December 10, 2020
We are delighted to welcome our newest Burgess Pediatrics team member, Michelle Guzman, who joins nurses Mary and Leslie in our office. Michelle is a Medical Assistant and medical administrative professional who has a bachelor’s degree in Liberal Arts, experience in electronic medical records management and employee wellness, and is now studying towards a bachelor of science in Health Administration. A native Virginian, she has lived in the Bay Area for the past four years and never wants to leave. She has two daughters, ages 17 and 11, and has strong empathy for those experiencing medical challenges. She loves working with children and families and is looking forward to meeting each of you!
Influenza Vaccine Update
We have a limited amount of FluMist nasal spray, approved for ages 2-49, that will expire on 12/15/20 and will not be replenished. We have also just received an extra shipment of injectable quadrivalent flu vaccine, so we will have ample supply available through the winter and spring. Influenza vaccination continues to be highly recommended. Please contact us by telephone or email if you would like to schedule vaccination with either formulation.
Unfortunately, the Bay Area is now experiencing a serious Covid-19 surge, with rapidly increasing positive tests, hospitalization rates, and ICU occupancy. We agree with local health authorities’ plans for outdoor spaces such as parks to remain open, while indoor public spaces are closed or very limited. Sharing indoor air with anyone outside your household in public or private spaces remains a very high risk activity, and unfortunately even masking and testing cannot make it completely safe. One bright spot is elementary schools, which around the country do not seem to be responsible for much viral transmission. We are hopeful that vaccines on the very near horizon may be approved and distributed soon, and urge caution in the months before we can all receive them. The safest way to gather for the holidays remains virtually, or outdoors with masks and distance.
Coronavirus Testing Update
We want to assure you that we are continuing to provide coronavirus testing through our office (nasal swab PCR sent to Stanford lab) for those with urgent needs. We expect this generally includes patients and household members who have symptoms or known exposures. We are still requesting that routine, scheduled screening tests (e.g. those for school and travel) be done through outside companies whenever possible, using an approved PCR test. You can find resources for this on our website on the Covid-19 Resources page and please feel free to reach out to us by email or telephone if you have questions or concerns. We are happy to provide guidance on the available options, which are numerous and rapidly expanding.
CDC Quarantine Guidelines Update
Recently, the CDC has added a shorter quarantine option, to try to help balance the burden of a 14-day quarantine for those with possible exposure against the risk to public health. The agency continues to endorse 14 days as the safer option, but acknowledges that 7 days with a test, or 10 days without a test, are alternatives. However, anyone with a possible exposure should continue to self-monitor for symptoms until 14 days after exposure, wear a mask, distance from others, and self-isolate and seek testing if any symptoms occur. Symptoms of Covid-19 can be mild and variable, so please contact us if you are experiencing symptoms as we can advise you about testing and isolation.
Holiday Office Schedule
The office will be closed for the holidays all day on December 24, 25, and January 1, and after 12:30 on December 31. As always, we remain available through the answering service for any urgent medical needs.
We wish you and yours a happy and safe holiday season!
November 19, 2020
Happy Holidays! We understand this time of year is especially difficult to navigate during the pandemic and we are reaching out to provide information and guidance for you and your family.
Covid-19 testing at Burgess Pediatrics
Stanford Lab and our office have both been impacted by extremely high demand for coronavirus testing, and the lab has recently experienced delayed turnaround related to equipment and reagents. In order to better serve our patients, we are currently asking that any scheduled coronavirus testing (such as that required for school, pre or post travel, gatherings with those outside your household, routine surveillance etc.) be done through an outside service. You can find a continually updated list of resources for such testing here. One strategy we recommend is to have LabCorpPixel, LetsGetChecked or Vault test kits on hand for immediate use. This may in fact provide quicker turnaround on your testing, and will allow us to use our coronavirus testing capacity for urgent testing needs, such as patients and their immediate household members with symptoms. If in the future we can reinstate scheduled testing, we will of course happily do so.
Staying Safe during the Surge
Unfortunately, we are currently entering a nationwide and statewide surge, and are seeing a local increase in cases as well. This is undoubtedly related to behaviors such as gathering indoors, indoor dining, and going to bars and other crowded spaces. Please remember that indoor dining and indoor gatherings continue to be very high-risk activities, and although some of these are currently allowed in our county, we do not recommend doing these with anyone outside your immediate household. Outdoor activities remain much safer; adding additional protection of masks and distancing is highly encouraged as well. Commercial air travel also remains of unknown safety, and precautions during and quarantine afterwards are recommended if you do choose to fly. School transmission appears to still be uncommon, although we have heard of a recent outbreak in an after-school program at a local middle/high school. Guidelines for quarantine after exposure can be found here.
Covid-19 Vaccine News
We were very encouraged to see the preliminary reports from Pfizer and Moderna showing their vaccines may have 95% efficacy and prevent most severe disease. Studies have not yet been done in children, so we do not anticipate vaccinating children in the first round; however, vaccines such as these may prove very effective at interrupting transmission of the virus if given to adults, since children are less likely to become ill and transmit the virus. Nevertheless, these vaccines are not anticipated to be widely available for months, so the above precautions will continue to be necessary for quite some time.
Influenza Vaccine Update
We have had an enormous response to our influenza vaccine offering this year, and are so glad that our families are protecting themselves from the flu. We have a limited amount of FluMist nasal spray vaccine left, which can be administered until 12/15/20. Please contact us if you would like to schedule vaccination.
Thank you for your confidence in us as we help you navigate these unprecedented times. We are here to help care for your family and hope you will call on us with any questions or concerns.
October 8, 2020
We are reaching out to you with a brief October update. It has been great to see many of you in person recently!
We have continued to offer coronavirus testing to our patients and household contacts. Currently we are experiencing a very high volume of requests, due to school surveillance testing, travel, and exposures. We are here for you, and we will be increasing our staffing to meet the demand. In order to continue to provide this service, we must begin charging for coronavirus testing. This charge will be $70 and covers our work to collect, send, and follow-up the test, and the Stanford Lab will continue to bill the patient’s insurance for the laboratory cost.
Lunch hour change
Our phones will now be off from 12:30-1:30 daily for lunch. During this time, you may leave a message, or press 1 to request to be connected to the on-call doctor for any urgent matter.
We appreciate you trusting us with your care during these challenging times!
September 23, 2020
We have this year’s influenza vaccine in stock and ready to go! We recommend getting the vaccine in October or early November, as it takes 2 weeks to be fully effective.
We agree with the Centers for Disease Control recommendation for universal influenza vaccination, and highly recommend flu vaccine for everyone over 6 months old. Although it is only about 50% effective in preventing influenza cases, it is extremely effective in preventing severe complications, hospitalization, and death from influenza. Although flu season was extremely mild this year in the Southern hemisphere, flu vaccine does continue to be highly recommended this year, especially given the ongoing Covid-19 pandemic.
We have both the injection and the nasal flu vaccine available. We recommend the quadrivalent injection for most people, due to better data on its efficacy, but also have the FluMist nasal spray for children ages 2 and up who have difficulty with an injection. The nasal mist is a live attenuated virus, and should be avoided by those with asthma, immune compromise, pregnancy, egg allergy, or any underlying condition that increases risk for severe influenza. More about the nasal spray and caveats around its use can be found on the CDC website. (We do not stock high-dose flu vaccine, so cannot vaccinate anyone over age 65.)
We continue to care for our patients outdoors using full protective equipment. We will administer the vaccine in your car whenever possible, and will be holding drive in flu clinics by appointment on Wednesday afternoons this fall. We can also accommodate other times and tent visits if needed. Please let the nurse know which arm you plan to receive it in and then sit on that side of the car. Wearing a short sleeved shirt is also super helpful!
Please call (650) 321-9555 or e-mail [email protected] to schedule your family's 2020 flu vaccines. As always, feel free to contact us with any questions.
August 26, 2020
Last month we welcomed Julia Cohn, RN to Burgess Pediatrics. Julia is a Peninsula native who earned her Registered Nurse degree with a Bachelor of Science in Health Sciences from UC Santa Cruz, and a Master’s in nursing from Johns Hopkins University School of Nursing in Baltimore. She is thrilled to be back home and has loved getting to know our Burgess Pediatrics families. You can read more about her on our website. She is working with us two days a week, and Mary and Leslie each continue to work 4 days a week. We are fortunate to have such highly educated, experienced, and dedicated registered nurses.
Flu Vaccine Update
There has been a lot of press about the emphatic recommendations to get the flu vaccine this season, to help prevent dual epidemics. We agree that anyone who is having contact with people outside their immediate household should get the vaccine this fall. Interestingly, reports from Australia, South America and South Africa showed a marked decrease in influenza activity this year compared to other years. This is logical because quarantine and other measures taken to prevent coronavirus infection will also prevent influenza infection.
In California, influenza typically starts circulating in late November or December. As the vaccine takes 2 weeks to become active, vaccination in October or even November is generally adequate lead time. We anticipate receiving our vaccine during September and October and have not been notified of any shortages this year. Vaccination will be available in our tent or in your car – drive through service! We will send another communication when flu vaccine scheduling becomes available.
August 18, 2020
Happy August! It’s back to school time, and schools are starting online but some are contemplating attempting some in person instruction if possible. We write to update you on our current understanding of the data.
We continue to have Coronavirus testing available at our office. We have just received guidance from the Stanford Lab that we can now use a mid-nasal swab for the Stanford PCR test. The swab is inserted 1 inch into the nostril, rotated several times, and then repeated in the other nostril. Some local schools are now requesting testing and we can accommodate this at our office. We continue to see all patients in our outdoor tent, using full PPE for every encounter. Please contact our front desk for a nurse appointment.
Masks are proving to be protective, not only to others, as previously accepted, but also to the wearer. New research at UCSF shows that wearing a mask can reduce inhaled dose of viral particles. This can prevent infection and has also been associated with a greater chance of asymptomatic or mild disease, as contracting symptomatic Covid appears to be related to the dose of viral particles inhaled. Double-layer cloth masks and disposable surgical paper masks appear to provide better protection than single layer bandanas or neck gaiters.
Child transmission and school reopening
It is clear that children are able to contract the virus and can carry high levels of virus in their nose when they do have it. The rates of children infected have increased, logically, because overall rates continue to climb across much of the country. However, to study whether school opening is reasonable, we need to look at transmission in the school setting, by age group. Many studies claim to study transmission but are looking at small pieces of the puzzle, such as how many copies of viral RNA are in the nose or what droplets form when you blow into a box. To truly study transmission, you need to study it specifically, using an epidemiological approach. This is costly and time-consuming, so these studies have been rare so far.
A contact-tracing study in Korea (during a time when there was no school) found that children in the 0-9 year old age group did not transmit the virus at a high rate to their household members or to non-household members. Children in the 10-19 year old age group transmitted it as efficiently as adults within households, but still inefficiently to non-household contacts.
An Australian school study conducted from Jan-April 2020 found very low transmission rates. Interestingly, the small amount of transmission that occurred was from staff to staff and from staff to student, rather than student to student or student to staff.
The virus is also increasingly appearing to be airborne with viable virus being found in small droplets that can linger in the air for hours. This is most relevant to indoor spaces where droplets are not dispersed by wind.
Exclusive surface transmission has not been documented, and while it cannot be completely excluded, airborne and respiratory droplets are likely the important types of transmission.
Therefore, when looking at school settings, protective factors for any setting, including schools, are the following:
- Outdoor setting or outdoor-like airflow
- 100% mask usage, especially adults and older children
- Distancing of 6 feet between people, especially adults and older children
- Limited time of gatherings
- Younger age of children
As always, we are happy to discuss individual situations. Please reach out to your doctor with any questions or concerns.
July 2, 2020
Here are two excellent and very detailed guidelines detailing recommended policies and procedures for school reopening:
June 22, 2020
We hope you are enjoying the sunshine and some safe outdoor activities this summer. We wanted to provide updates for you on a few timely topics: opening up, summer camps and school, multisystem inflammatory syndrome of children, and testing.
San Mateo County announced it is aligning with the state’s most progressive track towards opening up. It is now allowing dine-in restaurants, hair, nail and waxing salons, stores, gyms and other facilities to open up, and gatherings of up to 50 people to take place. We also now have a statewide mask requirement, requiring masks be worn whenever possible indoors, and outdoors if 6 feet separation cannot be maintained.
Does this mean that all of the allowed activities are now safe? Not necessarily. Cases continue to occur, and a second wave is widely expected. We have entered a phase where individual judgement must take the place of government mandates.
We suggest that each activity be evaluated on its own merits and risks. Factors to consider are:
- Is it indoors or outdoors? If indoors, is it a large or well-ventilated space? Small, enclosed indoor spaces are the highest risk.
- How close will you be to other people, how many people, and will they all be wearing masks? Remember that your mask protects others, and others’ masks protect you. Face to face contact is the highest risk, but sharing air in close proximity carries risk as well.
- How long will you be in the space with other people? Time is important, because your total dose of viral particles determines whether you contract the virus. An hour (particularly in an indoor space) is much higher risk than 5 or 10 minutes.
- What distancing and cleaning procedures are being enforced? Surfaces are not thought to not be a major mode of transmission, but to evaluate risk, consider how many people have touched the surface and how recently.
For example, a 6 foot-distanced walk outdoors or outdoor dinner with one other family, not sharing food or a bathroom, are likely low risk activities. A haircut in a small indoor salon is higher risk, even with spacing of customers and everyone wearing masks, as this requires close proximity, indoors, for an extended period of time, as well as potentially high-traffic surface contacts. Eating at a restaurant is probably even higher risk, as diners cannot wear masks while eating, so even if tables are spaced 6 feet apart, you are likely to be sharing air and respiratory droplets with many other diners for over an hour.
Summer camps and school
- Pre-adolescent children seem to be at very low risk of acquiring the virus. The mechanism is not completely understood, but they seem to have some natural immunity. When young children catch it, it seems to be when there is an infected member of their immediate household.
- Adolescents, on the other hand, are probably about as likely to get infected as adults. However, they are very likely to show no symptoms at all. How contagious they are to other people when they have an asymptomatic infection is unknown, but we must presume they can spread the virus. The one documented significant school outbreak occurred in a high school in Israel.
- School in the fall is likely to look very different than it did when we left it in March. We anticipate there will be distancing of students, perhaps smaller classes or cohorts, better ventilation, face coverings used by adults and adolescents, and frequent surface cleaning.
- Summer camps should be evaluated carefully using the above criteria, to ensure good precautions are being taken. Outdoor-only summer camps with small stable cohorts, masks worn by adults, and no shared equipment are a lower-risk option.
Multisystem inflammatory syndrome of children (MIS-C)
- This disease is thought to be a post-infectious inflammatory disorder, similar to Kawasaki disease, with cases typically identified a month or so after COVID peaks in an area. A couple hundred cases have been cataloged from New York. The incidence is currently unknown, as we don’t know how many children were exposed to virus in that area; however, experts consider it to be rare.
- Signs are persistent high fever for several days, gastrointestinal symptoms, lethargy or behavior change, and, in some cases, rash or skin changes. The course can be severe but good treatments are available and almost all children recover. There have been few cases in our area, likely due to the low incidence of COVID so far.
We have received some questions about testing after a possible exposure or higher risk activity, such as contact with someone who later tested positive, travel, or attending a protest.
- The most important recommendation for a significant exposure is self-quarantine for 14 days. No test is sufficiently sensitive to prove the absence of infection.
- Monitor your temperature during this time and seek testing if you develop any of the known symptoms: fever or chills, cough, shortness of breath, fatigue, muscle or body aches, headache, new loss of taste or smell, sore throat, congestion or runny nose, nausea or vomiting, or diarrhea.
- Testing without symptoms is likely to be less sensitive and there are no official guidelines for it. However, if you have had a significant exposure, consider testing 5-7 days afterwards.
The nasal swab PCR test, for current infection, and the blood antibody test, for prior infection, continue to be available through our office.
As always, we are here to help you evaluate your individual situation, so please do not hesitate to reach out with questions.
April 23, 2020
We are now in our 6th week of Shelter in Place, and I know that everyone is wondering when this will end as much as we are.
California, and especially the Bay Area, has managed to substantially flatten the curve. Infection rates continue to be very low in children. Unfortunately, there are still new cases daily, and we are not seeing a definite downtrend in deaths or hospitalizations yet. For this reason, and other reasons relating to preparedness (testing capacity, contact tracing readiness, PPE availability), the State and Bay Area counties are not yet ready to modify the Shelter in Place order. Los Angeles, in particular, has a lot of cases currently, and while travel is generally not permitted, avoiding Southern California especially is a good idea right now.
Antibody testing studies in Santa Clara County, Los Angeles, and New York City have all shown that the antibodies to the virus are much more prevalent than the number of documented cases, suggesting that we may be under-detecting cases by 10x to 50x. If confirmed, this would mean that many cases may be completely asymptomatic or only mildly symptomatic, and also that the case fatality rate of this virus is much lower than previously suspected, likely well under 1%.
Stanford Hospital Updates:
Stanford Hospital has been quite mildly affected by COVID-19 patients. They have not needed to use any surge capacity, and only have 4 COVID patients in the ICU this week. At Grand Rounds this week they commented that they haven’t inserted a breathing tube in a patient in 3 weeks. It is comforting to know that they have ample capacity to care for patients.
Stanford Medicine Occupational Health has been very aggressively testing healthcare workers (and finding a very low rate of infection in them) and is now even starting to test asymptomatic health care workers in order to provide maximal safety for patients and health care providers.
This week, the state of California announced that medically necessary surgeries may resume. If you or your child has had a surgery postponed, please contact your doctor to discuss next steps.
- Testing for Current Infection: We continue to have available to us the Stanford and Quest PCR (nasal swab) tests, which are excellent tests for active infection. The turnaround time has decreased as they have increased their daily test capacity dramatically. These tests have FDA emergency use authorization.
- Testing for Past Infection: We now have antibody tests at Stanford available. This blood test appears to have good sensitivity to detect IgG antibodies 3 weeks after recovering from COVID-19 infection. (The IgM, which arises faster than the IgG, does show some cross-reactivity so is likely not as reliable.) COVID may have been circulating in our community as early as January 2020, so if you had an illness since that time you suspect may have been COVID-19, the antibody test may be able to confirm this.
This antibody test currently comes with several caveats, however:
- This test does not have FDA approval.
- There is a possibility of false positives with antibody tests.
- It has not been demonstrated that a positive antibody test confers immunity to infection from the SARS-CoV-2 virus. Therefore, modifications to current social distancing protocols are not yet possible based on antibody test results.
Your doctor will of course be happy to discuss the pros and cons of different testing modalities with you.
There are no medications known to be definitely beneficial for COVID-19 infection. Current results have shown no benefit from chloroquine or hydroxychloroquine, and in fact in some studies this medication increases mortality in COVID-19 patients. Remdesivir shows the most promise so far, but placebo-controlled studies have not yet concluded.
Physical Distancing and Transmission Prevention:
This virus seems to be transmitted like common cold and many other respiratory viruses – by droplets that are emitted from our mouths and noses when we breathe, talk, cough, or sneeze. Those droplets can typically fly up to 3-6 feet. The use of masks or face coverings while in public spaces is now required in San Mateo County and strongly recommended in Santa Clara County. Any cloth or paper mask satisfies this ordinance, because the purpose of the mask in this case is to protect others from our droplets. They don’t filter enough to protect us from other people’s droplets; hence physical distancing whenever possible is still required. Masks are not required while driving or exercising outdoors when 6 feet separation can be maintained, and they are not required for children 12 years old or younger. Importantly, they are not recommended for small children (especially those under 2) as they are at risk for breathing difficulty from the mask.
We are aware of media reports recently of aerosols staying airborne for extended periods of time and of droplets flying much farther than 6 feet outdoors, and of the virus living on surfaces for days. However, no studies have shown that infection can occur in these extreme situations, and epidemiologically, this virus seems to be transmitted most efficiently by face-to-face contact and household contacts.
Mental Health during Shelter in Place:
Schools are very likely to be in “distance learning” mode through the end of the academic year. Whether summer camps will be able to operate is currently unknown. We hear that even when the shelter in place order is modified, it won’t be a flick of a switch, but more of a “dimmer” which moves gradually. This time is difficult for children and parents alike, because of physical and social isolation, including loss of contact with friends and family, loss of social rites of passage such as graduations and birthday parties, and loss of certainty about the future. Grief for these losses and difficulty coping are to be expected. Reach out to your doctor if we can be of any assistance; we also wanted to mention these excellent community resources:
Parents Place continues to offer child and parent expertise, now online, with one-on-one consultations, classes, and groups.
Palo Alto Therapy offers evidence-based Cognitive Behavioral Therapy via video for mental health concerns.
BACA provides online child mental health services, including a Dungeons and Dragons teen therapy group and a Minecraft social skills group.
Children’s Health Council has online videos and consultations available.
Stay safe and stay well!
March 24, 2020
Dear Burgess Families,
We hope you are hanging in there during Shelter in Place this week! We continue to follow the current situation and bring you updates. So far, COVID has not been prevalent in children; in California, under 2% of all cases have been in children. We have not yet seen any positive tests in our office.
Changes in Office Procedures:
Due to the increased awareness of spread of the virus in the community, potentially by asymptomatic or mildly symptomatic people, we are taking even further precautions in our office to help protect you and your family:
- We will now see all patients in our new “outdoor clinic,” as we can completely sanitize the chairs and equipment between patients and allow any airborne aerosols or droplets to blow away.
- Please contact us by phone or email for any questions or concerns, as we are able to address many needs by telephone or a video visit on Zoom.
- The American Academy of Pediatrics does support providing preventative health visits (well checks) and immunizations during this time. We will now offer Zoom video visits for well checks, and during the visit we can determine if any in-person follow-up is appropriate. If immunizations are due, we are able to do them in your car or our outdoor clinic.
A couple of medical updates caught our eye this week:
- The WHO rescinded its caution against ibuprofen the day after it was issued. (We agree it was hastily made and not made on robust evidence.)
- Loss of sense of smell and/or taste has emerged as a specific (although not completely sensitive) symptom in some patients.
- Many statements continue to be made about different drugs under investigation. However these drugs await rigorous controlled trials, and as such have not yet been shown to be effective, even if they are being used in patients abroad.
Coronavirus testing guidelines have become stricter again this week, after having broadened last week, due to a shortage of testing supplies. We do have testing available for our patients only, but will be following local health authority guidelines, which change frequently. We expect testing availability to increase again in another week or two.
Coping with Shelter in Place:
Adjustment to our new reality has been difficult for everyone we’ve spoken with. Kids are resilient but those with underlying anxiety may suffer more in the face of an invisible threat and such drastic changes in their routine. Reach out to your doctor if you are noticing concerning changes in your child, such as shifts in mood, sleep, and eating. We have compiled some resources for coping during this time:
Parents Place has multiple upcoming webinars and parent support groups.
This Kids Health article has some helpful ideas for talking with children about COVID
Christine Carter offers this advice on helping teens with social distancing. (warning: the video she says is wildly inappropriate…actually is…please preview before sharing!)
Common Sense media has curated resources to help with talking to kids, stress management, and help with homework, in additional to their usual guides to media.
We are expanding our email distribution list to include all family and household members who would like to receive our updates. Please reply with any email addresses you would like to have included in (or removed from) our mailing list. To help us manage this list, we have begun using Constant Contact. This will allow you to unsubscribe as well.
March 18, 2020
The current situation seems to be changing overnight! Here are today’s updates.
Yesterday we received the county order to Shelter in Place for 3 weeks. As a medical provider under this order, we are instructed to provide essential visits only, and use tele-health care whenever possible.
We will be using Zoom for tele-health appointments. Please sign up at zoom.us if you do not yet have an account.
- We are still open and providing essential visits. If you have an illness, injury or other questions or concerns please call or email. We continue to accommodate sick visits outdoors wearing full protective gear.
- If your need can be accommodated by video visit, please schedule as usual and we will send a Zoom link to you by email ahead of the appointment time. Phone calls are also welcome and can be scheduled as well.
- We will continue to offer in-person well baby checks for infants under age 2, as assessing growth and development and providing vaccinations are essential for health.
- For well checks ages 2 and up, we are currently postponing them. We will reach out with reminders to schedule these at a later date. However, we are happy to discuss current concerns by phone or tele-health and see patients if any in-person assessment is needed.
The World Health Organization and some European medical organizations have suggested caution in use of ibuprofen or other anti-inflammatories for treatment of COVID-19 symptoms. This is a controversial and not fully proven recommendation, but in the interim while more data are gathered, acetaminophen may be a safer choice for fever.
In other late-breaking news, a larger series of children was just released in a pre-publication article. The authors studied over 2000 children in China with COVID-19. They found that 94% of children with infection had asymptomatic, mild, or moderate disease and would not require hospitalization. Infants under age 1 year did have a higher rate of critical disease than older children (1.8% compared to 0.6%); however several of these cases were not confirmed COVID-19 cases so could also have been due to other infections such as RSV or influenza.
We will continue to keep you posted!
March 16, 2020
Dear Burgess Families,
We hope you are starting to settle into the current reality of social distancing. The CDC has just recommended an 8 week moratorium on gatherings of more than 50 people. This is a big change in life and routines, intended to slow the spread of the pandemic in our country.
We have been monitoring the local situation closely, participated in calls with San Mateo County, CDC and Stanford Medicine this week about COVID-19. The current headline for us is that children seem to be quite unaffected so far in our area. Of the positive cases in Santa Clara and San Mateo counties, the vast majority have been diagnosed in persons over age 18. Stanford’s Pediatric emergency room has been testing patients for SARS-CoV-2, and as of this weekend has not yet had a single positive test.
Worldwide, we have seen that children are much less likely than adults to be infected, and those who are infected are very unlikely to have severe disease. Children who do have the virus tend to have mild, non-specific symptoms, or none at all. Essentially all fatalities are being seen in people over age 30, and the vast majority over age 50, with rates rising significantly by decade of life.
A small case series from China studied 10 children with the virus, and their symptoms were mild and variable, and included fever in most, and various combinations of runny nose, cough, sore throat, and diarrhea. Children (unlike adults) are likely to be co-infected with other viruses simultaneously. We also know that the onset of symptoms tends to be gradual, over the course of several days, not sudden (as with influenza.) Overall, influenza continues to be a greater risk than COVID-19 for children.
Nonetheless, coronavirus transmission is certainly occurring in our community, and it appears that respiratory secretions and stool both contain virus, so respiratory droplets (e.g., from coughing) and contact with contaminated surfaces are the most efficient means of spread. Airborne particles are the least likely mode of transmission, so N95 masks should be reserved for health care providers in high-risk situations; they are not needed by the public. Hand washing, wiping down surfaces, and keeping a distance of 6 feet from anyone who is ill or coughing are the best ways we know to prevent contracting the virus. How much spread can occur from people with no symptoms at all is currently unknown.
Here is a compilation of questions we have been asked frequently last week:
1. Does my child’s asthma or other underling medical condition put him or her at risk for severe COVID-19?
In adult data, chronic pulmonary or cardiac disease and diabetes were risk factors for more serious disease. While we might suspect asthma would be a risk factor in children because COVID-19 presents with pneumonia, this has not been observed so far, and children and young adults are often avoiding infection or having only mild symptoms. If your child has asthma, please make sure to have non-expired inhalers on hand, but no other special precautions are necessary at this point.
2. Is there a medication I should have on hand in case of COVID-19 disease?
So far, the rate of secondary bacterial infection in cases of COVID-19 seems to be quite low. There is currently no proven therapeutic, although many are being studied. There are a lot of news articles and other information circulating about potential therapeutics, and we advise caution in interpreting these as many reports from the media can be extremely preliminary.
3. How extreme should my children and family be with our social distancing measures? What about nannies? Play dates?
It seems so far that parents and grandparents are at much greater risk from COVID-19 than children, but children might transmit the virus, and asymptomatic transmission might occur (and if so, would be especially likely within households.) In most cases we encourage those over 30 to talk to your own physician about your personal risk level in making these decisions.
4. Is it okay to travel?
Commercial air travel and other mass travel does increase your risk for contracting and spreading the virus. Once again, the decision depends on your own personal risk assessment – and generally more for the adults involved than the children. Private travel (e.g. in your own car) should not be considered high risk.
5. Should I have my child tested for COVID-19?
We have testing for COVID-19 available, and it is done by nasal swab, similar to the flu test. The symptoms of COVID-19 are nonspecific in children, and can include fever, cough, runny nose, diarrhea, or shortness of breath. So far, we are not finding positive tests in children with these symptoms, although this could change as the virus becomes more widespread. Whether to test or not at this point is not based on a strict guideline, but rather on individual family circumstances. There is no specific treatment available, but quarantine and public health reporting would be indicated for a positive case.
6. Is it safe to come to the office?
At Burgess Pediatrics we continue to see patients who have any fever, runny nose, congestion, sore throat, cough, or shortness of breath outdoors in our parking lot, while wearing full protective gear. This protocol, along with our pre-existing, very thorough room disinfecting procedures between every patient, is designed to keep our office safe for well child checks and other patients without respiratory symptoms.
7. I am pregnant. How worried should I be?
We received reassuring news this week about pregnancy and breastfeeding. The virus does not seem to be transmitted to the newborn if a woman is infected in late pregnancy, and it is not found in breast milk. Pregnant women also don’t seem to be at higher risk for severe COVID-19 disease. We don’t have information yet about the impact of COVID-19 in early pregnancy.
8. How can I help my child with his or her anxiety about COVID-19?
This is an unsettling time, and the change in routine can be difficult for children. Measures that can help include creating new routines and structure, limiting kids’ exposure to media and our own adult conversations about COVID-19, and provide simple and reassuring information about the disease, such as the information kids are unlikely to get sick. Emphasize hand washing, sleep, exercise, and healthy eating, and help kids stay connected with important people in their lives (such as grandparents) even if they can’t see them. Here are a CDC resource and a Parents Place article on coping with anxiety around COVID-19.
Please contact us with your other questions, and we will continue to provide updates as we learn more.
Drs. Cisco, Cueva, Miller
Nurses Mary, Leslie, Sue
March 3, 2020
We are writing to update you with new information about COVID-19. Currently there are nine cases in Santa Clara County and two in San Mateo County, and there is some evidence for community spread, potentially by people who have mild symptoms or no symptoms. So far in this country, as in China, those severely affected are the elderly and those with underlying medical conditions, and there are few or no cases in children. There is still much to be learned about the virus, including the range of presenting symptoms we might expect in children and healthy adults.
We are committed to caring for your children and family, and have been closely monitoring this very fluid situation. We intend to partner with you to provide the best possible care in the safest way for all patients and families. At this point, we must assume that community spread of the COVID-19 virus is occurring, although it is not currently known to be widespread in the Bay Area. We do maintain very strict hygiene in our office, including anti-infective cleaning of rooms and instruments after every patient; however it is not certain that this would be sufficient in the case of COVID-19.
In order to protect all of our patients, families, and staff, we are asking anyone who has fever, cough, runny nose, congestion, or sore throat not to enter our office.
Please also advise us if you have had contact with a known COVID-19 case or someone with severe cough, shortness of breath, and fever. We are triaging case-by-case, and can offer tele-health (e.g FaceTime or Skype) visits, and outdoor (or in car) in-person visits, depending on the situation. We plan to continue all other routine care in our office.
We have received some requests to rule out COVID-19. However, only county public health departments, with CDC permission, may test for the virus. We are hopeful that capacity for testing for COVID-19 will increase soon. As a first step, we can send a respiratory virus panel nasal swab to Stanford to try to identify other respiratory viruses as a cause of a patient’s symptoms.
Meanwhile, basic precautions remain: be very vigilant with hand washing, avoid touching your face, and stay home if you are sick. Prioritize sleep, nutrition, and other healthy habits. As always, we are here for your questions.
February 26, 2020
After yesterday’s CDC advisory, we have received some questions from families about how they can best prepare for COVID-19.
To summarize, there is not yet community spread of COVID-19 virus occurring in the United States, including the Bay Area. It is occurring in other countries around the world, and based on the patterns of spread in other countries, we anticipate that there is likely to be community spread in the United States at some point. The CDC is still restricting travel, quarantining, and tracking cases and contacts in an attempt to contain spread of cases within the US. This strategy is expected to slow the introduction of virus to the US. Yesterday’s message was a signal to businesses, schools, health care and other organizations to start planning for mitigation strategies to use in the case of community spread.
The good news is that currently, there are very few cases in the US and there has not been any community spread in this country, and therefore it is currently safe to continue your usual routines. In addition, children have comprised very few cases of COVID-19, and children positive for the virus have often been asymptomatic. Mortality and severe cases of COVID-19 have typically been in elderly and those with underlying medical conditions.
Many families have asked about individual preparedness for possible COVID-19 spread. We currently recommend the following:
- Continue usual health maintenance, including very regular hand washing, influenza vaccination (if not already done for this season), stay home if you are sick, cover your cough, and clean frequently touched surfaces.
- Make sure you have a supply of any regular medications needed, especially inhalers if you use them, ibuprofen and acetaminophen for fever control, oral hydration fluids, and a working thermometer.
- A portable pulse oximeter is an optional piece of equipment you can consider adding to your medical kit (especially if there is any history of asthma or pulmonary disease), as this can measure oxygen saturation in the case of pneumonia.
- The pneumonia from COVID is a viral process and antibiotics would not be expected to help; however it would be reasonable to have a course of antibiotics on hand in case of a secondary bacterial infection.
- Consider avoiding international travel.
- If you or a household contact have had international travel in the past 2 weeks, please advise us when scheduling an appointment, so that we can screen for any possible cases and keep our office safe for all patients.
If we begin to see community spread in our local area, other measures may be necessary, including tele-school, tele-commute working, tele-health visits with us, and avoiding mass gatherings. However, as there is no local community spread these aren’t currently necessary. We will continue to monitor the situation closely and update you with new developments and recommendations.
February 12, 2020
Please note that Burgess Pediatrics will be closed on Monday, February 17 for the President's Day Holiday. Our answering service will be able to reach the doctor on call if you need to reach us.
January 31, 2020
We are reaching out to provide information on the coronavirus (2019-nCOV). Today we participated in a live CDC conference call for health care providers, and we are regularly receiving information directly from CDC and other government and health care organizations.
Today on the call we learned that the 6 cases in the United States have all had a mild course so far. It is not yet known whether the virus can be transmitted asymptomatically, or only by people who are ill with it.
2019-nCOV is a lower respiratory tract virus that typically has an incubation period of around 5 days (range 2-14 days) and usually presents with fever, cough, or shortness of breath. Pneumonia can develop during the second week of illness. Only CDC (accessed via the public health dept.) can test for it, as our usual viral swabs do not detect it. No specific antiviral treatment is available for it; Tamiflu is not effective.
People who have traveled to Hubei province, China in the past 14 days or have had contact with a known case, and have fever, cough, or shortness of breath should be evaluated for the virus.
The first case was just reported in Santa Clara County late this afternoon.
There is currently no vaccine to prevent 2019-nCoV infection. The best way to prevent infection is to avoid being exposed to this virus. However, as a reminder, CDC recommends everyday preventive actions to help prevent the spread of respiratory viruses, including:
- Avoid travel to China and contact with possible cases
- Wash your hands often with soap and water for at least 20 seconds. Use an alcohol-based hand sanitizer that contains at least 60% alcohol if soap and water are not available.
- Avoid touching your eyes, nose and mouth with unwashed hands.
- Avoid close contact with people who are sick.
- Stay home when you are sick.
- Cover your cough or sneeze with a tissue, then throw the tissue in the trash.
- Clean and disinfect frequently touched objects and surfaces.
- Masks may be used in health care settings to prevent transmission.
We have received many questions on virus preparedness. At this point we suggest making sure you have any regular medications you need available, including inhalers if you have used them in the past, hydration fluids, fever medicines and a thermometer.
Links for further information:
When to call us: If you become ill during the first 14 days after arrival from Asia, or contact with someone who has recently arrived from Asia, please let us know by telephone. If there are risk factors present for 2019-nCOV infection, we will recommend a home visit rather than an office visit.
We will continue to monitor the situation closely and update you as new information becomes available.
We have updated our website to provide current and future patients with helpful information and resources. Appointments can now be requested and forms completed online. The new site is mobile phone- and iPad-friendly and works in all browsers.
You will find important announcements here. Other new content includes links to valuable resources, an analgesic dosing chart, and articles from the American Academy of Pediatrics (AAP).
Please take a look around our site and let us know what you think. We’d love to get your feedback at [email protected]
Posted January 8, 2019 by leigh
We hope you all had a wonderful holiday season!
We are excited to announce that we have hired Leslie Orban, a Registered Nurse, to be a part of our Burgess Pediatrics family. In addition to hospital work, she has experience as a school nurse and is fantastic with kids and families. She is really looking forward to meeting you all! You can read about her at our website: or on our Facebook page. She will be replacing Rachael Horn, who is stepping away from nursing for the time being to focus on her family (but has promised to stay in touch and stop by with her new puppy.) Of course, Mary Hansen, RN and Laura Lombardi are still here to help take great care of you and your family.
We also wanted to share with you that we have some openings for new patients in Dr. Shelly Miller’s practice, and offer these up to your friends and contacts first. If you would like to refer a family to us, please ask them to call to schedule a complimentary informational meeting with Dr. Miller, and to let us know whom we can thank for the referral.
We have been improving our Facebook page – if you follow us, you will find find medical news, announcements, holiday schedules, articles recommended by our physicians, photos, etc. We always love to see your posts and check-ins there too!
As always, please reach out if you have any questions or concerns.
All of us at Burgess Pediatrics wish you a happy, healthy new year!
Posted September 28, 2018 by leigh
It’s time for flu vaccine!
We have this year’s quadrivalent injectable influenza immunization in stock, and we recommend receiving it in October or early November.
We agree with the Centers for Disease Control recommendation for universal influenza vaccination, and highly recommend flu vaccine for everyone over 6 months old. Although it is only about 50% effective in preventing influenza cases, it is extremely effective in preventing severe complications, hospitalization, and death from influenza.
This year, the injection form is highly recommended. FluMist nasal spray is once again available and approved for use, but due to unknown effectiveness, it is only recommended for those individuals who would otherwise receive no vaccination.
We are also offering a special Saturday Flu Clinic – by appointment only on October 13, from 12-3pm in our office. Please call (650) 321-9555 or e-mail us at [email protected] to schedule your family’s immunizations for either this Saturday clinic or for regular office hours.
Posted August 23, 2018 by leigh
We wanted to let you know about the current EpiPen shortage and how to proceed. As you may have heard, there is a nationwide shortage of EpiPens and many pharmacies are out or have low and intermittent supplies. This is expected to be alleviated in a few months when the new generic EpiPen becomes available. Currently, there are three options if you have expired EpiPens:
- FDA has extended expiration dates of many lots of EpiPens so you can check your lots against their website here to see if you can use your current pens for school, etc. this year. EpiPens have been studied and found to have active medication in them for years after their expiration dates if stored at room temperature (not in a hot car, etc.), so this is a very reasonable option.
- Call local pharmacies to see if they have any today and we can send or transfer the prescription. Pharmacies are getting some limited shipments but are running out quickly.
- Go to the AuviQ website auvi-q.com and direct order AuviQ injectors. This is a different type of epinephrine injector and there are instruction videos on the website; we also have trainers in the office and are happy to help instruct new users. You sign up online for their program (to mitigate cost as they are extremely expensive and not covered by insurance) and they should contact us for the prescription and then deliver to your home.
Posted July 26, 2018 by leigh
The doctors at Burgess Pediatrics have extensive book collections and suggested reading on everything from general parenting, divorce, autism, feeding, new siblings, etc. And now they’ve put together a list of some of their favorite recommendations for your easy reference. You can find it under our Resources page here along with links on where to buy them.
Check it out!
Posted April 19, 2018 by master
We are thrilled to welcome Shelly Miller, MD, MPH, to Burgess Pediatrics as our new partner. She has a wealth of pediatric knowledge and experience, and a wonderful sense of humor. We are sure you are going to love her as much as we do. Most importantly, she loves working with children and their families.
Dr. Shelly started out as an anthropologist and worked in archeology for a few years and then moved into public health. After completing her master’s in public health at UCLA, focusing on international health, maternal and child health, she attended medical school in Colorado. She spent her senior year working in Zimbabwe and Malawi before returning for residency at UCSF Benioff Children’s Hospital in Oakland. Following that adventure, she completed a fellowship in pediatric infectious disease. Dr. Shelly says, “There is always more to learn!”
After working over a decade in a private clinic in San Francisco and Marin, practicing both primary care pediatrics and infectious disease consulting, Dr. Shelly moved to the East Bay and has been working in pediatrics with Stanford Children’s Health.
Dr. Shelly is very excited to join Burgess Pediatrics and cannot wait to get to know all of you. Stop by and say hello when next you visit and feel free to give her tips about her new home in Menlo Park!