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Does Your Child Have PANS/PANDAS?

Do you have a child who was totally “normal” one day, and the next day suddenly has new anxieties, fears, tantrums or rages, OCD behaviors and maybe even tics? Does your toddler have out-of-control tantrums, and your friends and parents think you may have parenting issues? Or do you have a child who has always been more anxious, but now has gradually worsening separation anxiety and mood swings, who used to be a great student but is now barely holding on because she can’t focus and has difficulty processing or remembering what she’s learned just the day before?

Are you thinking, and hoping:

It’s just a phase …

It could be, but it could be something more … it could potentially be an autoimmune illness that is affecting your child’s brain – something called Pediatric Acute Onset Neuropsychiatric Syndrome (PANS) or Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal Disease (PANDAS).

According to the American Academy of Pediatrics, at least 1 in 200 US school children has PANS (1), and that number is climbing every day, but many are misdiagnosed, or just plain missed.

Missed Diagnosis – Missed Opportunities

According to the PANDAS Parent Survey in April 2014 (2), it took over 3 years for 35% of children to be appropriately diagnosed with PANS/PANDAS. Almost 90% saw 3 or MORE doctors before being properly diagnosed. Over half of all children with PANS were misdiagnosed and mistreated for over 1 year. Most children are misdiagnosed as having psychiatric illness, behavioral problems, or parenting concerns. Many go through trials of multiple psychiatric medications and therapies with minimal to no benefit - because they're treating the WRONG thing.

PANS is so much more than a "mental health disorder." PANS/PANDAS is an immune-modulated, neuro-inflammatory encephalitis. What on earth does that mean?

Our kids’ brains are on fire!

Without appropriate antimicrobial, anti-inflammatory, and immune-modulatory treatments, our children with PANS/PANDAS will be facing an uphill battle in their fight to get well and heal their brains.

Unfortunately, by the time many children get the treatment they so desperately need, they've likely already been misdiagnosed and mismanaged. It is imperative that pediatricians, family practice doctors, pediatric occupational/physical/speech therapists, psychologists, psychiatrists and educators understand what PANS/PANDAS is. Providers who care for children play a vital role in recognizing how children may present with PANS/PANDAS so that they can be appropriately referred, diagnosed, and treated as soon as possible.

Only then is recovery possible.

What is PANS/PANDAS?

PANS (Pediatric Acute-onset Neuropsychiatric Syndrome) is an autoimmune encephalitis that can have multiple triggers - infectious and non-infectious. Infectious triggers appear to be more common than non-infectious triggers. PANDAS (Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal Disease) is a subset of infection-triggered PANS caused by streptococcal infection. However, many infections are now known to be possible triggers of PANS including Mycoplasma pneumonia, Influenza, Epstein Barr Virus, Lyme and other tickborne coinfections, HHV-6, HSV 1+2, Parvovirus B19, Coxsackievirus, Cytomegalovirus, and Candida. Non-infectious triggers include environmental toxins such as mold, heavy metals, and other toxic exposures, as well as metabolic disorders such as diabetes and lupus cerebritis. This diagram gives a better picture of how to think about PANS and all of its potential triggers.

How is PANS diagnosed?

The following are the current diagnostic criteria for PANS/PANDAS:

Symptoms of PANS/PANDAS can vary quite a bit, and the most common symptoms that I typically see in my patients include the following:

Dilated pupils
Anxiety
Separation anxiety
Behavioral regression (baby talk, watching cartoons from when they were younger, etc.)
Obsessive-Compulsive symptoms
Tics (vocal and motor)
Extreme mood swings/emotional reactivity
Rages/tantrums
Difficulty focusing
Slower processing speed (harder time understanding questions and concepts)
Poor short-term memory (doesn’t remember what they learned just the day before)
Handwriting decline
Food restriction (fear of choking, throwing up, contamination, etc.)
Hand tremors
Clumsiness
Heightened sensory issues (can’t stand certain sounds, smells, textures)
Urinary changes (frequent urination, feeling as though they always have some urine left)
Sleep difficulties

Not always abrupt and dramatic ...

While the current diagnostic criteria require an “ABRUPT, DRAMATIC ONSET” of symptoms, in my clinical experience and the experience of many other integrative and functional medicine practitioners – there are many children with a more “subacute” onset of symptoms. There’s a CHANGE somewhere in the past. Parents feel that their kid is different EVER SINCE some event. Maybe it was A CHANGE in mood, anxiety, sleep, focus/attention EVER SINCE the birth of a baby brother, or starting a new school, or after a divorce. A CHANGE that you think is “just a phase,” except the phase doesn’t end.

Consider the possibility of PANS/PANDAS whenever you find yourself thinking your child has changed, ever since …

If you don't look, you won't know, and yet another child will be missed…

Is There a Test for PANS/PANDAS?

PANS/PANDAS is a clinical diagnosis.

That means that there is no single test that will tell you if your child has PANS/PANDAS. Diagnosis starts with clinical suspicion.

While PANS remains a clinical diagnosis, the goal of testing is to determine the root causes(s) for why your child’s brain is on fire in order to better customize treatments.

Clinical history should be the guide as to which tests to run first.

Did your child have recent or recurrent strep infections in the past? Know that strep infections do not always present as classic strep throat. Kids can have strep in their throat, on their skin (impetigo), colonized in their noses, or as a bright red ring around their anus (perianal strep). Blood tests may reveal persistently elevated anti-streptolysin O (ASO) and anti-DNAse B strep antibody levels.

Did your child have any other infections that you remember may have occurred shortly before their neuropsychiatric symptoms appeared? Does your child get frequent cold sores? Do you hike in nature and enjoy camping as a family – could there possibly have been any tick bites in the past? Have you had any water damage in your home – could your child have been exposed to mold or mycotoxins? Any other possible toxic environmental exposures?

Quantitative IgG and IgM antibody levels should be assessed for possible infectious triggers of PANS, as indicated by clinical history or suspicion. These may include testing for Streptococcal infection, Mycoplasma pneumonia, Influenza virus, Epstein Barr Virus, Lyme and other tickborne coinfections, HHV-6 (the roseola virus), HSV 1+2 (the "cold sore" virus), Parvovirus B-19 (the "slapped cheek" virus), Coxsackievirus (the "hand-foot-mouth" virus), Cytomegalovirus, Candida, and potentially others as indicated by your child's history. IgM antibodies reflect recent or active infection. IgG antibodies reflect past infection. However, it should be noted that the presence of elevated IgG titers may represent persistent chronic active infection despite negative IgM titers. While under-recognized, this phenomena was noted as early as 1991 with severe chronic active Epstein-Barr virus infection syndrome (3). Targeted antimicrobial treatment should therefore still be considered for a child presenting with neuropsychiatric symptoms and very elevated IgG titers despite negative IgM titers.

If all antibody levels are negative and no infection is detected, non-infectious triggers must be considered. Appropriate testing should be performed as indicated by clinical history for mycotoxins, heavy metal exposures and other toxic exposures.

Despite the above testing, there will be children with PANS who do not have clearly identifiable triggers. For those children, the "Cunningham panel" offered through Moleculera Labs (4) in the United States can be a valuable piece of the diagnostic puzzle. The Cunningham panel, developed by immunologist Dr. Madeleine Cunningham who has been on the forefront of PANS research, tests for 4 neuronal auto-antibodies – these are antibodies against parts of your child’s brain (Anti-Dopamine Receptor D1, Anti-Dopamine Receptor D2L, Anti-Lysoganglioside GM1, and Anti-Tubulin) as well as activity of the CaM Kinase II enzyme (Calcium-dependent Calmodulin Protein Kinase II) found to be elevated in patients with PANS.

"Conventional" Treatment Approaches to PANS/PANDAS

Treatment guidelines for the Clinical Management of Pediatric Acute-Onset Neuropsychiatric Syndrome were published in the Journal of Child and Adolescent Psychopharmacology in July 2017. "Conventional" treatment for PANS incorporates 3 arms - psychiatric/behavioral interventions (5), immunomodulatory therapies (6), and antimicrobials to treat and prevent infection (7).

From a behavioral and psychiatric standpoint, it is critical that children work with a psychologist or psychiatrist who understands what PANS/PANDAS is. Even in the San Francisco Bay Area where I practice, just down the street from the Stanford PANS Clinic, there aren’t enough psychiatrists who really understand what PANS/PANDAS is. In fact, there are still too many psychiatrists who are skeptical that PANS/PANDAS even exists!

I have a beautiful girl in my practice with PANDAS who is now thankfully recovered.. Her family moved away when she was in elementary school and returned during middle school. She had been at the top of her class academically, loved by everyone socially, and a star competitive athlete. When she moved back, I barely recognized her. She had started cutting, and had extreme anxiety and OCD symptoms. Her pupils were widely dilated, heart racing, hands tremoring, and she had bruises all over her shins because she had become so clumsy. She was failing academically because she just couldn’t understand what was being taught. And if she did understand one moment, it would be gone the next. When I asked her questions, she would stare blankly at me, trying to understand what I was asking her, until she finally got it and slowly began to answer. Her psychiatrist had placed her on 2 different psychiatric medications – neither of which was really helping. I knew she was a different kid in front of me than the kid I had known years before. So I ran multiple tests, and found that she had very elevated strep titers. I started her on antibiotics and other functional medicine supports, and within 4 weeks, her mother called and said:

"She’s back."

Within 8 weeks, we were able to wean her off her psychiatric medications. She went back to her psychiatrist and told him what had happened, and his response was:

"You don’t have PANDAS."

Because it didn’t have an acute and dramatic enough onset. Because she doesn’t fit the “classic” PANS criteria. And because he’s not even really sure that PANDAS exists …

School accommodations must be in place so that parents are immediately notified of infectious diseases that may trigger a PANS/PANDAS flare in their children. Educational adjustments must be made with an understanding of the waxing and waning nature of PANS/PANDAS. There will be weeks where children will be completely neurotypical, emotionally regulated and performing beautifully in school, and weeks where these very same children will have debilitating fears, OCD symptoms, tics, memory and cognitive processing issues, severe handwriting decline and extreme mood swings.

Cognitive behavioral therapy (CBT) and family therapy are important adjuncts to any medical intervention. If access to a qualified CBT therapist is unavailable, Dr. Dawn Huebner's books cited below are invaluable tools to teach children and teenagers CBT techniques to manage their anxieties and OCD. Psychiatric medications may be necessary in times of crisis for severe OCD, anxiety, depression, ADHD symptoms, sleep disturbance, and other neuropsychiatric symptoms. However, these medications and behavioral interventions are only band-aids, and often not as effective as hoped until the underlying neuro-inflammation, infections, immune dysfunction, and other core clinical imbalances are addressed.

Anti-inflammatory and immunomodulatory treatments are often required in order calm the fire in kids’ brains, protect the brain and provide symptom relief in order for healing to take place. These therapies may include Nonsteroidal Anti-inflammatory Drugs (NSAIDs), oral and/or IV steroids, monthly high-dose Intravenous Immunoglobulin (IVIG), therapeutic plasma exchange or plasmapheresis, and IV rituximab. These treatments are designed to suppress the immune system, but do not address the underlying immune dysregulation that caused your child’s immune system to attack their brain in the first place.

Antimicrobial treatment and prophylaxis are critical in the management of PANS/PANDAS. Conventional antibiotic guidelines are more defined for the treatment of acute streptococcal infections in patients with PANDAS. The benefit of long-term antibiotic prophylaxis is less clear; however, most children do seem to benefit from prophylactic antimicrobials to reduce the likelihood of a PANDAS flare after repeat strep exposures.

There are fewer guidelines for the management of PANS triggered by non-streptococcal infections like viral infections or Lyme and other tickborne infections, and even fewer still for non-infectious PANS triggered by mold, heavy metals or other toxic exposures. For non-strep PANS triggers, working with an experienced functional and integrative medicine doctor is key.

The “conventional” treatment of PANS involves treating symptoms with cognitive behavioral techniques, psychiatric medications, immunosuppressive therapies, and antibiotics. While these may all be necessary, they often do not provide long-term relief. An Integrative and Functional Medicine approach is essential in identifying and treating root causes and core clinical imbalances from which many of our children with PANS/PANDAS suffer in order to achieve long-term remission and put out the fire in their brains for good.

Dr. Song’s 6-Step Approach to PANS/PANDAS

Integrative and Functional Medicine recognizes that there is no one-size-fits-all approach, especially for a condition as complex as PANS/PANDAS.

Treatment must be individualized to your child’s unique story.

My 6-Step Approach to PANS/PANDAS is not a protocol. It is not an algorithm. It is a guide that incorporates conventional treatments with integrative and functional medicine strategies that must be tailored to each child. I am sharing it now in hopes that it may be useful for parents who are embarking on a PANS/PANDAS journey with their child, for children with PANS/PANDAS who are “stuck” in their treatment journey, and for practitioners who are on the front lines helping our children in need.

STEP 1: IDENTIFY & TREAT THE ROOT CAUSE(S)

Let history be your guide to know which tests are most appropriate to do initially. Remember that there may be infectious triggers (Strep, Herpes 6, Herpes 1 + 2, Coxsackievirus, Parvovirus B-19, Epstein-Barr virus, Influenza, Mycoplasma pneumonia, Lyme and other tick-born infections, etc), and non-infectious triggers (heavy metals, molds, and other environmental toxins). There may be multiple triggers. And new triggers may arise with each “flare.” Treatments must be targeted appropriately.

Steps should also be taken to support the immune system to reduce the frequency of acute illnesses which may cause your child to spiral into a PANS/PANDAS flare. Immune supports may include optimizing Vitamin D levels, ensuring a phytonutrient-rich diet that reduces inflammatory foods (gluten, dairy, sugar, pesticides, processed foods, etc.), and optimizing lifestyle (sleep, exercise, time in nature, stress management tools).

STEP 2: PUT OUT THE FIRE

Inflammation must be reduced to protect the brain. Pharmaceutical options include “conventional” treatments with steroids and NSAIDs. More natural options include omega-3 essential fatty acids, curcumin, and antioxidants such as vitamin c and glutathione. Anti-inflammatory diet and lifestyle as mentioned above are key in putting out the fire and keeping it out.

STEP 3: KEEP THE FIRE DOWN

“Conventional” PANS treatments suppress inflammation, but this inflammation typically returns as medications wear off or new inflammatory triggers arise. Inflammation in an acute setting of infections or toxins is NOT a bad thing – in fact, inflammation is required to fight infections or toxic exposures. But once inflammation has done its job, the immune system needs to send out signals that it’s time to settle back down and restore a healthy, normal immune response. Chronic, unchecked inflammation is the problem in autoimmune diseases like PANS/PANDAS.

What is needed is a way to modulate the immune response so that a healthy immune balance can be achieved and maintained. Other than IVIG, which is inaccessible to many and does not provide lasting results in others, there are no conventional ways to modulate the immune response. On the other hand, functional medicine offers a variety of options that I have found to be very helpful in restoring a healthy immune response to keep the fire down. These immunomodulatory treatments may include Low-dose naltrexone (LDN), Specialized Pro-Resolving Mediators (SPMs), CBD oil and Chinese Skullcap (Baikal or Scutellaria baicalensis).

STEP 4: ADDRESS CORE CLINICAL IMBALANCES

PANS/PANDAS treatments should not just be about “killing” the bug(s). The goal of PANS/PANDAS treatments should be about restoring the WHOLE CHILD back to a state of optimal health. A Functional Medicine approach that identifies and treats core clinical imbalances is essential for whole child healing.

These Functional Medicine interventions may include:

Identifying and treating nutritional deficiencies and insufficiencies
Optimizing the gut microbiome
Treating a leaky gut and resulting food sensitivities
Addressing mitochondrial dysfunction
Optimizing methylation
Supporting detoxification

STEP 5: RESTORE THE BODY-MIND-SPIRIT CONNECTION

PANS/PANDAS is a journey with many ups and downs. The psycho-emotional and socio-emotional toll that PANS/PANDAS takes on each child and family cannot be discounted. Supporting the emotional health of the child and family with cognitive behavioral therapy, counseling, and support groups for the child, siblings and parents is essential. Stress management, mindfulness tools and vagus nerve work to restore the parasympathetic “rest-digest-heal” state are essential to not just restoring the mind, but to maintaining healthy immune, gut, and nervous systems. Read more about why this is so important in my article 6 Steps to a Stress-Proof Child.

STEP 6: INTEGRATIVE CARE

Be open and explore “alternative” modalities of care. Not one single practitioner has all the answers. And not one single treatment modality offers all the tools that your child may need in their healing journey. Modalities that may be beneficial include Homeopathy, Essential Oils, Acupuncture, Chiropractic, Osteopathy, and Energy Medicine, to name a few.

You can download my FREE 6-Step Approach to PANS/PANDAS HERE:

My parting message to you

To the mama and papa heroes going through a PANS/PANDAS journey with your child:

Don’t give up
Keep looking for answers, the right practitioner(s), the right team …
Don’t let anyone tell you that you, or your kid, is crazy

To the brave practitioners who are willing to believe, and to think outside the box…

Thank you!
We need more of you!
(For practitioners who want to learn more about my integrative pediatric approach to PANS/PANDAS and other chronic pediatric conditions, review cases, and get more mentorship, training, and support in pediatric-specific functional medicine, I created my Healthy Kids Happy Kids Practitioner Membership for you. I’d love to support you and see you inside.)

We're all in this together.

xo Elisa Song, MD

PANS/PANDAS Resources:

Dr. Song’s Talks:

Parent Online Resources

Aspire
The PANDAS Network
New England PANS/PANDAS Network
Northwest PANDAS/PANS Network
Stanford Area PANS Parent Support Facebook Group - this group also has monthly calls with guest speakers often from the Stanford PANS Clinic
The PANDAS Docs (Drs. Scott and Ellen Antoine)
Institute for Functional Medicine Practitioner Database

Practitioner Resources

School Advocacy

PANDAS and PANS in School Settings by Patricia Rice Doran

Books for Practitioners

The Comprehensive Physicians' Guide to the Management of PANS and PANDAS: An Evidence-Based Approach to Diagnosis, Testing, and Effective Treatment by Dr. Scott Antoine
Demystifying PANS/PANDAS: A Functional Medicine Desktop Reference on Basal Ganglia Encephalitis by Dr. Nancy O'Hara

Books for Parents

A Light in the Dark for PANDAS & PANS by Dr. Jill Crista
Brain Under Attack: A Resource for Parents and Caregivers of Children with PANS, PANDAS and Autoimmune Encephalitis by Beth Lambert, Maria Rickert Hong, Roseann Capanna-Hodge, Jennifer Glustra-Kozek, Lauren Stone
Childhood Interrupted: The Complete Guide to PANDAS and PANS by Beth Alison Maloney

Books for Kids

In a Pickle Over PANDAS by Melanie S. Weiss
What To Do When You Worry Too Much by Dawn Huebner, PhD
Outsmarting Worry by Dawn Huebner, PhD
What To Do When Your Brain Gets Stuck by Dawn Huebner, PhD

References:

http://www.aappublications.org/news/2017/03/28/Pandas032817
PANDAS Parent Survey April 2014, San Francisco
Okano Motohiko, Matsumoto Shuzo, Osato Toyoro, Sakiyama Yukio, Thiele Geffrey M,. Purtilo David T. Clinical Microbiology Reviews, January 1991, 4(1): 129-135. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC358181/pdf/cmr00042-0145.pdf
http://www.moleculeralabs.com/cunningham-panel-laboratory-testing/
Thienemann Margo, Murphy Tanya, Leckman James, Shaw Richard, Williams Kyle, Kapphahn Cynthia, Frankovich Jennifer, Geller Daniel, Bernstein Gail, Chang Kiki, Elia Josephine, and Swedo Susan. Journal of Child and Adolescent Psychopharmacology. July 2017, ahead of print. https://doi.org/10.1089/cap.2016.0145
Frankovich Jennifer, Swedo Susan, Murphy Tanya, Dale Russell C., Agalliu Dritan, Williams Kyle, Daines Michael, Hornig Mady, Chugani Harry, Sanger Terence, Muscal Eyal, Pasternack Mark, Cooperstock Michael, Gans Hayley, Zhang Yujuan, Cunningham Madeleine, Bernstein Gail, Bromberg Reuven, Willett Theresa, Brown Kayla, Farhadian Bahare, Chang Kiki, Geller Daniel, Hernandez Joseph, Sherr Janell, Shaw Richard, Latimer Elizabeth, Leckman James, Thienemann Margo, and PANS/PANDAS Consortium. Journal of Child and Adolescent Psychopharmacology. July 2017, ahead of print. https://doi.org/10.1089/cap.2016.0148
Cooperstock Michael S., Swedo Susan E., Pasternack Mark S., Murphy Tanya K., and for the PANS PANDAS Consortium. Journal of Child and Adolescent Psychopharmacology. July 2017, ahead of print. https://doi.org/10.1089/cap.2016.0151

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Reopening School in a Pandemic

As the start of the 2020-21 school year rapidly approaches, many of you have asked how I think schools should re-open. As a pediatrician who has cared for patients with COVID-19, a parent of 2 school-age children, and a mother of 2 children who had COVID-19 (1 of whom was hospitalized and had all the signs of possibly heading toward MIS-C), I have a unique perspective that I want to share. Know that this is my opinion, based on the limited yet emerging data we have about COVID-19 in kids, my personal and clinical experiences as a mother and pediatrician, and the reality we’re living in - which at the moment includes a surge in COVID-19 cases in most states, and a continued lack of adequate testing capacity for symptomatic and exposed individuals.

So how should schools re-open?

The reality is:
I don’t really know ... nobody really knows!

The reality is:
The world has never seen a pandemic like this before. Re-opening schools is one of the biggest social and medical experiments our kids will ever face - except they don’t get to provide consent.

The reality is:
In this time of uncertainty, the only certain thing is that within the first week or two of starting school, there WILL be a child with a fever, headache, runny nose, cough, sore throat, stomach ache, vomiting, diarrhea (all possible symptoms of COVID-19).

What Happens After a Child is Exposed to COVID-19 in School?

When there is a child in class with possible COVID-19, there are no clear guidelines what his/her classmates and educators should do - who should get tested and how long after exposure, is quarantine necessary and for how long, should the class quarantine together as a cohort?

The CDC defines an “exposure” as an “individual who has had close contact (< 6 feet) for ≥ 15 minutes” to a person with COVID-19 that is laboratory-confirmed or has a “clinically compatible illness,” whether or not they test positive. The CDC considers “exposure to have occurred “irrespective of whether the person with COVID-19 or the contact was wearing a cloth face covering.” Once exposed, the CDC recommends the exposed individual to “stay at home until 14 days after last exposure” and self-monitor symptoms - even if they test negative.

As for who should get tested, when contact tracing and testing is widely available (which it is not at the moment), the CDC guidelines include:

Contact tracing will be conducted for close contacts (any individual within 6 feet of an infected person for at least 15 minutes) of laboratory-confirmed or probable COVID-19 patients.
Testing is recommended for all close contacts of confirmed or probable COVID-19 patients.
Asymptomatic contacts should self-quarantine and monitor for symptoms for 14 days from their last exposure (i.e., close encounter with confirmed or probable COVID-19 case), whether or not they test negative.

I don’t know about outside the SF Bay Area, but it is virtually impossible for me, as a pediatrician, to find a clinic or ER that will test an asymptomatic patient who has had close contact with a known or presumed COVID-19 patient. And even if tests were readily available with a reasonable turnaround time (I’ve seen turnaround times of 14 days!), the CDC still recommends that all close contacts quarantine for 14 days post-exposure.

The California Department of Public Health just published its COVID-19 and Reopening In-Person Learning Framework for K-12 Schools in California, 2020-2021 School Year on July 17, 2020. It notes that if there is a confirmed COVID-19 infection in a classroom, the school should:

Identify contacts, quarantine & exclude exposed contacts (likely entire cohort) for 14 days after the last date the case was present at school while infectious
Recommend testing of contacts, prioritize symptomatic contacts (but will not shorten 14- day quarantine)

Your child will likely be home for 14 days after classroom exposure -
even if they're asymptomatic and test negative.

And let’s face it, in a classroom of elementary and middle school-aged children, even if their desks are spaced 6 feet apart and they are all wearing cloth face coverings, there WILL be “close contact” with a sick classmate. Have you ever tried to have a physical distancing playdate with your kids, whether they’re in preschool or in high school or any age between? We might as well call it physical magnetism... Even the California Department of Public Health has softened its COVID-19 Industry Guidance on physical distancing to recommend 6-feet distancing "if practicable." And when that close contact occurs, the CDC guidelines infer that ALL of those children should quarantine for 14 days.

Even if children start school this fall in-person, they will likely spend more time quarantining out of school than learning in school. And while everyone is rightfully concerned about the socio-emotional impact of kids NOT going back to school, I have huge concerns about the socio-emotional impact of kids actually GOING BACK to school. With mask-wearing, physical distancing, no recess or lunch, it’s not clear how much socio-emotional benefit and joy learners will actually derive from being in school. And considering almost ensured stops and starts to in-school instruction due to post-exposure quarantines, these unpredictable disruptions may cause significant socio-emotional harm.

In order to reduce disruptions to in-school instruction due to quarantines, parents must COMMIT to being responsible and NOT sending their children to school when there is even a remote chance that they might be sick - with anything. The days of giving your child Tylenol before school so that child's fever goes down and stays down for the entire school day are over. Symptom and fever checks may be useful in this regard, but nothing beats a mother’s spidey-sense when their kid is about to get sick. So if your spidey-sense is tingling, even if your child doesn’t have a fever or other symptoms yet, do your part and keep your child home.

Other countries who have reopened their schools have already witnessed these same starts and stops including Japan, South Korea, China, and Israel. France shut down its schools almost as soon as they were reopened after 70 new cases of COVID-19 were identified in school. This Summary of School Re-Opening Models and Implementation Approaches During the COVID-19 Pandemic dated July 6, 2020 shows that the highly-touted successful reopening of schools in Denmark and Norway without a significant increase in COVID-19 cases was due to low community transmission at the time of reopening - that is certainly NOT currently the case for the United States.

In areas of low community spread (which will require wearing masks, physical distancing, and flattening the curve), reopening schools likely SHOULD and CAN happen successfully. So if you would like your kids back in school soon, DO YOUR PART!

How is “low community transmission” determined? While it’s not a precise science, one of the factors to consider is the R₀ (pronounced R “naught”) of COVID-19. The R₀ value measures how easily an infection is transmitted, and predicts the potential for continued increase or decrease of that disease in a community. It basically is a measure of how many additional people, on average, a single person with COVID-19 will infect:

If R₀ < 1, each infected person spreads the virus to less than one other person. Case counts are predicted to decrease over time in that community and eventually fade away.
If R₀ = 1, each infected person causes one new infection. The number of cases in the community remains stable, but there won’t be big outbreaks.
If R₀ > 1, each infected person spreads the disease to more than one other person. The number of cases is predicted to increase exponentially in that community, with possible outbreaks or epidemics.

Michigan’s 2020-21 Return to School Roadmap, one of the most well-researched and thoughtful documents I’ve seen on how to reopen schools safely, recommends that schools NOT reopen for in-person instruction until the R₀ is <1 and community cases are decreasing. At one point in time, the R₀ of COVID-19 was predicted to be as high as 5.7. With inadequate testing and contact tracing, the true R₀ value is difficult to calculate as noted in this article, but it has NEVER been below 1 in the United States.

We know a lot more about COVID-19 than we did back in February, and the mortality rate has significantly dropped from early estimates of what was seen in countries like Italy and Spain that were hit especially hard in the early days of the pandemic - this is GREAT! However, the fact remains that as cases continue to increase at alarming rates, people are still getting very sick, and our ICU beds are filling up and reaching capacity again - precisely the situation we’ve been trying to avoid, so that doctors don’t have to be in the same tragic position that they were in Italy of choosing which patients should get the critical care they need.

The curve has NOT been flattened.

A study in China found that social distancing was paramount to controlling the spread of COVID-19, and “although proactive school closures cannot interrupt transmission on their own, they can reduce peak incidence by 40 to 60% and delay the epidemic.” Earlier data from China in April found that school closures alone would prevent only 2-4% of deaths, so community measures continue to be important. And remember, flattening the curve doesn’t mean never getting COVID-19. Flattening the curve does mean slowing the spread so that our hospitals can manage cases and adequately care for patients in need.

The reality is:

Even if schools reopen their doors for on-campus learning in the fall, if the COVID-19 pandemic worsens in the winter months as predicted, I think lots of us will be back to shelter-at-home and 100% distance learning at some point this fall/winter.

So, while I would love more than anything to see all children back in school, Kenzi and Bodi included, I really don’t believe that most schools and communities are ready to open up for in-person learning anytime soon - in a way that keeps our educators and children safe and thriving, and in a way that is practical and sustainable.

There’s no one, right plan. We’ll all be learning from each other, watching how other schools are doing it, seeing what works and doesn’t work academically and socio-emotionally, and observing which schools have outbreaks or not. And we all must be prepared to be flexible, on a week-by-week basis.

If there is anything that this pandemic has taught us,
it’s that life must be taken one day at a time.

We all want schools to look like they did pre-pandemic. But they WON’T ... at least not any time soon. And that’s the truth that we, and our children, must accept. It’s important that no matter how your child’s school decides to reopen, no matter how disappointed you or your child may be, that you remember:

Kids are RESILIENT.

Kids SEE the world through our lens. How positively or negatively we view an experience informs them how positively or negatively they should view that experience. School will reopen one way or another, and whatever the plan for your child’s school, they will remember this as a positive, or at least “OK” experience - IF WE DO, TOO.

Our school just announced that we would begin the school year with 100% remote learning with a phased plan for in-school instruction depending on community circumstances. And to my surprise, my first feeling was RELIEF. So many of us parents are in limbo right now, and we need informed leadership and wise decisions. Uncertainty creates the most anxiety. Before this announcement, though:

I had already decided that I would choose our public school’s 100% remote learning option and create our own “school pod” with a few of Kenzi’s and Bodi’s friends to stay connected socially and go through the curriculum together - even though Kenzi and Bodi both had COVID and may (hopefully!) have some immunity.

Yes, we are privileged to be able to choose this option. And I absolutely recognize that this is not a viable option for many families, YET. Not reopening school doors for in-person learning will have a disproportionately negative effect on children with special needs, our essential workers, working mothers, who during the pandemic have shouldered the brunt of child rearing and homeschooling, and many BIPOC and under-served families for whom school may be a necessary source of not just education but food and security.

But remember, we are almost assuredly going to be back to sheltering-at-home at some point this winter, and schools, childcare centers, and employers MUST be prepared to ensure the physical, socio-emotional, academic, and financial health of ALL of our children and their families. Whether or not school starts in-person in the fall, the time is NOW to figure out how to optimally support ALL of our children with a robust distance learning program that also fosters socio-emotional development and peer connection in a way that supports each families’ unique needs. And those schools that start with remote learning may have a leg up…

What about schools that are planning to re-open their doors to in-person learning?
How truly safe is that for our children and our educators?

Many schools are basing their decisions on the answers to 2 very important questions - the answers to which are still not clear but are absolutely critical to informed public health and education policy:

Do children get seriously sick from COVID-19?
Can children spread COVID-19?

THE PROBLEM: the data is LIMITED. Our children have been quarantining at home since shelter-in-place orders in March, and continue to be largely shielded from the outside world and coronavirus exposures. Most parents are still not taking their kids on Target or Costco runs like they did pre-pandemic (which might be a relief for some!). To say that kids don’t really get COVID-19, and don’t really get that sick from COVID-19, is a hopeful statement (I would LOVE for that to be true), but not based on an abundance of good data. As children re-enter society, we expect to see an increase in pediatric COVID-19 cases, just as we’ve seen an increase in cases in young adults as they have re-entered society. And with this increase in cases, the answers to these questions will become more clear.

Let’s look at the data we have so far, because to every extent possible, schools need to base their reopening decisions on the evidence at hand. The American Academy of Pediatrics issued a joint statement on July 10, 2020 along with the American Federation of Teachers (AFT), National Education Association (NEA) and The School Superintendents Association (AASA):

“Returning to school is important for the healthy development and well-being of children, but we must pursue re-opening in a way that is safe for all students, teachers and staff. Science should drive decision-making on safely reopening schools. Public health agencies must make recommendations based on evidence, not politics. We should leave it to health experts to tell us when the time is best to open up school buildings, and listen to educators and administrators to shape how we do it … schools in areas with high levels of COVID-19 community spread should not be compelled to reopen against the judgment of local experts. A one-size-fits-all approach is not appropriate for return to school decisions.”

Do Children Get Sick from COVID-19?

New pediatric data from Florida as of July 10, 2020, where they are seeing a skyrocketing number of new daily cases, reported that 31.1% of children tested were positive for COVID-19 - 16,797 children with COVID-19 out of 54,0222 children tested. That means 1 in 3 children tested were positive for COVID-19 - much higher than the 11% positive rate in adults in Florida. Cases were about evenly split between those children over 10 years (55%), and those under `10 years of age (45%).

The most recent US data on COVID-19 cases by age is from May 30, 2020 - which in “COVID time” is a lifetime ago. Between January 22 and May 30 ,2020, children 0-19 years made up approximately 5% of all laboratory-confirmed cases. That number is likely higher now. Data from California show that as of July 18, children <18 years represent 8.6% of all COVID-19 cases, but testing continues to remain woefully inadequate.

Kids obviously do get sick with COVID-19, and as children face more exposures with school reopenings, and testing becomes more widely available, this percentage will likely rise.

The data so far reassuringly shows that the vast majority of kids tend to do well when sick, sometimes get hospitalized and need ICU care, and rarely die.

Why children seem to get “less” sick from COVID-19 has been puzzling, as this is not the case for many other viral infections like influenza. The answer may lie in the ACE-2 receptor. In my article, Kawasaki Disease, ACE-2 & COVID-19, I describe how SARS-CoV-2 virus enters cells through ACE-2 protein embedded in the cell membranes of many of our organ systems (“functional” ACE-2 receptors). This recent JAMA study measured ACE-2 gene expression in the nasal passages of children and adults, 4 to 60 years old. Researchers found that children <10 years of age express significantly lower amounts of ACE-2 in their nasal passages than older children 10-17 years, young adults 18-24 years, and adults 25 years and older, with nasal ACE2 gene expression increasing in each age group.

CONCLUSION: Young children under 10 years of age may be less at risk for contracting COVID-19 and developing serious infection.

IMPLICATION FOR SCHOOLS: Reopening in-person instruction for preschool and elementary school-age children may be lower risk for children.

On the other hand, some children will get very sick. While death and serious complications like Multi-System Inflammatory Syndrome in Children (MIS-C) are rare, they are never to be taken lightly. As cases increase around the country, there are also increases in cases of MIS-C being reported in recent weeks, including in Florida, Wisconsin and South Carolina. And we have no data on the long-term complications of COVID-19 in children, including lung scarring and blood-clotting abnormalities, that may persist even for children with mild or asymptomatic disease. I will be looking closely for this data as it emerges.

Do Kids Transmit COVID-19?

I’ve heard many people comment that even if kids get it, they don’t spread it. So, if kids don’t get infected that easily, don’t get sick as often, and don’t transmit COVID-19 as frequently, then perhaps we should reopen school regardless of community spread since educators, parents and grandparents won’t have to worry as much about students giving COVID-19 to them.

Let’s look at some of the most recent data we have, because from a public health perspective, how kids transmit COVID-19 may be the most important question to answer.

Initial studies speculated that children were not big spreaders, especially young children. A Dutch study in March 2020 of 54 households with confirmed COVID-19 found that children under 12 were less likely to have COVID-19, and concluded that transmission appeared to be primarily between adults, and from adults to older children in the same household. There was a frequently-cited case of a 9 year-old French boy with COVID-19 who did not transmit the disease to more than 170 known contacts.

But more recent reports point to concerns that children may indeed spread disease, even if asymptomatic. A rigorous large new study from South Korea, where contact tracing has been extensive, found that children, especially older children 10-19 years of age, spread COVID-19 at least as often, or more often, than adults. Children under 10 years were about half as likely to transmit COVID-19. The average rate of COVID-19 transmission across all ages was 11.8%. Surprisingly, children 10-19 years had the highest COVID-19 rates of transmission any age group - 18.6% of their household contacts tested positive. Children 0-9 years with COVID-19 had the lowest rates of transmission - 5.3% of their household contacts tested positive. Better, but still not zero.

CONCLUSION: Young children under 10 years of age may be less at risk for transmitting COVID-19 to close contacts.

IMPLICATION FOR SCHOOLS: Reopening in-person instruction for preschool and elementary school-age children may be lower risk for educators and school staff.

The Korean study only looked at symptomatic children and adults. Given that as many as 40-45% of patients may have asymptomatic disease, it is also important to know whether asymptomatic children can spread infection. The answer to this is not entirely clear. However, a German study analyzed 47 children ages 1-11 years infected with SARS-CoV-2. Children who were asymptomatic had viral loads that were as high or higher than symptomatic children or adults. While this does not tell us how contagious asymptomatic children are, many studies show that a person’s viral load is closely tied to how infectious that person is. If this is the case with COVID-19, asymptomatic children may pose a higher risk to their classmates, educators and school staff, and household members than previously thought.

Socio-emotional, Academic, Equity & Other Concerns

The decision to reopen schools is not just about whether our kids, their families, and educators will get COVID-19. There are socio-emotional considerations. There are academic considerations. There are equity considerations. And there are non-COVID health concerns.

Young children in particular need peer interaction for optimal socio-emotional, behavioral, and speech/language development. The academic skills learned in grades K-2 set the foundations for future success in all subject areas. Young children in particular will have challenges sitting through online Zoom sessions - have you ever tried to FaceTime the grandparents with your 5-year-old?

For middle-school and high-school students, peer interactions become an essential part of their social development and emerging self-identity. Students are experiencing high levels of anxiety and depression due to the quarantine, and if continued lockdowns and school closures are a necessary part of keeping our communities safe, schools must find creative ways for students to stay socially connected and ensure that physical distancing does NOT mean social distancing and social isolation.

Children with special needs will likely be best served by in-person instruction and should be prioritized for safe return to school. If your child has ADHD, autism, dyslexia or learning difference, there is a very real concern that the academic gap will widen and they will fall further and further behind their peers.

Children in rural areas and underserved populations may have limited access to computers and internet access with enough bandwidth to support remote learning.

Families with working parents, especially single parents and essential working parents, must be prioritized for safe, in-person instruction, and must be supported by their employers with flexible work schedules, and job and financial security. The unacceptably high rates of joblessness must be addressed at a larger policy level.

Meal service providers must ensure that systems are in place to ensure that no child is hungry. A national Survey of Mothers with Young Children conducted in April 2020 found that 40.9% of mothers with children 12 years and under reported that their children did not have enough food to eat. US Census Bureau data from May 28-June 2 found that more than one-third of SF Bay Area households reported a lack of consistent access to affordable, healthy food.

We also must consider whether schools are structurally ready. Schools, especially those in urban and underserved areas, may not have the physical space to keep children 6 feet apart or hold classes outdoors. Given the increasing evidence for airborne transmission of COVID-19, schools may not have, or be able to afford, updated HVAC ventilation systems that minimize recirculating air, accommodate HEPA filters with adequate MERV ratings or have UV light technology that may reduce potentially infectious aerosolized particles.

The huge increase in screen time that school shutdowns have caused must also be addressed, for our younger and older students, with the resulting impact on anxiety/depression and potential lifelong implications for their developing brains. The Adolescent Brain Cognitive Development (ABCD) study is the largest long-term study of brain development and child health in the US that started in 2016, following over 11,000 children ages 9-10 years of age into early adulthood. Brain MRI scans of 4,500 children found significant “cortical thinning” (i.e., brain shrinkage) in children using digital devices for 7 or more hours/day (check your, and your child's, screen usage - trust me, 7 hours is easier to do than you think). Children using 2 or more hours/day of screen time had lower scores on thinking and language tests. While FaceTime, texting, social media, and internet games are an important way for children to stay connected socio-emotionally while physically distancing, the harmful effects of screen time must be balanced with the necessity of remote learning, and schools must think creatively about how they will present their curriculum to students, allowing for some non-screen learning and assignments.

Daily movement/exercise and optimal sleep hygiene must also be encouraged and prioritized by schools. The children in my practice who I saw doing better during school closures were the students whose schools maintained an online curriculum that mirrored their in-school schedule, with consistent start, end and break times. Predictability and routine are key for children to successfully navigate remote learning with minimal anxiety and stress. School attendance check-ins must be daily and required, so that children wake up at a consistent hour on school days, and hopefully go to sleep at a consistent hour on school nights. Even if the total number of hours seems adequate, going to bed at 3am and waking at 1pm is NOT a healthy sleep pattern that will optimize brain function and immune resilience during the pandemic. As part of this consistency, schools must maintain and require adequate movement and outdoor time each day. Too many children in my practice did not move their bodies every day, and some spent days without stepping a foot outdoors.

Optimizing sleep and exercise are critical for supporting our immune systems during the pandemic. An increase in sleep actually increases the number of your white blood cells. On the other hand, loss of sleep even for a few hours at night, increases inflammation in our body which makes us more susceptible to catching the flu and having more severe symptoms. Lack of sleep also exacerbates any attention/focus and behavioral concerns your child may already have. Moderate exercise can boost the production of macrophages, the kind of white blood cells that “eat” bacteria and viruses. However, intense exercise can actually temporarily decrease immune function – so don’t overdo it!

So, what’s my bottom line?

I fully support the reopening of schools - when it is SAFE(R).

In-person instruction is absolutely the ideal situation for children - as long as it doesn't put their health, or the health of those around them, at risk. In the meantime, while most communities experience continued rates of increase in COVID-19 cases, remote learning should be offered while ensuring the socio-emotional, academic, and financial security of all children.

When community spread is consistently on the decline, schools should re-open, beginning with our younger children under 10 years of age, who may be at lower risk for contracting COVID-19 and having serious complications, and may be less likely to transmit infection to more vulnerable school staff and family members.

In-person instruction should also be prioritized for special needs and underserved children for whom distance learning may not be feasible or safe for a variety of reasons.

But remember, the risk to educators and students of contracting COVID-19 will never be zero, even once community spread begins to decline. We can’t wait for zero risk. Our children, our parents, and our economy need schools to be open.

While the risk of infection remains, it is imperative to support our immune systems to be as resilient as possible. By the time this pandemic is over, the majority of us will have contracted COVID-19. If it’s a matter of WHEN, not IF, we will contract COVID-19, we must do everything we can to ensure that our children’s, and our own, immune systems are the least friendly host to the SARS-CoV-2 virus possible - that is what immune resilience is all about. The ability to contract an illness and bounce back quickly and fully, to be even stronger for the next hit. With an integrative and functional medicine approach to the pandemic, immune resilience is entirely possible. To get you started on understanding how to optimize immune resilience during the pandemic using food as medicine, diet & lifestyle, and targeted supplements, I’ve created the following resources for you based on my experience, clinical knowledge, and research as an integrative pediatrician and pediatric functional medicine expert.

COVID-19 RESOURCES:

Article: A Pediatrician’s Pandemic Immune Support Plan
Article: Kawasaki Disease, ACE-2 & COVID-19: what a pediatrician wants you to know
FREE Masterclass: A Holistic Pediatrician’s Guide to the Pandemic
Online Program: Integrative & Functional Medicine Strategies for the Pandemic

And be sure to stay tuned for my upcoming article on Preparing Your Child to Return to School Safely, to learn how to minimize your child's risks as their schools reopen for in-person instruction, whenever that happens.

Stay well ... we’re all in this together!

xo Holistic mama doc - Elisa Song, MD

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Kawasaki Disease, ACE-2 & COVID-19: what a pediatrician wants you to know

By now, many of you have heard that the UK has issued an “urgent alert” to all British physicians about a rare complication being seen in children called Kawasaki disease (1) - likely linked to COVID-19, upending our previous thoughts that children are “immune” to serious COVID-19 disease. Similar reports have come out of Italy and Spain.

There are increasing reports of other “non-classic” presentations of COVID-19 in children, including “Covid-toe” and hallucinations. And as I look back over the last month, I’ve seen ALL of these. My son with auditory and visual hallucinations (who ended up needing oxygen for 2 days in the hospital), 3 boys with swollen, bruised, “blood spots” (known as petechiae and purpura) on their toes, and 1 boy with Kawasaki disease. ALL of these boys tested NEGATIVE on nasal PCR swabs for COVID-19, but the UCSF specialists (and I) are convinced ALL of these results are false negatives.

So, what do I think is going on?

For the answer to that, we need to look more closely at how SARS-CoV-2 invades our cells.

How SARS-CoV-2 Invades

[All slides are from my FREE masterclass, “A Holistic Pediatrician’s Guide to the Pandemic: How to be prepared & what to do if you get sick.” Be sure to watch the replay before it comes down at midnight PST on **Friday, May 1, 2020**]

The SARS-CoV-2 virus has spike-like projections that look like crowns (hence the name “Corona-virus” for the Latin word “Corona” which means crown). These spike proteins bind to an enzyme called Angiotensin-Converting Enzyme 2 (ACE2), and once attached, the genetic material of SARS-CoV-2 (called RNA) gains entry into our cells. Viruses can’t replicate on their own, so SARS-CoV-2 hijacks our own cellular machinery to make more copies of itself. These copies are then released into our bloodstream to find other cells with ACE2 receptors to invade.

Here’s where it gets fascinating. The location of ACE2 in our body explains exactly why there are so many varied symptoms associated with SARS-CoV-2. It’s not that SARS-CoV-2 is randomly attacking ALL cells - it’s attacking those cells that have ACE2 attached to their cell membranes.

And guess where ACE2 is located?

ACE2 is attached to cells in our:

Lungs
Small intestine
Brain (cerebral cortex, striatum, hypothalamus, brainstem)
Blood vessels (veins, arteries, capillaries)
Heart
Kidneys
Blood vessels in our skin
NOT so much in our nasopharynx (maybe the reason for so many false negatives from nasopharyngeal PCR swabs?

This explains the respiratory, gastrointestinal, neuropsychiatric, cardiovascular, renal and dermatologic symptoms of COVID-19 - even the Kawasaki disease.

Kawasaki disease is a disorder characterized by inflammation of medium-sized arteries in various parts of the body. It can present clinically as prolonged high fever, red eyes, sore throat, swollen lymph nodes in the neck, swollen red palms and soles which eventually peel, vomiting, diarrhea, abdominal pain, and most worrisome - inflammation of the arteries of the heart which can lead to coronary artery aneurysm (bulging of the walls of the artery) with serious complications. We still don’t know yet exactly what causes Kawasaki disease, but it has been linked to various viruses, bacteria, chemical exposures, and now - COVID-19.

So should all of us parents be freaking out now?

NO!

Knowledge is power. And here’s where knowing more about ACE2 can help us understand from a functional medicine standpoint how to protect our kids from serious complications of COVID-19.

Serum ACE2 as a “Decoy”

ACE2 has gotten a bad rap these days, I think undeservedly. Initial concerns that medicines that block Angiotensin-converting enzyme (ACE inhibitors) and angiotensin II receptor blockers (ARBs) and INCREASE circulating levels of ACE2 could potentially worsen COVID-19 have been unfounded. No worsening of outcomes has been found with patients who are on ACE inhibitors and ARBs. And a recent study showed the exact opposite - that patients with high blood pressure hospitalized with COVID-19 who were on ACE inhibitors or ARBs had a 63% LOWER mortality risk than those who were not. (2) Current recommendations from cardiologists are that if you are on an ACE inhibitor or ARB for hypertension, to stay on it if you get COVID-19.

We need to understand the difference between:

ACE2 attached to cell membranes (aka membrane-bound ACE2 or ACE2 receptors), and
ACE2 that is floating around our blood (aka soluble or circulating serum ACE2)

We may not want more ACE2 attached to our cell membranes, as this could theoretically increase the number of entry portals for SARS-CoV-2 to enter our cells.

BUT, we probably DO want more circulating serum ACE2. Circulating serum ACE2 may actually act as a “decoy” for SARS-CoV-2 to bind the virus BEFORE it can attach to our cells and invade. Circulating ACE2 is PROTECTIVE against lung injury, septic shock and many of the chronic conditions that increase risk of serious COVID-19 infection in the first place.

Administering soluble ACE2 has been found to be protective in animal models of acute lung injury (ARDS) and sepsis. One mouse study (3) of acute lung injury and sepsis, that mimicked what is seen in human SARS coronavirus cases, found that lower serum ACE2 worsened acute lung injury, while higher ACE2 actually protected lungs. Another mouse study (4) of acute respiratory distress syndrome (ARDS) induced by avian influenza H5N1 (aka “bird flu”) found that ACE2 administration could improve lung function and survival rates. ACE2 inactivates Angiotensin II. Elevated serum levels of Angiotensin II were found in patients with H7N9 avian influenza, with higher levels of Angiotensin II correlating with worse disease severity and outcome. The authors speculate that treatment with soluble ACE2 could be beneficial for patients with SARS-CoV-1, which is very similar to the currently circulating SARS-CoV-2 that causes COVID-19.

And even more importantly, this study found that administering soluble human ACE2 could actually inhibit SARS-CoV-2 infections in vitro by a factor of 1,000-5,000. (5)

That’s a LOT of virus being stopped!

This diagram from the study demonstrates on the left how SARS-CoV-2 enters cells via ACE2 attached to cell membranes (“membrane-bound ACE2”), which can then multiply and release further coronavirus particles. On the right, we see that free-floating human recombinant soluble ACE2 circulating in our bloodstream (“hsrACE2”) can bind to SARS-CoV-2 BEFORE it can attach to membrane-bound ACE2, to prevent it from entering our cells in the first place, therefore reducing our total viral load, which would significantly reduce how many other cells get infected.

Lower number of infected cells = fewer complications (including Kawasaki disease).

How to Increase Serum ACE2

One theory behind why children in general still seem to have milder COVID-19 disease than adults is that children tend to have higher levels of ACE2 than adults. Most of us aren’t going to have access to human recombinant soluble ACE2 if we get sick. And ideally, we would have higher levels of serum ACE2 BEFORE we got sick with COVID-19 to stop as much SARS-CoV-2 from multiplying as possible. What if we could increase our baseline serum ACE2 to reduce the risk of serious complications in us and our kids - including Kawasaki disease?

Are there ways to increase our circulating levels of ACE2 naturally?

YES!!!

Here are the Top 5 Ways to Increase your Serum ACE2:

Regular aerobic exercise can increase ACE2, so be sure to MOVE your body every day! Both High-Intensity Interval Exercise and Moderate-Intensity Continuous Exercise have been shown to increase circulating ACE2 (6), so you don’t have to overdo it. And better yet - make it a family affair. Increase baseline serum ACE2 for the whole family!

Melatonin can increase ACE2 levels (7). Speculation has also been raised that perhaps children in general do better than adults because they tend to have higher melatonin levels. Make sleep a PRIORITY! Melatonin supplementation is actually being investigated as a potential therapeutic agent for COVID-19 (8). Most people know of melatonin as our “sleep hormone,” but did you know that melatonin also protects the brain and lungs; has anti-inflammatory, antioxidant and immune-balancing properties; AND can inhibit the NLRP3 inflammasome and NF-kB pathway implicated in ARDS, sepsis and cytokine storm associated with severe COVID-19 complications? In fact, the day after I started Bodi on melatonin, he quickly turned around, weaned totally off his oxygen, and his brain came back - my Bodi Bear was back! [Listen to my FREE Masterclass replay for more details on the top 3 supplements I believe helped Bodi turn around so quickly!]

Vitamin D is my #1 all-time favorite immune-boosting nutrient - so important during the flu season and especially now, during the COVID-19 pandemic. Cathelicidin produced by Vitamin D can neutralize LPS (lipopolysaccharides) that are responsible for so much of the damage that we see in sepsis, and also has antimicrobial and immunomodulatory effects. (9) Vitamin D deficiency may actually be considered a risk factor for sepsis and inflammatory disorders, and a new study finds a direct link between vitamin D levels and severity of COVID-19 disease (10). In this study, 86% of people with normal vitamin D levels had mild COVID-19 disease; on the other hand, 73% of people with low vitamin D levels had severe or critical COVID-19 disease. The authors conclude:
"This means that serum (OH)D level in the body could account for the clinical outcomes of the patients infected with Covid-2019. An increase in serum (OH)D level in the body could either improve clinical outcomes or mitigate worst (severe to critical) outcomes. On the other hand, a decrease in serum (OH)D level in the body could worsen clinical outcomes of Covid-2019."
Vitamin D deficiency is one of the most common nutrient deficiencies in children and adults. See my article A Pediatrician’s Pandemic Immune Support Plan for more guidance on getting in those Vitamin D-rich foods and potential supplementation dosages.

Vitamin A has amazing antioxidant and antiviral properties, and can increase ACE2 expression (11). As far back as 1928, vitamin A was known as the “anti-infective” vitamin (12). In fact, in regions where vitamin A deficiency may be present, the World Health Organization (WHO) recommends a 2-day high-dose vitamin A protocol to treat measles (13). Vitamin A is found in all those yummy, red-orange fruits and veggies. See my article A Pediatrician’s Pandemic Immune Support Plan for more ideas for Vitamin A-rich foods and possible supplementation dosages.

Curcumin is one of my favorite anti-inflammatory nutrients found in turmeric - think yummy Indian curries and golden lattes. Turmeric has caffeic acid (NOT related to caffeine), which was the active component in Sambucus Formosana Nakai (similar to Sambucus nigra or black elderberry) found to significantly inhibit replication and block attachment of another human coronavirus, HCoV-NL63 (14). Curcumin was also found to increase ACE2 and protect kidney function (15) - even more reason to believe that curcumin may be beneficial in protecting against serious COVID-19 disease.

Be Prepared When Society Reopens

As society reopens, we will see a surge in new COVID-19 cases, in children and adults.

Kids are getting sick, and we need to be prepared. As many as 5.7-20% of children with COVID-19 may require hospitalization, and 0.58-2% may need ICU care (16).

💗 I am NOT telling you this to scare you.💗

💗 I AM telling you this because I firmly believe that KNOWLEDGE IS POWER. And that a functional and integrative medicine approach to the pandemic is essential. 💗

The average length of hospital stay for pediatric COVID-19 is: 14 DAYS

Bodi was hospitalized for: LESS THAN 2 DAYS!

I absolutely believe that an integrative & functional medicine approach made a HUGE difference for Bodi, and that it can for your kids tooThat’s why I taught my free Masterclass: A Holistic Pediatrician's Guide to the Pandemic that is packed with actionable and practical information to get started on your family's immune support regimen. And for even more in-depth information as we re-enter society, I created my online program, Integrative & Functional Medicine Strategies for the Pandemic, to teach you everything I know as a holistic pediatrician and mama who’s had 2 kids recover beautifully from COVID-19, so you can:

💥Stay calm.

💥Be prepared.

Learn more about my program HERE: Integrative & Functional Medicine Strategies for the Pandemic. I’m here to support you and your family. We’re all in this together.

xo Holistic mama doc - Elisa Song, MD 💕

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