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Melanie Cole (Host):  There’s no handbook for your child’s health. But we do have a podcast, featuring worldclass clinical and research physicians covering everything from your child’s allergies to zinc levels. This is Kids Health Cast by Weill Cornell Medicine. Today, we’re discussing evaluating the risk of summer activities for your kids amid the COVID-19 pandemic. I’m Melanie Cole and joining me is Dr. Paul Chung. He’s the Site Medical Director for Primary Care, Brooklyn Heights. Dr. Chung, it’s a pleasure to have you back on with us today. You’re a great guest and as the summer is in full swing, kids want to go to beaches, play at parks, see their friends. What are the current recommendations as to activities that kids can do? What are some guiding principles that we should be keeping in mind in these unprecedented times?

Paul Chung, MD (Guest):  Hi Melanie. It’s a pleasure to be speaking with you again. As far as summer activities, most activities are not going to fall into a category of absolutely allowable or not allowable. There are going to be various factors that affect the level of risk of any given activity. At the same time, there are many benefits of being outdoors, and some degree of socializing. Therefore, it’s a matter of making good decisions and limiting the risks as you still try to obtain the benefits of spending time outdoors.

In general, there are four very important factors that affect the level of risk of any activity. The first is going to be the number of people that are participating with a higher risk with a larger number of people gathering. The second, is going to be proximity with a higher risk if it’s more congested and people are gathering closer together. Next is going to be the amount of time with a higher risk with the longer duration of activity and finally, the forth factor is going to be the level of air circulation with a higher risk involved with indoor activities especially if the ventilation is not good.

Other very important factors that are going to add to the level of safety are going to be reliable mask wearing by all the children and adults and frequent and proper hand hygiene.

Host:  Thank you so much for those really, really important bits of information as we’re talking about activities and really the importance of doing something. Why are activities so important for kids and their development and what have you seen Dr. Chung is happening to our kids with social isolation and quarantine? Are you seeing a change?

Dr. Chung:  Yeah, there are many acknowledged benefits of being outdoors and in nature which include less anger, less aggression, and improvement in stress and depression symptoms, improver motor development, a chance to exercise, decrease obesity and even improve learning outcomes. So, if parents have kind of taken safety measures way to the other end of the spectrum; then we are seeing some instances where children are having higher levels of some of the symptoms that I just mentioned as far as feeling pent up, maybe excessive weight gain because not being able to exercise as much, maybe an uptick in possible depression symptoms because you are not able to talk and enjoy the company of friends.

So, it is a matter of trying to balance safety with not prolonging the degree of isolation and avoiding the benefits where spending time outdoors and with friends can provide.

Host:  So, what’s the first recommended age they should start to wear masks around Dr. Chung? I saw in a Sesame Street special that above two years old they can wear one. Tell us a little bit about when it’s safe to put a mask on our children.

Dr. Chung:  So, what you said is accurate so two years old and above it’s recommended to try to have children wear masks. Younger than two years old, there’s going to be a risk to the breathing and obstruction of the breathing so, it’s not considered safe. And even with the children who are above two and it’s considered safe to wear the mask; some of the things you have to remember is how reliably those children are keeping their masks on, especially if they are two, three, four years old. So, with proper coaching and modelling, if you child is able to do that reliably, that’s going to contribute a lot to safety around others. If despite all you’re trying to do, and the coaching and your child is ending up just touching their face more and more frequently because of the discomfort or not being used to the mask; then it’s possible that the risks of touching their face frequently might outweigh the benefits of the mask. So, then in that case, you might just have to be extra careful about who you are around, how many people you are around if not able to keep the mask on reliably.

Host:  What a good point that you make. I mean kids are going to touch their face more if there’s something on their face to touch. So, how can we promote behaviors that reduce spread on our kids? Where do you feel are some important areas that we really should be concentrating on with our kids?

Dr. Chung:  In addition to kind of good modelling by the parents for the masks; of course you want to coach and model them through coughing and sneezing into a tissue and properly disposing of that tissue. If a tissue isn’t available, then coughing or sneezing into a child’s elbow rather than into their hands and then potentially touching a surface that can spread the virus. Another would be providing positive reinforcement, washing your hands properly. The proper way is with soap, with warm water for at least 20 seconds. And providing hand sanitizer as much as possible. You do have to be careful a little bit with the hand sanitizer for younger children. It’s recommended that children who are younger than 6 years old, you need to be supervising them any time you provide them with hand sanitizer. Because the recommended alcohol content for effectiveness is at least 60% alcohol which is a very high alcohol percentage in the sanitizer and therefore even a small amount of ingestion whether it’s accidental or because the child got into something that they weren’t supposed to; can be very, very toxic. So, with young children, you do have to be very careful about using the alcohol based hand sanitizer.

Host:  Oh, something that I didn’t even think about but what a great point. And as long as we’re talking about our little guys; hand hygiene, respiratory etiquette, what you’ve just discussed as far as sneezing, coughing. Kids are notorious nose wipers and nose pickers and all of these things. Is there any way to even try and convince them not to do those habits? Do you have some words we can use for them?

Dr. Chung:  I don’t have a good solution, because children just like you said, depending on their age; it’s not necessarily reliable that with good parenting, that you are going to be able to keep them from doing that 100%. So, things I already mentioned would be just good modelling, good positive reinforcement rather than negative reprimanding for not carrying those things our adequately. But I would say the most important things are is that just ensuring that other safety measures are in place. Make sure that if they go to a certain activity such as some type of class or camp; that soaps and sinks are readily available. Make sure that hand sanitizer for older children is readily available for all activities. Avoid shared toys and supplies. If supplies are going to be shared, then make sure there’s protocols for sanitizing them frequently. Make sure there’s protocols for frequent cleaning and sanitizing high touch surfaces like tables, rails, sinks, door handles and again, I think one of the most important things is just for adults to be good role models.

Host:  Well that’s true and now as we were talking about our little guys, there’s older kids that we’re dealing with and they are feeling the stains of social isolation and quarantine. They are not digging the masks completely. Tell us a little bit about the message for older kids and summer activities and they’re craving the social interaction, but they also need to learn to be responsible and held accountable and communication is so key when we’re dealing especially with our teenagers that are really feeling the strain right now.

Dr. Chung:  Yeah, and it can be confusing for older children and teenagers because depending on what your listening to or what you’re reading, there can be mixed messages. One important message about being responsible would be the following. Is that just as important or even more important as protecting yourself because we’ve seen a lot of data that older children are not nearly as severely affected as older elderly adults or other people with severe underlying medical conditions. So, one message of being responsible would be take these safety and protective measures not only to protect yourself, but to protect your parents, your grandparents, those others around you with serious medical conditions so that you’re not passing the virus on. Because it can be passed on even when you are asymptomatic.

So, some recommendations would be participating in activities that decrease the risk factors that we discussed earlier. So, try to participate in activities that are outdoors, with spacing, with not a high number of other people. So, an example of safer activities that parents and pediatricians and teachers could encourage would be playing tennis, playing catch, kicking a soccer ball around, jumping rope, going for a run along a non-congested path. It’s going to be safer shooting hoops or playing basketball with maybe one other friend rather than going to a park and playing a pick up game of four on four with potentially many other people who you are not familiar with.

Host:  What a great idea. So, you mentioned parks. Pool parties. Kids we know they love their pool parties. Are the parks safe to play, the equipment? Are we still concerned that COVID could be sitting on the swing sets or any of those things. And even museums are starting to open up again. Is it safe to go? Tell us about risk levels for those kinds of things, parks, pool parties, museums, all these places that we might see kids.

Dr. Chung:  Yeah, things that many, many families are wondering about these days as the weather is nicer. So, with something like parks, one of the benefits is that again, it’s outdoors. There’s good air circulation. There’s room for people to space out. So, going to parks can be done in a safe manner. You get the benefits of being outdoors. But like you mentioned, you still have to take safety measures. You had asked about the mode of transmission. So, the highest risk of transmission because the SARS COV2 virus is spread by respiratory droplets; probably the highest risk is if you are in an enclosed space and someone coughs or sneezes or speaks directly in front of you or close to you and then you breathe in those respiratory droplets or they come into contact with your eyes or nose.

With that being said, the respiratory droplets they do remain on surfaces. We don’t know exactly how long. But it can be spread that way where if respiratory droplets someone touches their mouth with the virus and they touch something like a railing or something in a park, part of what kids play on and if another child touches that and then touches certain part of their face like their eyes, nose or mouth then they could contract the virus. So, that is something you have to be careful about. So, within the park, you still have to be careful about distancing, are you in close quarters for people, with people that you don’t know, take hand sanitizer with you for older children and be extra good about washing your hands when you get back.

You had asked about museums. Along the same lines, we’re not going to say that museums absolutely is not allowable, but you take on one of those risks in that it’s indoors and so the circulation is not going to be good as an outdoor activity. So, if you do decide to go to a museum; there’s things that you can ask about that the museum can do to make it safer. Check to see if they have markings on the ground, signs in place that require people to wear masks, that require people to stand at least six feet apart from each other. It’d be better if they rules in place where they are only going to let the museum into a certain level of capacity to again, decrease the level of congestion.

For pool parties, now that’s an interesting concept because going to the pool again, there’s benefits to getting sun, to being outdoors, to potentially socializing with others. There hasn’t been any evidence so far that the SARS COV2 virus that causes COVID-19 is spread through bodies of water like pools or lakes. So, going to a pool, as long as there’s precautions in place like we just talked about, markings on the ground, signs reminding people to wear masks, soaps, sinks, hand washing stations and hand sanitizers. As long as those measures are in place; it can be a good activity for the summer. Reminders that if you are going to do that, would be maybe don’t use the water fountain, any type of high touch surface that people are cycling through and touching that. But bring your own water bottle. Bring your own supplies. Don’t be sharing anything with others at the pool.

And now the thing that of course, is going to be worrisome is the party part. So, if you’re gathering at somebody’s pool or a public pool; it’s going to be a higher risk where if multiple, multiple people are gathering where people can’t distance from each other, where it’s congested. It’s going to be safer if you have a smaller gathering with maybe a dedicated socialization group that you know well and trust that even when you’re not together is going to be safe about what they’re doing.

Host:  That’s such great information and thank you for telling us about water fountains because I was wondering that myself. And we haven’t really talked about summer camp because there’s still plenty of time left in the summer and there’s sports camps and theater camps and all these things where they are outside for the majority of the time. What do you want us ask the camps, if we want to send our kids to a two or three week camp or an overnight camp, any of these kinds of things before the summer is over? What do you want us to know?

Dr. Chung:  You know that is an important question because there are many benefits to these socialization activities for children like camps. It can improve self-esteem, socialization skills, independence, leadership skills, their willingness to try new things. But the reason we need to talk about it is because again, it takes a couple of those risk factors that potentially adds them to that activity because usually, camps are going to be for a prolonged number of hours, even if it’s a day camp. And depending on the camp, it usually involves a group or a higher number of kids not just one, two or three children interacting together.

So, the things that parents can check on they can ask the camp to make sure that it’s being conducted in a safe manner would be one, make sure that the group of children is not too large. And example would be maybe 10 children or less as part of a small group but the smaller that number, the better. Try to avoid that small group of children interacting and mixing with other groups at that camp. Have them dedicated throughout the day, moving together as a unit. Try to prevent counselors from cycling through different groups but have a dedicated counselor for that small group. And try to have a lot of activities outdoors. If you are indoors, then try to improve the air circulation as much as possible with safely opening what windows you can, keeping doors open if possible. Try not to use communal spaces like let’s say a mess hall or a cafeteria. If you do have to use that type of communal space; then again, have that small group of children cycle through at different times instead of all congregated together. Shared objects. Try to avoid that. If you completely have to do that, then make sure there’s protocols for sanitizing it in between uses. And as much as possible, children bringing their own supplies.

So, during meal time, bring their meal or have prepackaged meals, one time use utensils where you throw away after so that children aren’t having to rely on whether they are washed properly in between uses. And one of the last things I’ll mention is having good policies in place for the staff. So, do they have policies in place for what do they do if a counselor has symptoms of feeling ill? Do they have any type of testing availability? Do they have strict quarantine rules if a counselor feels ill? Another added layer of protection would be having policies in place for back up counselors or staff so that there isn’t any type of pressure or negative consequences for a counselor reporting any symptoms and not being able to come in to work.

Overnight camp, again, because of more hours spent together is going to be a slightly added layer of risk but if your child is going to participate in something like that, then an added layer of protection would be having the bunks spaced at least six feet apart and the children sleeping alternating head to toe.

Host:  Wow, great suggestions. This is really good suggestions. As we wrap up, how can we encourage exercise and activity when our kids are feeling pretty unmotivated. I mean we’re all feeling that way to a degree. If we want them to get involved in sports, team protocols if they are in place. We want them to get active Dr. Chung, but it is a little bit of a tenuous time and we’re not sure what to do. Wrap it up for us please with your best advice.

Dr. Chung:  Yeah, parents are under so much pressure to keep their family safe. So, that message has been drilled home and therefore there’s confusion, then where do I draw the line with having my children exposed to different things besides being isolated in the home? So, I think the biggest step is pediatricians and teachers, people who are holding these types of podcasts just to let families know that being isolated all the time or for long periods is not necessarily the best thing. I think it’s important for us as health experts to give them permission to go outdoors, socialize to a certain degree, exercise, get fresh air and I think that as we give that message, as parents start to understand what are the safety precautions to do that in a safe way, kick off a cycle. Children will go outside with their families or with a small group of friends and as you get more sunlight, as you get outside, as you get a little bit of exercise; those things decrease stress and they improve your mood and they improve your overall energy level and then you feel like doing that a little bit more.

And the more information that we can provide about doing these things safely, then again, I think the mood and overall energy level of our community of children is going to improve and that way, we as a community are going to be able to achieve a good balance of doing things safely but at the same time, maintaining and optimizing good overall mental, emotional and physical health in this very difficult time.

Host:  It’s great information. Dr. Chung, what a great guest you are. Thank you so much for joining us today and Weill Cornell Medicine will continue to offer video visits for consultations and discussion to minimize travel and you can be confident of the safety of in-person appointments if needed. Thank you so much to our listeners. That concludes today’s episode of Kids Health Cast. Please remember to subscribe, rate and review this podcast and all the other Weill Cornell Medicine podcasts. For more health tips and updates please follow us on your social channels. I’m Melanie Cole.