Babies, Germs, COVID, Flying, etc

In the pandemic, when people ask how we are, Jesse has taken to telling them it’s a range from Adequate-Minus to Adequate-Plus. I hope you are all Adequate-Plus.

I took a labor day break this week and spent some quality family time before we are back to school. We picked went to the beach, had a picnic and picked apples. It was nice. Almost felt normal, minus the masks and the fact that one of us had to take a break Saturday afternoon for a (routine, university-required) COVID test.

Thanks for amplifying the schools effort last week (details here if you missed it). We’re live with the baseline survey now. Fingers crossed…

Babies & Germs & Stuff

First off: hats off to all of you who are new parents during this pandemic. I whine a lot about home school and not being able to be in my office, but at least my kids sleep through(ish) the night. Having a new baby is hard and isolating in the best of circumstances. So, good job new parents: you may not feel it, but you are doing great.

From these new pandemic parents, I’ve been getting a lot of emails about babies, germs and some combination of travel or visiting.

When is is it okay to fly?

Can other people hold the baby? When?

My partner’s family wants to rent a beach house together and our baby is three weeks and I cannot imagine anything I’d less like to do and can you please give me an excuse to say no? Thanks so much.

People are asking this in the context of COVID, but as usual I think it is helpful to step back and give the problem some scaffolding. That is: let’s start by asking about this question in general, and then we can add on the COVID circumstances.

Stepping even further back, we can note that these questions are basically all the same question: how concerned should I be about germ exposure?

I wrote about this in Cribsheet, so I’m going to excerpt that below, and then return to the COVID situation.

The Non-COVID Answer

Virtually all doctors will suggest you try to avoid exposure to illness in the baby’s first couple of months. One reason for this is simply that the smaller the child, the more vulnerable they are to serious complications. But a second reason is that for very young infants—especially those younger than twenty-eight days—medical protocols suggest much more aggressive interventions in response to illness.

What does this mean? Basically, if your otherwise well-seeming six-month-old gets a fever—even a pretty high one—and you go to the doctor, they’ll probably look them over, tell you they have a cold or a virus, and send you home with instructions to give them Tylenol and fluids. In fact, many doctors’ offices will tell you not to bring this child in at all unless you are very concerned.

In contrast, if your two-week-old has even a low fever, you’ll need to take them to the hospital, where they’ll be subjected to lab tests—likely including a lumbar puncture (spinal tap)—given antibiotics, and admitted as an inpatient. With very young babies, doctors have a harder time distinguishing between high- and low-risk fevers. Babies in this group are somewhat more susceptible to bacterial infections, including meningitis, which is extremely serious. Somewhere between 3 and 20 percent of infants under a month old who come to the doctor with a fever have a bacterial infection. These are mostly urinary tract infections, but they must be treated, and reasonably quickly.

The combination of this higher risk of and difficulty detecting infection means that aggressive intervention is an appropriate approach, but most babies with fevers are actually fine.

When a slightly older infant—between twenty-eight days and two or three months—presents with a fever, there is more ambiguity about treatment. Some doctors will still preform a routine spinal tap, although there is less evidence that this is beneficial. The procedure for managing infants in this age range (and younger) is many-stepped and varied.

Two of the key points here are whether the baby appears sick (this sounds crazy—of course they appear sick, they have a fever—but if you are a pediatrician, this distinction apparently makes sense) and whether there is an obvious viral exposure. If you come in with a forty-five-day-old baby who has a cold and a low-grade fever but seems otherwise fine and bring along the baby’s two-year-old sibling, who has a cold from day care, the doctor is likely to react differently than if you come in with the same baby, with no sibling, and the baby is listless.

How does this all relate to the question of germ exposure?

The big downside of being exposed to germs—or specifically, to sick kids—during these early weeks is the possibility of setting off this chain of interventions, including the spinal tap. If your infant does get sick, these procedures make sense, but if they just caught a cold from being pawed by a germy two-year-old, you’ll be doing a lot of interventions for no reason. It’s therefore better to keep the germy two-year-old away from the newborn, if at all possible.

Once your baby is over three months, and especially after they’ve had a first set of vaccines, treatment of a fever is closer to what you’d expect with an older child—basically, give them some Tylenol, keep them hydrated, and wait for it to go away. At this point, the downside of germ exposure is simply a sick kid, not a cascade of invasive testing.

Adding COVID

How does COVID-19 change the calculus? Many of the considerations are the same. At the core, especially in kids, COVID-19 is a respiratory virus like a cold or a flu. If your infant has a fever — whether it is COVID-19 or not — the medical reaction considerations above apply.

What is different about COVID? The first thing is the risk to you. When you think about visiting or flying or any of the rest of it, you’re now factoring in your own illness risk in a way you wouldn’t do normally. If you do not feel it is safe for you to visit someone — or for them to visit you — then adding the baby isn’t going to improve safety.

Imagining, though, that you are comfortable with whatever the activity is if ther were no baby in the picture. Then, the key questions that we add to the above in the era of COVID are: (1) whether the presence of the virus means a much elevated disease risk for infants relative to the status quo and (2) if your infant does contract COVID-19, how worried should you be?

The answers to both of these questions, as I’ve said before, are mostly reassuring. Most affected infants have mild or asymptomatic cases of COVID-19. They also seem seem fairly unlikely to contract it, even from a COVID-positive mother. For a good and recently updated summary, you can check out either COVID-Explained or Don’t Forget the Bubbles.

Having said this, there is reason to think more people have COVID-19 than the flu. So if you asked about the random chance of someone who interacts with the baby having an illness, it’s going to be higher right now than otherwise. Also, COVID-19 is more likely to be asymptomatic. You may be able to more easily avoid someone with the flu because they seem sick.

The combination of these things leaves you, I would say, with some easier answers and some less easy ones.

  • Easier: Even in non-pandemic times, my argument is that it is good to avoid unnecessary infant germ exposure before the first shots, so around 8 weeks. This includes, probably, limiting random visitors or limiting their holding of the baby and, ideally, not flying. If you have to, you have to. But if you can avoid it, do. Your friend thinks it is selfish for you to miss his destination wedding in Aruba? Too bad.

  • Also Fairly Easy: From the baby perspective, some limited exposure to close family (grandparents, for example) shouldn’t be very different than normal times. The fact is, that although COIVD greatly changes the disease risk environment for older people, this is simply less true for babies. You should always be careful to have grandparents wash their hands before holding the baby. This was true before, and it’s true now. (The greater worry is transmission to, rather than from the grandparents, so this is something to keep in mind).

  • Less Obvious: So, your baby is now three months old and you want to fly to (say) see some family further afield. This is more complicated. In a normal time, you’d do it for sure. I’d send you back to my post on grandparents and day care for this one: frame the choice, mitigate and evaluate risks, think about benefits and decide.

    You can limit the risk by washing hands carefully on the flights, wearing masks, etc. The airplane itself is actually fairly low risk, due to the extensive air processing. But, still, an airport is riskier than your house. So it really comes down to the benefits. If this is the chance to see the grandparents, that’s different than the destination wedding.

Weigh in!

Keep the thoughts coming. I cannot write back to everyone but I do read all of your emails, I promise.

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