The New Normal

by Jennifer Ashton, M. D.

  If an older relative or friend is comfortable with your visit, you should still weigh the risks of whether doing so is actually prudent in our new normal. Here are three variables to consider in making your decision:

  Their risk factors: The older they are, the bigger their risk of infectious illness in general. The chance of dying from COVID-19, for example, increases drastically with each decade: Those who are eighty-five and older have a 630 times higher chance of death from the disease, while those in the sixty-five to seventy-four age bracket have only a 90 times higher chance.2 Similarly, older people who are overweight or obese or suffer from heart disease, diabetes, high blood pressure, or another health ailment are much more vulnerable to getting seriously sick.

  Your exposure: We all have varying degrees of exposure to infectious illness. A person who lives with a big family, works outside the home, and/or doesn’t wear a mask has a greater chance of contracting a bacterial infection or virus than a person who lives alone, works from home, and/or always takes precautions. Consider your daily activities as well: Going to gyms, restaurants, bars, and other indoor places boosts your chance of exposure to illness. Similarly, if you live in a COVID-19 hot spot and are traveling to see an older relative or friend in an area with a relatively low case rate, your exposure will be comparatively much greater.

  The visit: How and where you visit can significantly increase or decrease the risk level. For example, do you plan to visit for two hours or two weeks? Can you see the older person only outside or will you need to be indoors, too? Will you be in a house where everyone can stay at least six feet apart, or does your older relative or friend live inside a small apartment? In the instance of COVID-19, can you isolate for up to two weeks or get tested before you go?

  If you weigh your conclusions from these three variables, you should be able to reach a decision fairly confidently about whether to visit an older friend or relative. Remember that you’ll never be able to obviate the risk entirely, but you can take every step possible to mitigate the likelihood of disease transmission by asking everyone to wear a mask when visiting or getting testing before you go.

  Treat Them Like a Newborn Baby

  If you’ve ever visited a newborn baby, you likely know that you can’t just smother them with kisses and put your hands all over them. Think of older family and friends in the same way and avoid kissing, hugging, and other forms of direct contact.

  It’s Okay to Say You’re Worried

  While you might be anxious about getting an older person sick, they may not share your concern. Many baby boomers and elderly adults in our new normal aren’t taking their health seriously, refusing to wear a mask and continuing to socialize like it’s 2019. Some feel as though they’ve seen it all and are invulnerable to disease, while others would rather chance getting sick than give up their autonomy or way or life. Either way, the obstinacy has left millions of younger people fearful for their safety.

  If you’re worried about an older relative or friend, talk to them rationally and reasonably about your concerns. Use facts, not fear tactics, to explain why you’d like them to take certain precautions, and ask how you can make it easier or more sustainable for them. If they’re unwilling to be safe for their own sake, ask them to do it for you and others who want to enjoy their company for years to come.

  Why Nursing Homes Are Different

  Older people who live in nursing homes have one of the highest death rates of COVID-19, not just because of their age, but also due to the fact that the facilities are often revolving doors between staff, visitors, and residents coming from hospitals and homes. If you want to visit a relative or friend in a nursing home, I suggest you carefully consider your exposure and the risk-benefit ratio. If you decide to go, call ahead to find out if the facility is mandating any special precautions. Upon arrival, be prepared to have your temperature checked and/or to fill out a surveillance questionnaire. Once inside, always wear your mask, keep at least six feet away whenever possible, and wash your hands frequently and meticulously. Be aware, too, that masks and limitations on visitors may be permanent precautionary measures for many homes.

  Staying Safe with Children

  There’s a saying in pediatrics I learned in medical school that I’ve repeated often on air during the pandemic: Kids aren’t little adults. That’s why the specialty of pediatrics exists. You can’t just take adult diseases, shrink them down to fit inside a smaller body, and expect the results to be the same. The coronavirus is a perfect example of this.

  Here’s why: After early reports found children weren’t getting seriously sick with COVID-19, many parents and some doctors misinterpreted the headlines to mean kids don’t get the virus, which isn’t true (another example of why it’s important to read behind headlines—see chapter 8 to learn how). Both Dr. Fauci and I, among others, tried to correct the misperception on TV, telling viewers that children can and do get infected, but most don’t become as seriously ill or have anywhere near the same death rate as do adults with the disease, though there are deaths among children. But the damage had already been done, priming the pump for some future missteps surrounding kids in our new normal.

  While we’re still figuring out the role children play in viral transmission, we now know that kids can and do get COVID-19, and just like adults, spread the disease to others. Children also appear more likely to have mild symptoms or be asymptomatic, making it more likely that they’ll be silent spreaders of the virus. Kids may also have higher viral loads than adults3 and shed the virus for weeks after becoming infected, which may or may not increase their ability to transmit the disease.4 Moreover, kids never live alone: They live with parents, grandparents, and/or other caretakers who can, do, and have become seriously ill with COVID-19.

  Even within the specialty of pediatrics, it’s not one size fits all. There are extraordinary physical, mental, and emotional differences between toddlers and teens, and all age groups have different distinct risk factors when it comes to COVID-19. These variables should influence how you interact with children, whether you’re a parent, relative, or friend. Here, we’ll address four different age groups—newborns and infants, children under age ten, preteens, and high school and college-age kids—and tell you what you need to know to keep each group safe in our new normal. I will take you through the aspects that make COVID-19 in pediatric age groups unique, distinctive, and emotionally charged. In understanding the subtle and developmental differences between different age groups, you can better navigate these challenging and ever-evolving issues.

  Newborns and Infants

  Babies rely on their mothers for a substantial part of their immune system. They receive antibodies in utero and via breast milk, along with some protection from vaccinations. But their immune systems are still very immature, and if they get sick with anything, the outcome can be far more severe than if an older child contracts the same illness.

  For this reason, you should be very careful around newborns and infants in our new normal, just as you should have been before the pandemic. If you’re a parent, limit or avoid visitors altogether for at least the first month after your child’s birth. You’ll also want to keep your pandemic pod very small to reduce your overlapping area of exposure. If you have any reason to suspect you may have COVID-19, the flu, or any other contagious illness, speak with your obstetrician or pediatrician and be prepared to temporarily separate or distance yourself from your baby—the risk of giving your child an infectious disease likely outweighs the risk of not participating in parental bonding.

  If you’d like to visit a newborn, talk with the baby’s parents beforehand to make sure they’re comfortable with the encounter. Be sure that you’re healthy and asymptomatic for at least one week before you see the baby. While you don’t have to change into a sterile hospital gown when you go, wear a mask and wash your hands frequently and thoroughly. You’ll also want to minimize close contact with the child, as well as his or her parents, who can spread whatever you give
them to their baby. If you’re close family, it may be okay to hold an infant for a few minutes. But if you’re not close family, I’d ask yourself if it’s really necessary for you to hold the baby, even if the parents are amenable. Either way, don’t kiss a newborn, especially on his or her face or hands, which will go straight inside the child’s mouth.

  What to Do If You’re Pregnant During a Pandemic

  Most women are likely taking a number of precautions already to protect their health and well-being if they’re expecting. But during a pandemic, you may need to be even more cautious about what you do, where you go, and whom you see. Because pregnant women are considered to have a compromised or suppressed immune system, they’re more susceptible to infections, which may include COVID-19. Keep in mind that you’re not the only patient, but that your fetus’s well-being could be compromised if you become seriously ill while pregnant. Even if you’re young and healthy, err on the side of safety. If you have specific concerns, talk to your obstetrician and/or midwife—good communication will help ensure everything goes as smoothly as possible during both your pregnancy and delivery.

  Children Ages One to Nine

  At baseline, young children are difficult to control. They don’t follow directions well, their overall hygiene isn’t great, they constantly touch their faces and everything around them, they don’t understand personal space, and they need to be supervised in nearly everything they do. Young children also don’t have well-developed fine motor skills, which can lead to difficulties when washing hands, putting on a mask, and trying not to touch handles, railings, adults, and other possible supporting objects.

  Despite these realities, it’s still very important that kids wear masks, wash their hands well, and practice social distancing. Young children can get COVID-19, and while they don’t usually get seriously sick and the fatality rate is very, very low, they can still pass the disease on to parents, grandparents, and other possibly vulnerable adults. Young children also appear less likely than older kids to show symptoms of COVID-19, increasing the likelihood they’ll be silent spreaders.

  What’s more, children in this age range are more likely to have close contact with other kids, which can immediately and dramatically widen your circle of risk if they’re not social distancing and wearing masks. Keep in mind, too, that some children may have preexisting medical conditions, making them more vulnerable to severe complications with COVID-19. Finally, young children can develop multisystem inflammatory syndrome, a rare but serious condition associated with COVID-19.5

  I realize that teaching and enforcing safety precautions in this age group can be a tall order. But I believe that if kids can be taught how to use a toilet, they can learn how to wear a mask and keep their distance from others. It’s not easy, but neither is toilet training. And similar to toilet training, once young children learn how to do it, they can usually adhere without continual oversight.

  Whether you teach your kids safety precautions may play a role in the bigger decisions so many parents face in our new normal: Is it okay to let children engage in the group activities that are so important for their development, including in-person classes, day care, team sports, music or dance lessons, summer camp, and similar events with other children and adults?

  To help make this decision, I suggest you look within and without. What do I mean? Looking within means assessing the health of everyone in your pandemic pod. Is everyone generally healthy? Does anyone have any preexisting conditions, including obesity, that would put them at a higher risk of severe complications with COVID-19? Are grandparents or older relatives helping to care for your child? Do you regularly visit older adults?

  Next, look without, which means evaluating the risk of activities in your community. What is the infection rate of COVID-19 or other contagious illnesses in your area? Is the activity being held outside, inside, or in a well-ventilated space? Will everyone be wearing masks? Will teachers or supervising adults help keep kids apart or at least discourage hugging and other close contact?

  Now, consider the worst-case scenario: your child gets infected and exposes your pandemic pod. If your pandemic pod is relatively healthy and/or low risk, the activity is low risk, and/or there’s not a lot of infectious illness in your area, it may be okay to have your child participate in group activities.

  What about individual playdates during a pandemic? This has been a loaded question for many parents in our new normal, with families sizing one another up and often making uncomfortable judgments about each other’s health behaviors and practices. This in turn has led to many disagreements, social stigma, and ostracism.

  From a medical perspective, I would advise you to find families who share your health practices and level of risk tolerance. It’s okay to ask questions. In our new normal, no one should be offended if you want to know whether everyone wears masks when out in public or has been vaccinated.

  Whether it’s playdates or group activities, keep in mind that you’ll never be able to bring the risk down to zero. What’s more, there are significant mental, emotional, and even physical detriments to keeping kids out of school or away from other children. Finally, remember that there are risks in everything your child does. You can choose to keep your kid home out of fear of COVID-19, but then he or she might have a bad fall, get burned, or accidentally ingest something poisonous, all of which are leading causes of injury in this age group.6

  Children Ages Ten to Fourteen

  The same safety measures for younger children also apply to this age group: Everyone should be wearing masks, washing their hands frequently, and physically distancing. Preteens can be infected with COVID-19 and don’t often show symptoms, so they can also transmit the virus unknowingly to adults and other kids.

  Unlike younger children, however, this age bracket is more mature and will usually listen to direction. They are also more likely to be able to fully comprehend why it’s necessary to wear a mask, for example, if it’s explained to them. At the same time, many preteens are very impressionable, so they’re more apt to follow guidance than older teens. In a way, this makes this age group the “sweet spot” for adopting safety measures in a pandemic.

  To take advantage of these attributes, parents should (1) explain the facts, and (2) be specific about which measures they want their preteens to take. Have a mature conversation with your kids, telling them what we know about the virus (or any another illness) and how they can transmit the illness without knowing it. Be clear that they can spread the disease without feeling sick, which could make other people very sick. Focus on facts, not fear, and ask them to share their feelings and concerns in our new normal.

  High School and College-Age Kids

  With teens and young adults, it’s critical to know your patient population. Otherwise, if you treat this age group like you would younger kids or older adults, you’ll miss the mark 99 percent of the time. Whether you’re a parent, relative, or friend of the family, leveraging the psychology of high school and college-age kids can help you better guide their behavior and keep everyone healthier and happier in our new normal.

  As you likely know, the teenage years are when children exert their independence, separate from their parents, and question or even challenge authority. They may struggle to find their identity, learn how to manage their emotions, and develop more mature relationships outside the family.

  Parenting teens and young adults was challenging in pre-pandemic times, but in our new normal, managing this age group can be particularly tough. The last thing any teenager wants is to be told what to do. Their social lives are their lifeblood, and they want to see their friends. As they try to establish their identity, many don’t want to wear a mask that makes them look like everyone else. They long for close contact and many want to start exploring their sexuality, too. All of this is normal behavior.

  My advice for this age group is what good doctors do with all patients: start with honest and open communication. Recognize that while the pandemic is diffi
cult on everyone, it’s especially tough for them, socially and developmentally. I believe you have to acknowledge this—otherwise, they may not hear anything else you say.

  As you would with preteens, explain the science behind the disease and what we know about this age group’s role in transmission, or that they can spread the disease easily and unknowingly to you, the rest of your family, their teachers, their friends, and their friends’ families. Since this age group can be self-absorbed, take the time to emphasize that being safe isn’t about them—it’s about everyone around them and the greater good. Tell them that this is their time to step up and prove they can be adults in a situation that requires both maturity and responsibility. After all, part of being an adult means doing what we need and should do, even if it isn’t what we want to do.

  When you talk with teens or young adults, be direct about the specific precautions you want them to take. At the same time, be realistic about your expectations: Know that you likely can’t control everything they do. Ask them to stay at least six feet apart from their friends, but emphasize that seven feet is better than six feet, and both are better than six inches. If they’re resistant to wearing a mask, encourage them to find a face covering that lets them express their personality, either by color, fashion, or design.

  You can also ask your teen or college-age kid what you can do to make the pandemic more sustainable for them. For example, I agreed to include my kids’ significant others in our pandemic pod, which made it immensely easier on all of us. (This was possible since technically my “kids” aren’t really kids: They are twenty-two and twenty-one, but of course they will always be kids to me.) You might also consider offering a diversion within your home or family that could help compensate for the activities they can’t do. For example, adopting a dog or cat and making the pet your teen’s responsibility may make it easier for him or her to stay home. Similarly, maybe there’s a project your kid could do, like repainting his or her room or caring for younger children in exchange for a small fee.