate to winding down the good night process: Getting good sleep is important. My body does a lot of growing when I am asleep. My family is very proud of me when I stay in bed all night. If I get up too much they might get grumpy (photo of silly grumpy faces) Now it is time to say good night and to turn off the light; maybe I will get a special massage (optional but what a nice way to end the day)   Good night!! See you tomorrow!!   A note from Akira Seuradge, Certified Pediatric Sleep Consultant and Founder of The Sleep Good Co:  No one is immune to bedtime battles. They can happen to us all and I say this not only as a sleep consultant but also as a mum of three. In order for your child to sleep well they need 2 things:  To feel Safe, Secure and Comfortable A need for the brain and body to be ready for sleep  A key way to prioritize this is by setting limits and boundaries around bedtime which will translate to confidence around night time sleep. This does not mean they will no longer need you but it will give you both the confidence to sleep well.    One of my favorite ways to let your little one know that you are always nearby is to visit them during the night and snap a photo of you with them or leave a sticky note near their bed to remind them they were never really alone. Final note: No matter how drama free your bedtime routine is, there will be disruptions. Travel, occasional special events and/or illness can throw big curveballs into the mix. Take a deep breath. You can recognize that sometimes exceptions will happen, with the understanding that once you are back home/or the illness is over you go right back to the established routine.