ASPIRE interview with Dr. Nancy O’Hara on COVID-19
We are so excited to have Nancy O’Hara, MD, MPH, FAAP, a member of the ASPIRE Professional Advisory Board, kick off our series of Q&As on COVID-19. Dr. O’Hara is a board-certified Pediatrician. Prior to her medical career, she taught children with autism. Dr. O’ Hara entered general private practice in 1993, and in 1998 began her consultative, integrative practice solely for children with special needs. Since 1999 she has dedicated her practice to the integrative and holistic care of children with neurodevelopment disorders, ADHD, PANDAS/PANS, OCD, Lyme and Autistic Spectrum Disorder. She is a leader in the training of clinicians, both in the US and abroad. Dr. O’Hara’s Website & Full Bio
Please Note: Coronavirus disease (COVID-19) is a new strain that was discovered in 2019 and has not been previously identified in humans. The WHO is closely monitoring and updating the information regularly. Recommendations regarding prevention and treatment will change and evolve as more data is processed. It is essential to communicate with your Primary Care Provider (PCP) directly regarding you and your family’s unique healthcare needs. The WHO-COVID-19
Gabriella: Thank you, Dr. O’Hara, for taking the time to talk to us today about COVID-19 and PANS/PANDAS. There are a lot of parents out there who are trying to learn as much as they can, and we are so thankful to have you provide us with such valuable information. So let’s get started.
What are your top three points you would like to emphasize, and we will dive into further as we go along?
- Remain Calm. Do whatever you can to decrease your stress and your child’s stress. Remember, stress can cause a PANS flare.
- Social Distancing is essential to stop the spread of coronavirus and to keep your family safe.
- Discuss your child’s symptoms and concerns directly with your PCP; this includes fever and difficulty breathing.
Gabriella: Please give us an overview of coronavirus. What are the symptoms? Who is it affecting? How is coronavirus transmitted? And how do we prevent transmission?
Dr. O’Hara: COVID-19 Symptoms: Remember, all symptoms need not be present.
- Can have congestion
- Shortness of breath
- Can have diarrhea. Nausea and Vomiting are less likely.
The majority of infected people appear to have mild infections with mild cold-like symptoms, fatigue and fever. As seen with the influenza virus, the elderly and people with underlying chronic medical conditions appear to be most at risk for severe complications from COVID-19. However, young and middle-aged adults do have a higher rate of hospitalizations. Unlike influenza, children so far appear to be relatively protected.
COVID-19 is a very contagious virus. It is in the cold virus family; it is not an Influenza virus. Transmission is mainly through respiratory droplets so it can be transmitted person to person. Droplets can stay on surfaces for prolonged periods. The average time is 2-7 hours but it could be much, much longer. So because of that, social isolation – being at least 6 feet from anybody is crucial. We know that you can’t be 6ft away from your children but 6ft from anyone else.
Prevention of Transmission Basics
- Social Isolation
- This may be necessary for months
- No playdates
- Don’t take unnecessary trips into public place
- Be at least 6ft away from people
- Clean surfaces like clothes, furniture, doors, handles, phones, keys, anything brought into the house
- Good handwashing for at least 20 seconds – rubbing vigorously
- If you do go outside
- Wipe down all surfaces of goods you bring in, doorknobs, keys, phones and anything else that you or someone else came in contact with
- Change your clothes when you get home
Gabriella: What if someone in our house is positive or has symptoms?
- They should be isolated from everyone including those in the home
- Only have one contact person within the house, and at least a 6ft distance must be maintained. Proper handwashing and cleaning must be done.
- We don’t know right now how long someone should stay isolated. Although we are recommending 14 days, the data is not clear; it is not definitive yet.
Gabriella: We know someone can be asymptomatic before they show any symptoms. Can someone remain asymptomatic the entire time they are positive for the virus?
Dr. O’Hara: Yes, it is possible for someone to be asymptomatic while carrying the virus and never show symptoms.
Gabriella: Can the coronavirus trigger a PANS flare?
Dr. O’Hara: Any virus, including the coronavirus, can present as behavioral symptoms.
I would like to emphasize that if your child starts to have PANS symptoms right now while you are practicing social isolation, do not assume they are triggered by coronavirus. There are other things that cause a flare.
For one, our own stress or any psychosocial stressors can trigger a flare. The stress does not have to be the child’s stress but could be your stress they are feeding off of.
Secondly, other viruses or bacteria are still a factor. Do not get your child tested for COVID-19 just because they are having a flare. If they are having COVID-19 symptoms, then contact your PCP right away.
Gabriella: Do you think PANS/PANDAS patients are at higher risk for developing symptoms of COVID-19?
Dr. O’Hara: So far, there have been no hospitalizations in the US of children with COVID-19. In general, children are spared more. Children with PANS are immuno-dysregulated, and therefore they may be slightly more susceptible. There are also children with PANS with a diagnosed immune-deficiency. I would say 30% of my patients are IgG deficient, but almost all are immune dysregulated. So we have to be careful with them, but as I said, that age group is relatively protected.
Just because that age group is doing fairly well, does not mean that kids with PANs are not more susceptible to having a more severe form of the disease. Therefore, I firmly recommend social isolation. This means no playdates, no going to the grocery store with that child or any public place where there is increased risk of exposure. Do go outside and take walks and places where you can remain socially isolated. Good exercise remains important as is a good diet and plenty of fluids.
I am concerned about the hospitalization rate of those in the age group of 20-55 as it is higher than those over the age of 65. That age group must be isolated as well.
Gabriella: Do you think that PANS patients are more or less likely to flare from coronavirus?
Dr. O’Hara: That is totally patient specific.
Gabriella: Would you treat a flare from COVID-19 differently than you would treat a flare triggered by another virus? Or would you continue with the three-pronged approach that you tailor for that individual patient?
Dr. O’Hara: Again, patient-specific, and yes, follow the three-pronged approach but let’s discuss Ibuprofen and Elderberry.
- If your child’s doctor has already placed him/her on ibuprofen daily to control inflammation and PANS symptoms, then continue that.
- However, if your child gets a fever, contact your PCP before giving it. No matter what, you must call the PCP if your child has a fever or other symptoms. Your PCP is best suited to make that decision based on the needs of your child. They will also have the most up to date information from the WHO.
- Still not recommending acetaminophen as it decreases glutathione by 21%.
- If your child has a mild fever (101 degrees and below), tepid baths, lots of fluids, homemade fruit juice popsicles are what I suggest.
- If fever becomes significant, 101.4 degrees or lower than that if they have other symptoms like fatigue, cough, etc., then contact your PCP immediately.
- It is very safe to continue taking if your child is doing well on it as a preventative measure but stop if your child shows symptoms of COVID-19.
- If your child gets sick/shows symptoms, I would not recommend its use at all; I recommend contacting your PCP.
- If your child is not currently taking it and is sick, I would not start it now.
Gabriella: Can you explain what a cytokine storm is?
Dr. O’Hara: Cytokines are molecules within the immune system that are meant to fight infection and mediate and regulate inflammation. When you have a large amount of cytokines being released, you can have a storm. It is an overproduction of immune cells that, with a viral infection, can be associated with a surge of activated immune cells, for example, into the lungs.
Gabriella: What does Glutathione do? Why is it significant that acetaminophen depletes glutathione by 21%?
Dr. O’Hara: Glutathione is the primary, motherload molecule of our bodies. It is what detoxifies all of our cells from the toxins and chemicals that are causing the problem. So at the time your child is getting sick, you do not want to deplete their natural ability to detoxify.
I recommended that when your child gets a fever, that you contact your PCP before giving anything. If you can’t control the fever with tepid baths, fluids, natural popsicles and you thus need to give it, then that is a different story. You don’t want to give ibuprofen with a fever necessarily. Yes, the WHO modified their stance on ibuprofen usage with COVID-19, so it should be fine, but again, talk to your PCP and follow their guidance.
I would prefer not to suppress a low-grade fever because the fever is actively fighting the infection. Again I urge parents to discuss any fever (or any other symptom) with their PCP and whether testing for coronavirus is warranted at that time. A low-grade fever should not cause panic; remember it is critical to reduce your stress and the stress of your child. Stress can cause a PANS flare.
Gabriella: What other basic considerations do you have for families?
Dr. O’Hara: First and foremost, you should be checking with your child’s doctor about ways to support health, if your child has a fever or if they have difficulty breathing.
Below are some basic considerations. This list is available on The New England Center for Health’s site.
- As always, a good, healthy, anti-inflammatory diet is key with lots of fresh veggies, fruits, proteins and healthy oils, minimal fiber-rich carbohydrates and no sweets. Eat lots of spices and foods with antiviral properties such as turmeric (curcumin), coconut oil, raw garlic, oregano, ginger, kimchi and other fermented foods, walnut, pomegranate, green tea, apple cider vinegar, and medicinal mushrooms.
- Lots of fluids, good sleep and moderate exercise
- Good and repeated hand washing and avoid touching contaminated surfaces and shaking hands
- If you or your child has cough/congestion, sneeze/cough into a tissue, discard immediately and wash hands thoroughly. If no tissue is available, sneeze/cough into your elbow, not your hand
- Consider XCLEAR (XYLITOL) nasal washes for congestion
Preventive measures to consider or if you or your child is mildly ill: (REVISED 3/23/20)
- Contact your primary pediatrician or other primary care practitioner to see if you or your child should be seen if they have symptoms.
- The flu shot provides no additional protection against Coronavirus or any virus not included in the vaccine.
- For immune support, consider the following. However, if you or your child is sick, stop Vitamin D and A (continue ZINC and VITAMIN C) and contact your primary care provider
- Vitamin C – up to 5-10,000 mg/day as tolerated; extra vitamin C may cause loose stools but it is not toxic and unneeded amounts will be excreted
- Vitamin D3 – an additional 1000 IU/day
- Vitamin A – an additional 10,000 IU/day
- Zinc – an additional 15 mg/day
Gabriella: I have been fielding questions about whether mushrooms, melatonin, air purifiers are helpful.
Dr. O’Hara: In general, they are not going to make a significant difference. They may give more of a false sense of reassurance, so I don’t think it is worth it. Air purifiers are fine but make sure having one doesn’t decrease your efforts in cleaning surfaces or lower your commitment to social isolation. Plus, you have to make sure you clean it consistently.
Melatonin may possibly be used to treat COVID-19 as it is a cytokine modulator. But we are focusing on things that support your immune system, so it is as healthy as possible. As I said earlier, sleep is vital to overall health; if it is helpful for that, then continue it as needed.
Gabriella: What do you think about the talk of a treatment that includes Azithromycin, when added to hydroxychloroquine?
Dr. O’Hara: I would not recommend looking until, and if, your child has symptoms and then only under the direction of your PCP. I don’t think we really know enough yet about it to say exactly how hydroxychloroquine, a malaria and Lyme treatment, works to help the body heal from COVID-19. This combination may have promise, but speak with your PCP as there are no set treatments; everything is speculative and fluid at this time.
Gabriella: If you have/had the virus, can you get it again?
Dr. O’Hara: We do not know yet though it is possible. We know viruses mutate. It is too early for a definitive response.
Gabriella: Thank you so much. You, as always, have been so informative. We appreciate your time and your dedication to educating the community on COVID-19, PANS/PANDAS and other health-related topics.
Dr. O’Hara and her colleagues at New England Center for Health are continuing to host a series of zoom calls on COVID-19. The schedule will be updated weekly. This week Vicki Kobliner will discuss supplement and nutrition, Dr. Wells will dive deeper into elderberry and other immune interventions, and Dr. O’Hara will be joined by Brian McCabe to discuss teaching and learning during isolation.
This week’s Zoom schedule. Also, in a couple of weeks, Dr. O’Hara will be hosting a zoom call on PANS/PANDAS. We will be sure to post the information on the ASPIRE site as well as our social media accounts. Make sure you check back in with us for the date and time.