What Italian pediatricians can tell us

Last week I took part in an online conversation in which a large group of American pediatricians listened as some of our colleagues from Italy talked about pediatrics in the coronavirus crisis, because what they are dealing with there is what we will be dealing with here very soon.

We Americans were hoping we could learn from our Italian colleagues, who are further along in handling this epidemic.On Feb. 23, several Italian towns were quarantined, with what then looked like fairly severe measures, and some large events — including Carnival in Venice — were canceled.

By March 4, schools and universities were closed, and by March 9, the whole country was on lockdown, which has grown progressively more stringent, with factories and “nonessential businesses” closing, with roadblocks stopping cars, and with many regions closing parks and outdoor areas as well.

“We are all facing something new and unknown, and also rapidly changing, for which we don’t have durable protocols,” Dr. Federica Zanetto, a family pediatrician who works near Milan, one of the areas where the pandemic is most severe, wrote in an email. “I went to reread the communications of three weeks ago,” she wrote, and the situation has changed so rapidly, “we seem to be catapulted into another world.”

Dr. Giorgio Tamburlini, a friend who is a pediatrician and epidemiologist who directs the Centro per la Salute del Bambino Onlus (Center for Child Health and Development) in Trieste, sent me a piece he had written called, “The (precious) Time of the Coronavirus.” We have to find ways to answer children’s questions and address their fears, he wrote, but we also must make a virtue of necessity in how parents spend this time with their children.

In Italy, as everywhere, the coronavirus has been hardest by far on the elderly. Pediatric patients, for the most part, have not been terribly ill; in pediatrics there is no comparison medically to the acuity — and the danger — faced by those who are tending adults, managing ventilators on the front lines.

But pediatricians and parents are still worried, of course, about how the children are doing and about what kinds of dangers may loom even for this population which is — thank goodness — relatively safe from severe COVID-19 disease.

So for three weeks now, these Italian colleagues have been trying to provide medical care for children while having a minimum of contact with them. As most pediatric practices are now doing here in the United States, they are trying to keep children out of medical offices and clinics. Essential vaccines are still being given (nobody wants to see one pandemic complicated by the emergence of other infections which could have been prevented).

“Our main task at the moment is supporting families,” wrote Zanetto. “Every day more and more parents are infected or have relatives infected.” The pediatricians reinforce the importance of the government recommendation about staying home, and direct parents toward correct and authoritative information about the epidemic, and away from what she called “fake and disturbing news crowding social media.”

My friend and colleague Dr. Stefania Manetti practices in Southern Italy as a family pediatrician, in a town not far from Naples, in a region of the country which has so far been relatively spared. The children she takes care of have been locked in at home for three weeks, with drones and the military deployed to make sure there are no gatherings.

People can go out for health care, but that is meant to be a last resort; like many pediatricians in the United States now, Manetti is mostly attending to her patients by telephone and video conference; for vaccines, she can refer them to the public health office where vaccines are given — though some parents are afraid to take their children out.

Many parents are calling her, she said, because their children are having trouble sleeping — in fact, she switched from telephone visits to video conferencing because she wanted to be able to look people in the face while discussing the anxieties that are turning into sleep disturbances, loss of appetite, stomach aches and other physical symptoms.

“We have a lot of somatization,” she said, using a term that usually means the emergence — or expression — of anxiety or depression as a physical symptom. “They keep going to the bathroom, they have abdominal pain, all these things.”

The bedtime advice in Italy — as here — is to minimize the child’s exposure to news, to do quiet and pleasant activities for an hour or two before bedtime, reading books, listening to music, playing quiet games. “It must be a moment where the child has to be calm before going to sleep, a moment when he switches off,” Manetti said. “The children are afraid of switching off, they don’t know what will happen when they switch off.”

There are families, she said, who have found some positive aspects to being home together, but that’s much harder when parents are anxious about their jobs and their economic prospects. “If there’s a stressor in the family, it’s extremely difficult” to follow the advice about engaging children, distracting children, caring for children. “These families have to be economically sustained somehow.” These are also questions that American pediatricians are realizing we must address.

How does she suggest that parents talk with their children about the coronavirus? “I tell them, as I do in other situations, that children need to know facts in a simple, clear way, and they also need to know that parents are there to support them,” Manetti said. And it’s not a one-time conversation, she said. “What you explain to a child has to be reinforced,” she said, comparing it to when a child asks questions about a book you read, and some days later you read the same book again, and the child asks the same questions.

A couple of days ago, Tamburlini sent me another piece that he had written, about acknowledging the deaths of grandparents. In Italy, with a culture legendary for close family ties, the epidemic has devastated the grandparental and great-grandparental generations. “Ciao, Nonno,” the essay began — a phrase that can mean either “Hi, Grandpa” or “Goodbye, Grandpa.”

“We have a double tragedy,” he said. “Most of the people who die are the elderly, and most of these people die without being assisted by the family, due to the absolute emergency in the hospital, and then can’t even have a funeral.” Families need to find ways to explain this to children, he said, and they need to find ways to acknowledge, salute and celebrate the people they are losing.

“You have to talk to children, you cannot leave children with their fears,” he said. “It’s better to talk rather than avoid talking.” “We will return, sooner or later, to the life of before,” Tamburlini wrote. “Or rather, it will no longer be the same as before. For many reasons — but also because we will have discovered a kind of time … time to fill, or to let flow by, more slowly than usual. With our children. That they will remember.”

For more news your way, download The Citizen’s app for iOS and Android.