COVID-19 and Children with Special Health Care Needs: CCHCs Can Help

COVID-19 and Children with Special Health Care Needs: CCHCs Can Help

Kimberly Clear Sandor: Welcome, everyone. We'll let you all get signed in for a moment there. Wonderful to have you joining us today. Excellent. We're going to go ahead and get started. Welcome to the COVID-19 and Children with Special Health Care Needs session. My name is Kimberly Clear-Sandor, and I am a senior trainee and technical assistant associate with the National Center on Health, Behavioral Health, and Safety. Today's webinar – Child Care Health Consultation: CCHCs Can Help. We're pleased to see so many people are interested in this topic. And joining us today, child care health consultants can play an important role in supporting children with special health care needs in early childhood programs. As you continue to navigate the impact of COVID-19 pandemic on children with special health care needs, we hope today is an opportunity to consider approaches to common challenges and concerns.

But before we get started, I'd like to go over a few housekeeping items so that you can get the most out of today's webinar. First, we're using the Adobe Connect webinar platform. That is what you see on your screen. The beauty of this platform is it allows us to give you access to web links and file shares immediately. But the bummer is we can't see or hear you. That being said, we highly encourage you to chat with each other in the chat. Say hello, let folks know where you're coming from. Use this as an opportunity to connect with other colleagues across the country who are doing similar work. But I love it when everyone gives a little shout out and lets us know where they're from, and throughout the session, you can either type a specific question in the Q&A box, which is right below your screen. That's very helpful to us because then we won't miss your question in the chat. But please feel free to ask any questions as we go of each other and share any gems, or words of wisdom, or things that you've learned along the way that you think you may help with your colleagues out there in the chat as we go.

I'd also like to direct you to a couple of resources. Right below, in the middle of the screen, is a web link and a file share pod. In these two pods are actual clickable, downloadable, open items. In the web link pod, you can see the evaluation link is in there, as well as some other items we're going to direct you to and reference throughout our session. In the file share pod, you'll also see our certificate for today's session, a couple of handouts that we're going to talk about, and a PDF of today's slide deck presentation. Again, that information is below the screen. You will also be able to do an evaluation and get a certificate at the end. And we'll just remind you at the end how that will work at the end of the session today. This webinar is being recorded, and following this session, you will get an email with a link to the recording that will be active for a period of time. All right. Let's get going.

To begin, my name is Kimberly Clear-Sandor, as I mentioned before. I am a nurse and a family nurse practitioner who's worked in the Head Start and child care area for a very long time supporting nurses, working in early childhood settings – whether it be pre-K programs, in schools – special education programs, Head Start, and child care. I also work as a child care health consultant myself, which I love to get into the program, get to see the kids, and work on everybody working together for health and safety. Today, despite what our announcement said, I have a surprise guest that's joining with me today. And I'm very pleased to introduce Dr. Jill Sells. She is my colleague and the medical advisor at the National Center on Health, Behavioral Health, and Safety. Jill?

Dr. Jill Sells: Hi, everyone. I'm so happy to be here with Kim and all of you today. I'm a general pediatrician. And I’ve spent about 20 years really focused on early childhood and have really just been a joy to be able to partner with early childhood programs and other aspects of early childhood systems over the years, so this is near and dear to my heart. I'm currently serving as a medical advisor to the National Center on Health, Behavioral Health, and Safety, and that's how I've been able to connect with Kim for this. One of my roles with that is to lead our COVID expert work groups, so I've been spending a lot of time with our partners working to develop the tools and resources to support folks in the early childhood world. Happy to be with you today.

Kim: Thank you, Jill. We're happy to have you. I'd just like to ground everyone in. We're throwing out this big word – the National Center on Health, Behavioral Health, and Safety. And I just wanted to show you all the expertise that contributes to the National Center. The National Center is part of the Administration for Children and Families, National Training and Technical Assistance system, that's to build the capacity of Head Start and early childhood programs to promote health, mental health, and safety of children, families, and staff. And this slide really captures the breadth and depth of expertise that informs the product and the work we do at the National Center. We're all very happy to be working together to support you in doing your best work and supporting you to be successful in the work you're doing.

With that in mind of keeping us connected, I would like to encourage you to join our mailing list so that when we do have any resources or upcoming webinars, tip sheets, all the good stuff that we're putting out, that you get notice that it's coming out. You can subscribe to our mailing list and be in touch with us as we are able to share all the good work that we are doing. Now that you've got the chance to meet us, let's see who's joining us today. Kate, could you launch that poll? Go ahead and click the thing that best represents your title. Are you a child care health consultant, a Head Start health manager, a program center director, a teacher or caregiver, or someone that we haven't listed? We know there's lots of you out there that hold other titles, so please go ahead and type in the chat box what those other roles may be. We'd love to see who everyone is. And we know that some of you hold two roles as well, so appreciate that.

We see a child development specialist, a health specialist, health and mental health, a health consultant, monitor, mental health services coordinator, excellent. Disabilities and mental health, disabilities, family services specialist, thank you. Head teacher, agency nurse, excellent. Oh, we even have a home day care provider. Woohoo! Shout out to the family child care programs. And Blaine, thank you for sharing that you hold three jobs. I need a whole other poll for all of those. All right, thank you. Keep chatting away. I'd love to see all these names coming in. And I do know that some of you are Head Start folks that are also a health consultant or a health consultant working with the Head Start program as well. And what a wonderful combination of skill sets.

I'd just like to draw your attention for one moment to all the resources that are available, whether you're a director, whether you work in child care administration, or a teacher. If you work with a health consultant, please share these resources with them. I think you'll find them very helpful in the work that you're doing, and it will help to connect more health consultants to the work that we're all doing. The National Center for Health, Behavioral Health, and Safety does put on quarterly webinars for child care health consultants. Our last one was back in February maybe or March. We did it on health consultants in COVID. We're doing this session today on children with special health care needs and kind of looking at asthma as a case study. What does that look like right now? And then we have our third webinar coming up the end of August. I actually did put the link to register for it in the web links. You have to scroll down to the bottom. [Background noises] Yes?

But it is on August 26th, and we will be talking about the importance of well-child exams and immunizations especially in this time where we know so many children are playing catch up after the long year of the pandemic. But as you can see, there's a lot of resources online. We do post our webinars online. There's an online interactive community where you can chat with each other across the nation. We have child care health consultants competencies, as well as materials to help build folks' competency. The web link is there. I encourage you to check it out and consider how it may help you doing your work in the future.

Today, as we think about children with special health care needs and the work of a health consultant, health consultants specifically work together with programs. And I think that's the beauty of the relationship, is that it's a shared a vision, a shared goal on the work that you're going to be doing with your programs. And during the past year, COVID-19 and the pandemic has brought so much health and safety information to the forefront. I think all of us and everyone out there knows the importance that health plays in having healthy and safe environment and how important it is in order for children to be able to even come into early childhood programs. The health care consultant really is going to be thinking together with their program about the impact of the COVID-19 pandemic on children with special health care needs. Child care health consultants play a big role often in supporting reviewing plans, maybe doing training, talking to teachers, talking to families, and bridging that bridge between the families, the program, and the health care provider.

So important that we do pause and think about how the pandemic may be impacting some of our children and to think about the new strategies that are being used in early childhood programs. We call them the risk reduction strategies. How may they impact children with special health care needs? And also think about different areas that may need to be created, updated, readdressed because of the changes of the pandemic and ensuring that staff, children, and families are connected to resources they need. Child care health consultants have so many different responsibilities in supporting health and safety in early childhood programs across the country. I always say it's like 50 flavors. A lot of states do it differently. But we do very intentionally tie the content we provide to our child care health consultants competencies. Today's session, we did draw upon competencies related to consultation skills, health, safety, and wellness practices, policy development and implementation, health education, and resource and referral. And these are all areas of specialized knowledge and skills that health consultants bring to their work in working with early childhood programs.

Let's go ahead and we start talking about children with special health care needs, let's just do a quick poll to see what are the most common health conditions you see in your program. And you can choose more than one. We have anemia, asthma, allergies – and we're specifically thinking about those ones that require epinephrine – seizures, diabetes, and other. And please type those others in the box – chat box. Asthma is running away with it [Laughs]. We know asthma is the most common early childhood condition. And allergies and epinephrine is big. Seizures is big. Many of you are noting diabetes in your programs. Let me see if I can go in that chat box here and see what else is popping up in there. Lactose intolerance, eczema. We see a lot of the children with allergies. Whether they require epinephrine or just general allergies, we see that eczema component. Lactose intolerance, obesity, Chiari malformation, wow. Excellent.

Regardless of what common conditions you have in your program, all children have been impacted by the COVID-19 pandemic. We'd like to just start off talking broadly about all children with special health care needs. And then we're going to take a little bit of a deeper dive just kind of looking at asthma and thinking about asthma and how our children and families impacted by the pandemic, as well as thinking about what they may be impacted on in your programs as you're doing the risk reduction strategies. With that, I'm going to turn it over to Jill.

Jill: Thanks, Kim. We wanted to just lay out the definition that the Maternal and Child Health Bureau uses for children with special health care needs or chronic conditions. I'll just read the definition that we're going from. It's anyone who has or is at increased risk for a chronic physical, developmental, behavioral, or emotional condition, and who also requires health and related services of a type or amount beyond that required by children generally. It's formal language, but it's just to point out that basically everyone has some children with special needs in their program. And we're talking about the whole spectrum, from kids early on to people who have ongoing disabilities. It's a broad definition. And that's the context in which we're moving forward with this.

There is a national survey on child health that provides a lot of information that's done periodically. And from that information, we know that children with special health care needs are very common. Here, it's close to 25% of households. We would expect about one in four children would be in this situation. And as you saw on the poll, the data from there are very consistent with what you guys were talking about. A lot of asthma and allergies, ADD and ADHD are going to be more commonly noted as kids get older. But those are some of the common things just as you've described. They also talk about whether children have access to the medical care that they need, including a medical home. And in the most comprehensive definition of a medical home with all its components, which is what they're talking about here, less than half have that. It doesn't necessarily mean they don't have a place that they go, but it doesn't have necessarily all the characteristics that we're hoping to see. It's just important to be aware of both of these things at the same time. That this is very common and that families may not have all the support they need through the health care system.

We know that children who have special health care needs have things that impact their daily lives or their function. And from the surveys, here are some of the information that they've found – that the children may feel more anxious or depressed. They may have more behavioral problems that are a manifestation of the actual condition that they have or a result of how difficult they're finding it to live with the condition that they have. They may have difficulty learning, or understanding, or paying attention. They may have difficulty breathing or respiratory problems – certainly, folks who have asthma, that's the case. And all of these things might also show up as difficulty with speaking, or communicating, or being understood. And we don't have to tell you that – interact with young children in the programs that serve them – that all of these things can be interrelated and compound each other.

Kim: Yeah, I think this is so great, Jill, because – well, not that is great, but it's such good information to have as we're thinking about how important these skills are in early childhood programs and how children are developing these skills at this time. And after this year-long pandemic, if this is the baseline for many children with special health care needs to have their conditions have such an impact on these items, as folks are returning to program and coming back into your programs, working with our director and staff to anticipate that – just to be on alert that this may be worsened or heightened. And just to be aware in case it's a concern.

Although, we think about the year – I keep saying a year and a half. I should probably really count the months. But it's been a long time in the pandemic. And 18 months in a young child's life is a very long time, and they could have grown and changed in so many different ways. It's also just a good moment to pause and intentionally consider together with your programs about our children with special health care needs and to think about how can we provide them the support to be successful in coming back to the classroom? Thank you.

Thinking globally about children with special health care needs, we're going to just shift gears for a minute and look at COVID-19, the condition caused by the SARS-CoV-2 virus. And this virus continues to shape the way we interact and connect with each other, the way we learn, the way we play. It's touched on so many different aspects of our lives. And it is impacting children with special health care needs as well. Jill, can you just start off by telling us what we know about COVID-19?

Jill: Sure. And just really briefly, we've all been living this, so I know we know some of it. But sometimes a quick basic review is helpful. Just a reminder, as Kim said, we have this novel virus that's called the SARS-CoV-2, and it causes the illness that we call COVID-19. And while we have been in this pandemic for more than a year, this is still a relatively new virus, and we're continuing to learn more about it every day. But at the same time, there are things that are basic about it that are good reminder. It's a virus. It's contagious. You can catch it from other individuals who are sick from the virus or who have the virus. And some of those people are obviously ill and have symptoms, and some don't have any symptoms at all, which, of course, makes it trickier. What we do know is that the more people you are around, and the longer that you are around them, when there is COVID in the community, the greater the chance you have of catching the virus. That's why the precautions and things that we will talk about later to reduce risk have to do with limiting how much time you spend in close contact with other people who could potentially carry the virus.

Now, over time, as rates go down and more people get vaccinated, we will move more towards normal life, and we're in a transition phase now, so we hope is going in the right direction finally. But it's important to the local COVID information in your community, and the CDC does have a great tracker that's called the COVID Data Tracker. And in that, you can look up your state or by county, and it can be really helpful to look at those periodically. And overall, the healthier that we all are, the better chance our bodies' immune system has of fighting any virus including this one. It's important for all of us to remember and to share with others the importance of engaging in these risk reduction strategies but also health promotion activities –the things that we sometimes forget to do well when we're busy or stressed – eating well, sleeping well, and getting exercise.

A reminder, this is a virus that we know now is transmitted through the air. It is expelled when people breathe, and when they talk, and when they sing, and it travels through the air. There are different sized droplets that come out when that happens, and some of those small droplets stay in the air and can get spread directly that way. Some of the larger ones may fall and land on surfaces. And if you touch that surface and then touch your nose, eyes, or mouth, you may introduce the virus to yourself. Early in the pandemic, we were worried more about touching surfaces than we are now. It's certainly still possible. But we know that the biggest risk is through the air directly.

Let's see. As you know, we've talked about it before it's really important for our health consultants and others working with programs to understand the different ways that the virus is transmitted and the ways that we can reduce that risk because each of those risk reduction strategies takes a different approach. And together, they can help in limiting spread of the amount of virus within any given environment. When we think about children with special health care needs or adults over time, one of the things that the CDC and others has worked to understand is who – we know anyone can get sick from the virus, but who might be more at risk? And this has continued to evolve over time. But it is true that some children who have certain medical conditions might also be at increased risk of severe illness compared to other children. And the bottom line is this really depends on the child and their condition. And understanding this risk is something that the family – really want to support families to do in consultation with their child's health care provider. But we know that asthma and chronic lung disease are things that can increase risk. Other things like some neurologic, genetic, or metabolic conditions, having heart disease since you were young, being immunosuppressed or having other complex medical disorders.

We don't want to exclude children from programs but we're trying to move towards what we've always done, is wanting to be inclusive and support the needs of all children and families that come in for care, and for school and other services. But in this situation, we want to help families understand what the risk might be if there is one and how to mitigate that.

Kim: And Jill, they can really work with their health care provider. And I think as health consultants, if children and families have concerns or staff have concerns, it's such an opportunity to bring everyone together, talk about those concerns, connect with the child's health care provider so that together, you can develop a plan that's going to work for everyone. Making sure everyone's aware of what things are happening in the program to mitigate the risk. For instance, you in an office may not know all the cleaning, sanitizing, daily health checks –everything that's going on in an early childhood program that's mitigating those risks. And how are we using that? And what types of things are we doing? It's a great opportunity to really strengthen that relationship with the team surrounding the child by having this kind of a conversation. Thank you for bringing that up.

We thought we'd just take a moment to just chat with all of you to hear what's going on in your area. What challenges are your programs having with children with special health care needs? What are your concerns about children with special health care needs back in the program? Let's hear from you. Go ahead and chat in the box. Any things that are going on in your program. I will give you a second to go ahead and type those in there. Carolyn said, “We definitely need guidance about toothbrushing in the classroom.” There are some resources on the Early Childhood Learning and Knowledge Center for Head Start programs about toothbrushing in the classroom. I'm not clear if there's other guidance out there, but that is something we can look into for you.

Children with diabetes, children with asthma whose parents prefer nebulizer treatments – we'll talk about that a little bit. If a child has allergies, they typically have a runny nose. Thinking about those symptoms that require children to be excluded is definitely a big challenge when a child may have special needs. I know this is moving fast, so I know I'm missing things. The rainy days, the pollen, the windy weather. You must live in the Northeast with me, Judy. All these weather changes are definitely irritating young ones, especially if they have asthma or reactive airway disease. Folks are having a hard time collecting health information during this time, thank you. Yes, Head Start programs have suspended toothbrushing at this time, encouraging families to brush teeth at home. We have to wait … Some folks are having trouble with medical provider documentation, getting health care forms filled out, great. Collecting health forms. I see a theme there, Jill. Go ahead. Keep typing them in there because I'm going to keep glancing while Jill is sharing more. Jill, can you tell us a little bit of what we've been hearing about how COVID-19 has impacted children and families?

Jill: Sure. Yeah, there are several areas that we've heard a lot about. One is health care provider access. We'll talk a little bit more about that. Medical equipment and supplies and community supports. These things can be challenging – all of them – for children special health care needs in normal times. And for the most part, they may have all been made more difficult in these times. As you know, health care changed a lot at the earliest part of the pandemic. And for a period of time, many services were shut down or really curtailed – in-person visits. Pediatric providers across the country – everyone was trying to be careful about this new virus that we didn't understand. There was a move towards engaging more with telehealth, with video visits, or phone call visits, or other ways to try to minimize the risk of interaction between people in the office. A lot of those modifications have happened. And where we are now, however, is there definitely has been a move to change that and get people back into the office. We now know how the virus is spread. We know all the risk reduction strategies.

And going into a medical setting, following those protocols is really quite safe. There is a recognition of the need to understand what health care kids have missed in the past, whether they have health special care needs or not, and to try to encourage folks to come in.  But given that backlog, given that there's a lot of people who need care, it is certainly possible that there will be challenges for folks to get in. Encouraging programs and supporting programs in their efforts to work with families to understand if they're trying to get into appointments or not. And if they aren't, to encourage them to understand that it's important to get back into care and that it's safe to do so following precautions. And then helping support them if they are finding barriers to being able to do that.

Kim:  I think when you said supporting barriers and helping folks realize it's safe to do so, Jill, a couple of the comments in the chat, folks said that parents are worried about bringing their children in for those visits. Anything you can do to have conversations with the office and find out how they're doing things to help support the families in feeling safe in going into the programs I think is critical. And like you said, the transportation – the schedules have changed, the access has changed, the mobility to get back and forth is tricky.

Jill: Yeah, and I think it's really important not to make assumptions because things – any given family, you might have one family who hasn't tried to make an appointment because they don't think they're supposed to, or they're still working under the assumption that they aren't available. Or they're nervous for good reasons, like Kim has described. Some provider offices have plenty of appointments and are working hard to do outreach and to encourage folks to come in and could use assistance with that communication and say, messaging. Others may have shortages of appointments of what they need. I think the bottom line is being aware that any of these things may exist and to open the conversation in a proactive way of, “How are things going? And what do you need?” And understanding the situation and then helping to bridge whatever the challenges are that you find.

Kim: Yeah, thank you. Oops! Advance – there you go. Jill, what about medical equipment and supplies?

Jill: I was talking about it while I was muted. Sorry about that. The same issues really apply to medical equipment and supplies. You can't assume except to know that there might be challenges. We are seeing shortages in all kinds of products across the country, not just in the medical world. The pandemic, the way that it shut down the economy in various places may have impacted a lot of those things. But it may not have, or families may have not been going in to regular appointments where they normally would get the renewal that they need or the paperwork that they need in order to access things which might be covered by insurance, for example. The best thing again, is for us all to be aware that this might be an issue. That people's normal supplies may have dwindled to a lower amount than normal or that processes to get refills for whatever they need may take longer. Again, asking the question of families and learning in your community what the reality is so we see whether there are actual barriers and then help to address those barriers in the same way.

Kim: And as health consultants, you may be very tied in to the resources in your community that families or other providers may not have uncovered or tapped into – working with children's hospitals, working with your local food pantries. Sometimes they also have connections with other supplies. It really taps into your role as a connector to those resources in the community to try and support families' problem solving. It's a great comment too that they might have had a lot and now they're just dwindled down to the last little bit. When we're asking families to bring medical equipment and supplies into the program as well, that really gets to be a challenge because they are balancing two places where their child is being cared for. Approaching that with care and support is really critical. And what about community support?

Jill: Yes, so likewise, communities have had all kinds of challenges during the pandemic. And these can vary tremendously geographically. Again, I think the – starting with the assumption that probably some things are harder than they used to be is a good place to start. And understand also that many families have been in need of services now that weren't necessarily in the past. There's new needs around food and other things that some families have never experienced the need for. Communities may have less services in the past for all of the reasons you might guess. But they might also have implemented creative new strategies during the pandemic. We've just seen really a lot of ingenuity and people in communities discovering a need and creating new ways to address that need and make sure families have what they need.

Again, it's important to just be aware and ask questions and encourage those who are supporting to ask those types of questions. Both of those you serve and with your community partners so that you can be in a good position to try to bridge the needs and the capacity to meet them.

Kim: And really talking with your program leadership, and teachers, and staff to just kind of keep their ear open. As Jill said, many folks may be in a position where they haven't accessed services before and now they may have a need. Being a good listener and hearing any of those concerns, approaching these things in a very sensitive nonjudgmental way, it's going to be such an important way that we can support children and families. It may be a good time to share. Just make an assumption in this case right, Jill? Make an assumption that somebody out there may benefit from this information. And post information in a newsletter, on a bulletin board just to normalize using resources and make them available and accessible so folks know where they are. I think it's so important.

And I think food is such a great example of some of the changes that we have seen during the pandemic. Jill, do you want me to review this, or is this something you want to talk about?

[Inaudible]

Jill: The resources? Go ahead.

Kim: There we go. Yes. Food is a great example of a community support the families may rely on from time to time. We know that in early childhood having good healthy food is so critical because there's so much growth and development that happens in the early childhood time. We also know that poor access to food impacts education and learning, and we want to do everything to put our kids in a best position to fully benefit from all the wonderful things happening in early childhood programs. Food insecurity is a new idea. They do have a definition, and they say it's having “limited or uncertain access to sufficient, safe, and nutritious food to meet dietary needs and food preferences for an active and healthy lifestyle.” And some of you perhaps during the pandemic may have partnered with school systems or been part of different things going on in each community that help provide food to folks with changes in employment and other services that are out there. And the pandemic has really heightened the concern about food security.

How do you support food security with children and families? They have these questions that you can ask. According to the American Academy of Pediatrics, a screening assessment tool as simple as a question can actually help identify families struggling with food insecurity. It can be done by asking families if they can relate to the following statements. And they are: “In the past one to two months, we were worried whether our food would run out before we got money to buy more. In the past one to two months, the food we bought just didn't last, we didn't have money to get anymore. And in the past month or two months, we've had to lower the quality of food because money was tight.”

Answering yes or relating to the style of question may indicate a family is struggling with food insecurity, and they may not even realize that they were expressing it. This may allow staff and others to recognize the need and then connect folks to resources. Note this is a nice example of a way that health consultants can support programs in thinking about the broader needs around health for children and families and the way the pandemic has impacted them. If you do want more information about food security, please feel free to reach out to the Center. And we have lots of information on the Early Childhood Learning and Knowledge Center.

I do want to just comment that quite a few of you have been chatting in the box that you've been open for quite a long time, implementing the health and safety protocols and doing very well. And I just want to amplify that, congratulate you, and I think it's so helpful that you share all your successes out there. Some folks have been returned or have been open and are really thriving at this time. Some folks are just starting to open up and welcome children back. No matter where you are in the continuum, you've got this. And I love that your colleagues are sharing those successes with you in the chat. Take a look at that chat as we go along, and maybe you'll find the words of encouragement as well.

All right. COVID-19 has also adjusted how our programs operate. And like your colleagues are saying, you've got this. Early childhood programs have always handled infectious disease. It's not a new concept that young children have colds and get sick during the year. And when you bring groups of children together, they do seem to spread around illnesses. I think as early childhood folks, you're very familiar with that. But in our last Health Consultant webinar series, we really dove in-depth into these risk reduction strategies and the importance of the consistent and correct use of this strategy to really help minimize the transmission of COVID-19 in programs.

And it's really what we're thinking about now. The pivot is to think about what are these risk reduction strategies and how are they impacting children with special health care needs? The risk reduction strategies that programs are implementing – you may need to adjust policies; you might need to do some additional training. But these are the basic strategies. The first is screening. We do daily health checks. We often do them outside because we don't want anyone who's sick to be coming into the program and to be potentially spreading illness around. Masks – wearing masks is a brand new thing. This is being done in early childhood programs to prevent the spreading of the infection.

We do distancing. We are recommending 6 feet of distancing. Pre-pandemic we had cots and cribs 3 feet apart so that children didn't spread the air. And now with the pandemic, we're extending that to 6 feet apart so children don't spread the air. And that's also part of keeping groups together, and not sharing spaces, and still keeping staff that 6 feet apart. Hand hygiene. Covering a cough using a tissue. Early childhood programs excel at teaching these skills. And they're just as critical now as they have always been. And the cleaning, sanitizing, and disinfecting. Again, this is part of the early childhood routine. We're really paying attention to the labels, ensuring folks are using things correctly. Mixing them correctly, letting them sit on surfaces for the required amount of time is really, really critical. And the new thing is that disinfection of those high-touch surfaces frequently throughout the day.

Our programs are looking at ventilation – how can we bring in more fresh air? How can we exchange the air that's in the room, move it out, and get fresh air in? That's a big strategy. Folks are sometimes doing more things outdoors so that we really can achieve that maximum ventilation. And then we have vaccines. We know that our early childhood teachers were part of that first line essential worker opening to get the vaccine, and many of them have been getting the vaccine across the country. All these mitigation strategies together really provide the greatest level of protection in the program. And not all of them are new, but they all work together to really keep everyone healthy and safe.

What we're going to do now is say, “OK, so we're doing all of these things. How might any of these things impact children with special health care needs?” And we're just going to go through the idea of asthma as an example. But we encourage you to think through the strategies and think about how they may be impacting your children with special needs in your specific program. We're going to go ahead and start with looking at asthma. We're going to consider how the needs of a child with asthma may benefit or be challenged by some of the risk reduction strategies that we're implementing because of COVID-19. We saw from your poll, the majority of you also have lots of kids with asthma. Hopefully, this will be a helpful exercise. Jill, tell us a little about asthma.

Jill: Sure. As we've already talked about, very common condition, and it can vary in different groups. And we know the prevalence is higher in Black and Hispanic families than white children across the country, but it's a very large number no matter what group you are looking at. And how asthma manifests is different in each child. And the younger the child is, the less that the family has learned so far about how their child is developing and how their asthma is acting. It's just so important to be in partnership with families around understanding the individual child, and then we will talk here about some general ways that we can make things better for kids with asthma.

Just a really quick review. When I was in medical school and early in training, we talk about reactive airway disease. And I think it's helpful to think about these are airways that react. They are normal in appearance, but they react differently than a person who doesn't have asthma. And this is just a cross-section of those small airways showing that you have a tube, and that tube has a lining in it, has space in there, and has muscles surrounding it as well. And when those airways react in a person with asthma, several different things can happen. Those muscles can tighten and just spasm and narrow that airway, mucus can be produced and fill up the space inside that straw, and swelling can happen in the walls of the airway. All three of those components can be happening in a person with asthma at any one point in time.

Asthma triggers. There are tons of them, but some are more common than others. But it is important for each child and family to understand what tends to set them off. I'm not going to go through this whole diagram. But certainly, getting colds, just having a virus of any kind, whether it's COVID or anything else is often a trigger for kids, exercise – it happens – various allergens, pollution. Any of these things may be a trigger for a individual child.

Kim: And I just want to point out – you mentioned the respiratory infections is a big trigger. We also know air pollution can be a big trigger. Strong smells, such as fragrances, chemicals, can be the trigger. And those are important to keep in mind with our strategy.

Jill: Yes, exactly. And if you are a person who is fortunate and doesn't have asthma, but you've got a good sense of smell, you may notice things in your environment that just bug you, or that you noticed them, or you might feel them in your throat. Or certainly with the bad wildfires, anyone who was around that kind of smoke, which could feel uncomfortable even if they didn't have asthma. You think about the kids who have this tendency and all of those things are going to be magnified in their lives when they're exposed. This just shows an example of an exposure to pollen and that all of those changes that I just described might happen with them. It's really just a reminder that prevention is always the best approach in anything that we do. It would be nice if no one ever reacted. If their airways never had this reaction.

To the extent that we can reduce the presence of triggers in children's lives at home, and in child care, and Head Start, and other settings, the better off the child will be. That's the importance of understanding those triggers and trying to eliminate them.

At the same time, it's understanding again what a child's triggers are and what a child looks like when they're having a reaction. There are certainly things that sometimes are obvious in terms of looking at kids – they may be coughing more. They may be obviously having a harder time breathing. But each kid looks a little bit different. And some children are able to perceive that something is changing in them, and others are less able to do so. It is important, again, to understand what the common symptoms are. Understand what they are for this child so that if they are having a response to something, it's recognized early and is addressed to see if they need some medication in the child care or other setting.

We wanted to tie this back. As Kim said, we're using this as an example of a health care need that someone might have and a very common one. But we're also trying to highlight that many of the normal preventive strategies that we use in early childhood education settings to reduce the risk of health problems also work to help with COVID. And many of the things that we are doing with this added precautions to reduce the risk of COVID transmissions, they're all actually really good things for all kids and for kids with asthma. By doing things that help minimize the spread of COVID, you're helping all the kids and particularly those with asthma. The wearing of masks, the washing of hands, good ventilation, all of those things are good for children's respiratory symptoms if they're done in the ways that are recommended.

I'm going to hand this back to Kim here for a second. I know she’s already talked about some of this, so maybe you just want to do this briefly, Kim?

Kim: Yeah. I'm actually going to pop right over this slide here. I just want to let folks know that we actually made a tip sheet on caring for children with asthma during COVID-19. It's in our file-share pod. It's a nice one or two pager that highlights some of the pieces that we're going to be talking about next. First off, we just want to highlight screening. As you said, many of you are doing your daily health check. It is the first layer because it keeps anyone who's sick from coming into the program. And it's impossible to predict who's going to get sick during the day, but it's important that we communicate all the signs and symptoms of infectious disease, including COVID-19 with children and families.

Because there's a huge range of symptoms for children with asthma – I mean, the children with COVID-19, it's also important to know what's your child's baseline? Or what other children in your program with asthma, what's their baseline? Many of you mentioned coughs. That the children have coughs. Children have asthma with coughs. It's important to know what's normal, what's not normal, and what are your staff and teachers supposed to do when a child with asthma comes to the center and you're doing the daily health screening. Jill, can you tell us a little bit about the overlap of those symptoms?

Jill: Sure. You know COVID-19 is a virus. It's related to cold viruses, and so it can look similar to many other things. And it could trigger some similar symptoms as a child with asthma have. And you'll have this slide to look at. But I think the most important thing to remember is that we need to understand what a child's baseline is.

What does this child look like normally when they're living with asthma? What do they look like when they're at their best with asthma? What do they look like when things are changing? And are there things that are happening that make us worried they might have a new illness? By screening through the normal protocols related to COVID-19, we'll be able to distinguish – not distinguish, but consider what we need to consider for all kids in terms of the risk of their exposure to COVID. But for the kids with asthma, it's really about understanding and supporting their health care needs around that.

Kim: And just to be clear, the symptoms that are posted on the slide are just a way to look at the COVID-19 symptoms compared to the asthma symptoms. This is not the exclusion list that's posted on the CDC. This is really looking at the difference of those two symptoms, which is important for your families to understand so that you're having those good conversations.

OK. Let's just think for a minute about masks. We know that masks are a simple barrier to prevent droplets from traveling into the air and sharing with others. As folks have noted in the chat, children under the age of 2 should not be using the mask. If someone's not able to remove the mask, they should not be using the mask. And there should be no mask during meal and sleep time. And it's important to make sure that masks go all the way around the face. And this might have been a new conversation a year ago. I don't think talking about masks now is new for anybody. But Jill, are there any concerns about children with asthma and wearing masks?

Jill: No, in the sense that children who have asthma that's controlled should be using the same guidance as anyone else using masks. It doesn't reduce their oxygen level or anything sort of at baseline. Now, if the child is having respiratory distress and concerns with their asthma, we need to manage that situation. That may mean taking off the mask and understanding what's happening and having precautions. But in general, they should be wearing masks just like anyone else would be.

Kim: Yeah. And if they're having an asthma episode, they would be taking the mask off, having their medication if that was needed. That might be something to plan for, but in general, they're good, right?

Jill: That's right.

Kim: Cleaning, sanitizing, and disinfecting. Again, not a new concept for all of you out there in early childhood programs. We know that viruses go in the air, and they land on places. When they land on surfaces, they can be picked up by hands and brought to the nose, the eyes, the mouth. Cleaning, sanitizing, and disinfecting is just as important now as it ever was. And really, the guidance on cleaning, sanitizing, and disinfecting hasn't changed. It's really the increased focus on disinfecting those high-touch surfaces. But things to keep in mind because of children with asthma, and we talked about those triggers. Choose and use products very carefully. Look at your labels, see if you can find things that are fragrance free. You want that because that's going to irritate their airways less. Look at those label instructions, and be sure you're following them closely. More is not better [Laughs]. You really just want to follow what it says to achieve the sanitizing and disinfecting levels of germ killing that you are looking to do.

It's important as always to not use these products when children are nearby. And when you're using them, really make sure that airflow is good so that any odors that are there are not just sitting in the environment. There are lots of new products that are out there that are less likely to cause asthma attacks, such as some products with hydrogen peroxide or ethanol. Lots of different things out there. Pay attention to that as a strategy because you know that there's so much intentionality around the cleaning, sanitizing, and disinfecting. And because these triggers are the most important thing in keeping asthma lungs healthy, this is an example of an asthma-friendly child care checklist. You can also find it below in the file share. And it talks you through many different things you can do in your program to reduce the triggers that are in your program on a regular basis and may help you think about others in addition to the strategies you're using for any particular child. There may be strategies that you can just employ globally in your program to reduce the amount of triggers in your program.

The ventilation is another strategy that there's a lot of attention in at this time because it's all about fresh air. Bringing nice fresh air into the room so that any virus and things in the air is either getting cleared out or it's moving along. As Jill said, the respiratory droplets can get into our nose and mouth and really make someone sick. Health consultants can bring up ventilation with their programs and really be a resource to direct them to some of the resources on the CDC that help guide some of the adjustments to ventilation programs. If you're going to be opening windows, really working with programs to do that in a safe way and to ensure that you're not going to cause any harm to children. Also, spending time outside is something else that needs to be very thoughtful to make sure they have that good air quality. Jill, could you talk a little bit about good air quality?

Jill: Yeah, I'll just echo what you said, and I'll add a lot more to it. But just that we're understanding more and more how important it is and that we're paying attention to what's happening within the indoor setting. And having it be as filtered and as clean as is visible for the setting is important. And bringing in outside air to the extent that it's safe to do so is really important. It's just an opportunity to ask those questions to the programs that you're supporting and see if they are seeking the support from folks who know how to make their ventilation system as healthy as possible to support them in their efforts to do that.

Kim: Yeah, the CDC has a great ventilation page that you may really like [Laughs]. As Jill was talking about knowing every child, knowing their baseline, knowing what to do … Oh, Jill. I'm totally jumping in on this on you. [Laughs]But is this the other action plan?

Jill: No, no worries.

Kim: I know we're running out of time.

Jill: No worries. It's just that we've talked about this in general before. And just a reminder, that asthma in particular has had a lot of work over the years in really writing up these plans for families to have at home and for use in child care in school settings and is really – really helpful. Reminding folks that these should exist, reminding folks to get them updated as needed, and spending time, if needed, so that people understand the different components of what a child looks like when they're in the screen, doing well zone, and if that child is taking any medications or not, and then what happens if we move it to the yellow zone with some concerns. How should the family or the program respond? And when we're even more concerned in that red zone, what do you do?

And I want to answer a couple of questions because they've come up with this. One about the use of nebulizers. Years and years ago, nebulizers were used really frequently in asthma. It was our main way of treating kids in distress. And now, most kids can do just fine with an inhaler if it is attached to a face mask. You can put a face mask that's designed for that purpose over the nose and mouth of a child. And it's actually the preferred way to give most medications. It's not very common anymore that most children with asthma ever need a nebulizer at home or in the child care setting. I'm not saying it's never needed, but it's far less severe than it did years ago. It's much easier to use that than to use the machine. But if a child has an asthma plan where their doctor has been very clear that they need that and a program is accommodating that, we recognize that there are aerosols that are produced by the nebulizer. And we don't actually know for sure how risky that is. But certainly, there's the theoretical risk that COVID could be spread that way. If a child needs to use a nebulizer in any setting, then protecting adults and those around them with protective equipment is important. The recommendation is still to avoid the nebulizer if it's at all possible, but to have that individual consultation with the family and the medical provider if there's a special situation that a child might need that.

Kim: Yeah, I just want to just jump in because this is such an important thing that the health consultant does with the program – is to review the action plan. And with the difficulties of children accessing health care providers, getting follow up visits. Some specialty areas the pandemic in telehealth has made follow up a breeze. Obviously, different things, it's been a little bit trickier. You really do want to make sure things are up to date because where a child was, they grow and develop so fast. 18 months ago may be very different at this time. And this might also bring up issues around medication training. Who's trained in your program? Who can give the medications? With the changes in the cohorting and the staffing turnover, this might be a really important need. And the training on each child's individual health plan with a consultant, with its actual staff members caring for the children – these are all very important things to make sure that the loop is closed and that everyone knows what they're doing where these information and things are. And children are doing really well with inhalers and spacers. Research data shows the spacer with the inhaler is just as effective as those nebulizers in giving kids the medication when they're used correctly. Sometimes a health consultant can work with a health care provider, and the family, and the child to really be able to be successful in using that.

I just want to close with our slide as a reminder about the importance of that ongoing communication regardless of the special needs a child may have. But the health care provider and related service provider working with the family and the program staff all being in concert and communicating together is the best way to support any child with special needs in the program. Because if things change, children change, and families are all on a different trajectory of learning about their child's condition. Really ensuring that you have that open communication in an ongoing way and being intentional about it is critical. There was some conversation about how often do things have to be updated? You want to update things at least annually. There's going to be different rules in different states in different settings, but best practice is at least annually and when there's changes. Whether it's changes in the child's condition, medications, the hospitalization. But ensuring that the ongoing communication is there is what's really critical.

I think we answered the questions about the nebulizers. I think we got that. And some folks had asked about the toothbrushing. In Head Start programs, they're still not toothbrushing. Really encouraging families in the programs themselves – they're encouraging families to do a lot of toothbrushing at home. All right. I see we are at the top of the hour. I'll just add some last thoughts to leave you with. What policies need updated around now that COVID-19 is here? Those of you that are open, what needs to get refreshed and looked at? What's working well? What additional training do we need? How can we support and provide those supports for children with special health care needs and their families? And what work do you have to do as a health consultant to be a really helpful resource to connecting families and staff to the resources they need to be healthy, as well as to support children with special needs?

We hope this session has been helpful for you and has provided a way to think through what the impact of some of the COVID-19 risk reduction strategies may be on children with special health care needs. I'm sure many of you have thought about all these things already. Hopefully, it was just helpful to think about them in the shared stage together. And I want to thank Dr. Jill Sells for all of her expertise during today's session and thinking about these recommendations and what is going on with children with special health care needs. It was great to have you here today.

Jill: Thank you. And I just want to remind folks – I'm sorry that we ran out of time – to please sign up for the various resources that come out of the National Center and through ECLKC. We are planning, as a center, upcoming webinars, other updates related to COVID and one on ventilation as well and want to be an ongoing resource to you for your questions even though we couldn't get to all of them today.

Kim: Yes. And we do have a health line. I'm going to put it in the chat so that you have that as well. It's an email. You can send us an email at any time, and we're happy to answer your questions. You want to get your certificate for today's session. We want to hear back from you about what's working? What else can we provide for you to support you in the work that you do? A link will pop up when we close out of today's session. I also put it on the screen if you want to capture it there and go there on your own. At the end of the evaluation, you will be prompted to download and save the certificate. You need to select the link to the certificate, download the certificate, and save and print it. We've also provided the certificate in the file share pod below the screen. If you'd like to take a minute now, you can save it that way as well. When we close the session, we will wait maybe about 30 seconds before we close out just in case you want to download anything else that is there.

Again, this is our mailing list. I know Jill mentioned this, and it was also on the first slide, but this is the way to go ahead and be connected to us on a regular basis. And here's our health email. Thank you for staying with us a little late. I appreciate you hanging in there. Thanks for all your great sharing, and feedback, and suggestions in the center. Thank you Kate, and Libby, and Barbara in the back end for helping with all the support, and good luck. Thank you for all you do, and we look forward to seeing you in August. Be well, everyone.

Jill: Thanks, everyone.

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