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David Rosen, MD, a critical care pulmonologist based in Bergen County, NJ, arrived home from a 3-day stint in the ICU. As usual, he changed his clothes in the garage, put them in a plastic laundry bag, and, clad only in underwear, he headed straight for the guest room shower.

Earlier that day, Rose had seen five patients very sick with COVID-19, in a hospital with only four ventilators. He was devastated by the agonizing situation that had ensued. How could he force a smile and pretend everything was okay when he greeted his young children? On the other hand, he didn't want to burden or frighten them.

Rosen's 6-year-old daughter could tell something was wrong. Rosen carefully explained that Daddy was sad because there were a lot of sick people in the hospital and he couldn't help all of them.

"There's a constant balancing act between being there for patients, acknowledging my own feelings about their suffering and the horrors I've been seeing, and being there for my own family and their day-to-day emotional needs," Rosen said.

While this balancing act is part and parcel of being a physician, it has been especially wrenching during the pandemic, when the needs of family seem to be pitted against the calling to be a doctor.

Fear of infecting children has motivated some to stay in hotels, send their children to live with grandparents, self-quarantine in a separate area of the house, or avoid physical contact with the children, according to Sara "Sally" Goza, MD, president of the American Academy of Pediatrics (AAP).

"These are hard, anguishing choices, which contribute to stress and burnout," she said, emphasizing that it is a very personal decision, based on individual and family considerations, and no single solution will fit everyone.

Rosen said that staying at a hotel was not an option for him because he has a newborn baby, a 3-year-old, and a 6-year-old. "It would have been an unfair expectation for my wife to shoulder all those parenting duties without any help from me."

He added, "Of course, I'm always concerned about potential contagion and I take every precaution through rigorous decontamination procedures, but I remind myself that it's right for our family for me to be as present as possible at this time."

Ilana Friedman, MD, a pediatric ophthalmologist, starts her workday well before she leaves for the Bronx, New York-based hospital where she is the associate director of a residency program.

"I've been setting the kids up for school in the mornings, making sure they have the food they need for the day, that they're organized and ready to begin their online classes, and that their schoolwork is done," she said.

"They also text me during the day if something comes up, and I check in with them to make sure they're on task with their work," reported Friedman, whose children are 10, 11, and 13 years old.

"When I'm at work, I'm thinking about the kids at home; but when I'm at home, I think about my patients, so I never feel fully present in either place," she said.

Even when you're home, you may not have emotional or physical energy to be present for children, according to Katherine Gold, MD, MSW, associate professor of family medicine and obstetrics and gynecology at the University of Michigan in Ann Arbor.

At the end of an intensive period in the labor/delivery unit, "I can't do anything but crawl into bed, so sometimes my kids fall behind on homework and chores because I'm the person in the family who tends to make sure these things happen," Gold recounted.

Conducting telemedicine visits from home often with young children underfoot has its own challenges. Although some practices are reinstating in-person patient visits, reopening amid COVID-19 often necessitates at least a partial work-from-home schedule.

"There's no question that it's disruptive to care for small children while trying to take care of patients," said Damon Korb, MD, a developmental pediatrician based in Los Gatos, California. How to navigate this depends largely on the age of your children.

It may not be realistic to have much telemedicine time when you're the caregiver to infants or toddlers; but for preschoolers, Korb recommended "stations in different parts of the room, such as specific areas for mushy stuff, balls, books, blocks, dress-up, and eating" and "rotating the child from station to station."

He also suggested "parallel play if possible, bring your computer next to them so they can be involved with their 'work' while you're involved with yours." For the sake of patient privacy, he suggested using a headset so the patient's words remain confidential.

Although child-related interruptions during a telehealth visit may be distracting, "it might be comforting for patients to recognize that their doctors also have challenges with children at home and that we're not doing everything perfectly which they may be experiencing in their own lives," Gold said.

By the time a child is 4 or 5 years old, you can set a timer and say that when the bell rings, you'll play with them for a few minutes or reward them for their cooperation, suggested Korb, who is the director of the Center for Developing Minds and the author of Raising an Organized Child.

Maiysha Clairborne MD, an integrative medicine physician who coaches other physicians in business and entrepreneurship, said her 5-year-old son has been home from school since the end of March. His preschool held classes 3 to 4 hours per day, and "that's been a big help in keeping him occupied and up with his schoolwork." She has organized for him to be "autonomous in class" while she conducts virtual sessions and coaches colleagues.

"I check up on him between patients and clients and have lunch with him as often as I can, make sure he has virtual play dates and activities such as arts and crafts, and I try to go on walks with him around the neighborhood," reported Clairborne, who is the founder of Stress Free Mom MDand the Next Level Physicians Entrepreneur's Institute.

When your children are in front of the screen, make sure they're doing so safely, Gold cautioned, noting that there has been an increase in online sexual predators since the beginning of the pandemic. "Regularly talk to your children, including teenagers, in an age-appropriate way, tell them not trust strangers online, and monitor their activities."

Gold suggested asking an older sibling, relative, or friend toengage with the youth on social media andbe the "eyes and ears"to ensure safety online.

Summer is usually associated with camp, sports, travel, and hanging out with friends. But how many of these activities can take place this year?

Some activities will be available, according to the CDC. For example, camps are allowed to open, with specific guidelines and protocols to prevent the spread of COVID-19. Experts recommend doing your "due diligence" to find out which group activities, if any, might be appropriate for your child, taking into account your own needs as well as those of your children.

But many physicians may prefer to keep children at home rather than risk sending them into group settings.

Korb encourages parents with children of all ages to maintain a daily structure. "Get up, get dressed, don't lounge around in pajamas all day, exercise each day, and do something social and creative."

He suggested making sure that kids have "outlets," like going for walks or hikes with the family, virtual play dates, or get-togethers with friends while keeping social distancing in mind or trying a new experience, such as guitar, cooking, gardening, or learning sign language.

Talking to children about social distancing and sanitizing requirements is especially critical as they begin getting together with friends in person.

"Even very young children can understand that 'germs' cause sickness and if you get too close to other people or touch things that they touch, you can catch the sickness," AAP's Goza said.

She recounted the story of a 5-year-old patient who proudly went to the sink in her office and began washing her hands "to make sure the germs don't get to us."

Rosen's 6-year-old daughter understands the importance of not getting close to people outside the family, and even his 3-year-old understands not to touch something lying on the ground.

"It empowers kids to know that they can help themselves and others stay healthy and safe," Goza said.

Even with the most creative alternative summer plans, children of all ages are facing disappointments about missed activities, missed milestones, and uncertainty about the future.

Korb's daughter, a high school senior, missed out on her prom, graduation, and visiting the colleges she had been accepted to. She still has not made a decision about college and does not know if colleges will even be open in the fall.

"This situation is difficult for all children, but especially for adolescents, whose identity is based on the friends they hang out with and what they do with them, and many are grieving the loss of their normal lives," Korb noted.

"When people are grieving, they have to grieve," he continued. "As physicians and parents, our job is to listen, not tell them what to do, not belittle what they're saying, but support them while they find their way through the situation."

Delaney Ruston, MD, documentary filmmaker of Screenagers and Screenagers Next Chapter, which focus on solutions for healthy screen use and adolescent stress, anxiety, and depression in the digital age, agreed. "Validation is the number one skill parents should master because teens want to be understood as much as they want anything."

"Most adolescents don't have a long-term perspective on what's going on in life, so it's important to provide reassurance and place things in perspective after validating their concerns and distress," Korb advised.

Taking a "big picture" view is also helpful. "I remember my high school and college graduations, but neither have played a huge role in my life in the long run, which I have shared with my daughter," Korb said. "I'm proud that she has handled the disappointment wonderfully."

It's unknown whether schools will fully or partially reopen, and physicians may still face challenges in helping children with homework in the fall.

Korb suggested that home schooling might be different from what it was during the beginning of the pandemic. "The need for online school caught most schools off-guard, but schools will be more prepared for online teaching this time around."

He suggested turning to teachers for additional help if you're unable to provide your child with sufficient support. Additionally, "there is an entire network of online tutors popping up in response to the pandemic," he said.

Asking family friends and relatives, such as grandparents, to pitch in with helping your child with schoolwork can also go a long way toward relieving the burden that has fallen primarily on parents and it might also make schoolwork more enjoyable for the children.

Like Friedman, Michigan family medicine professor Gold feels "pulled in all directions," but has concluded that she needs to adjust her expectations.

"It's simply not feasible to be a parent, educator, emotional support system, disciplinarian, entertainer, and therapist all at once, especially during a pandemic," Gold pointed out.

"As physicians, we have high expectations of ourselves. But the most important message I can share is that none of us can possibly be as good a parent as we would like right now, so we need to recognize we're doing the best we can and give ourselves permission to fall flat sometimes," stated Gold, whose younger children are teenagers.

"At the beginning [of the pandemic] I think my kids felt they were missing out because I wasn't home while their friends' parents were," New York ophthalmologist Friedman said. "But since then, they've become proud of me. I overheard one of them say to a friend, 'My mom's a healthcare hero.' "

She added, "It's not that I feel like some kind of 'hero,' but it was validating to know that my children understand what I'm doing and why, and this helps somewhat to alleviate my guilt at being away from them so much."

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MD Parents: Trying to Keep the Kids Busy and Safe During COVID-19 - Medscape

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