By PERRI KLASS, M.D. OCT. 23, 2017 NYTIMES
As cold season and flu season settle in, many parents worry about taking children to the doctor’s office, and sitting in a waiting room full of sick children.
It’s well known that hospitals can be dangerous places for disease transmission; that’s why they have thorough infection control policies. But most pediatric medical care takes place in the office or the clinic. So on Monday, the American Academy of Pediatrics issued a new policy statement, “Infection Prevention and Control in Pediatric Ambulatory Settings,” to help minimize the spread of germs in waiting rooms and exam rooms.
Much of what the policy recommends goes back to the essentials of preventing infections, like the importance of hand hygiene and immunizations. But specific advice for the waiting room includes bringing along a toy from home. Even if they are disinfected daily, as the policy advises, toys that multiple children handle in the waiting room may harbor germs, so the new statement suggests that parents pack their own.
There can also be microbes on the chairs and the tables and, of course, the doorknobs, so avail yourself of hand sanitizer, and discourage any passing toddlers from making contact with your baby, even if they look healthy.
It’s not just the obviously coughing children you have to worry about. Plenty of children look well but are still contagious, especially at the beginning of respiratory illnesses. While some pediatricians have separate waiting areas for sick kids and well kids, “there’s no good data that says having a sick kid waiting room is going to prevent transmission,” said Dr. Mary Anne Jackson, the director of infectious disease and professor of pediatrics at Children’s Mercy Hospital in Kansas City, who is a co-author of the policy statement.
But concerned parents don’t necessarily have to stay in the waiting room, she said; you can check with the desk about how long it’s likely to be and then take a walk or wait in the car, and ask the staff to call your cellphone when it’s your child’s turn.
The policy also provides guidelines for cleaning exam rooms in between patients, disinfecting equipment (including wiping stethoscopes with alcohol), cleaning up after any spills involving body fluids, and general housekeeping. (Certain infections require more than just cleaning, of course; if a child has measles or chickenpox, we have to track down everyone who was exposed and offer specific protections to those who aren’t fully immunized, and measles is so infectious that cleaning the room isn’t enough — we actually have to leave it empty for a while to get rid of the risk.)
Parents might want to ask about infection control when they are choosing a pediatrician, Dr. Jackson said. Look to see that surfaces and toys look easy to clean, that tissues and a place to dispose of tissues are provided, that hand sanitizer is easily accessible.
You might also want to ask how the practice handles children who are not adequately immunized, and whether they are kept out of the waiting room when they’re sick.
Ask, “How do you triage? What does your waiting room look like? Are your health care workers immunized against influenza? Do you have a policy for infection control?” she said.
No matter where we start, we always come back to good hand-washing or the use of alcohol-based hand sanitizer. “Hand hygiene at all levels” is critical, said Dr. Mobeen H. Rathore, the lead author on the policy statement, who is a professor of pediatrics at the University of Florida College of Medicine in Jacksonville, and the chief of pediatric infectious disease at Wolfson Children’s Hospital. Parents should be vigilant, he said, “teaching their children hand hygiene, practicing their own hand hygiene, insisting health care providers practice hand hygiene — it’s O.K. to ask.”
And then there is what we now refer to as “cough etiquette,” that is, covering a cough, coughing into your elbow rather than your hand, and, yes, again, practicing hand hygiene after wiping your nose or dealing with a cough.
But while infection control in the waiting room and the exam room are important, the best ways to protect your child actually go back well before that trip to the doctor. First and foremost, make sure your child is fully immunized, including getting the annual influenza vaccine as soon as it’s available. Yes, I know, that means going to the doctor’s office, but it’s still the most crucial thing you can do, and if you get the flu shot early in the season, your child will have had time to generate a full immune response before there’s a lot of flu going around.
And if the bad thing happens, in spite of everyone’s best efforts, and there’s that dreaded waiting room exposure for a very contagious disease like measles or chickenpox, you at least want to be one of the people who was there with a fully immunized child. “There’s nothing better than giving your child vaccines to prevent infections,” Dr. Rathore said.
More immediately, for any given visit to the doctor, good infection control precautions start before you actually come in, and they involve both the parent and the pediatric office staff. The people you talk to on the phone should have the training they need to ask you if there are concerning symptoms — a funny rash, a fever, a bad cough — which suggest that your child should not spend any time in the waiting room.
If you have a sick child, make sure to explain the symptoms when you make the appointment, and tell the staff if there are additional details that might raise the odds that it’s something contagious (recent return from exotic travel, exposure to someone with a known infection, child not properly immunized). Maybe they can put you into an exam room right away or have you come at the very beginning or the very end of the day.
“We had a case very recently, a parent who called us, said the child may have chickenpox,” Dr. Rathore said. “We asked them not to bring the child in to the clinic. We looked at the child outside.”
If you have a child who is particularly vulnerable to infections, you might ask whether there is a way to minimize time in the waiting room, especially during the winter months. Some practices try to batch the well child checkups, or the newborn and young-infant checkups, for example, so that there are certain hours or days when the waiting room and exam rooms are dedicated to infants, too young to be fully immunized (we don’t start giving flu shots till 6 months, and babies born premature are especially vulnerable to respiratory infections).
“If you have a child who is at risk for serious complications of certain infections, like flu, you don’t want them waiting in the waiting room,” Dr. Jackson said. Again, ask if you can come at a particular time when you can go right into an exam room.