'Tis the season

It’s that joyous time of year that too often is ruined by sickness.

We’ve been busy in our clinic, but I know more is to come. We’ve only seen a few cases of influenza A and a little COVID-19 in our office, but quite a few babies have had bronchiolitis, probably from RSV most of the time.

We know RSV is in town from hospital testing. This is especially heartbreaking this year because we were led to believe vaccines would be available to protect babies during the end of pregnancy and for infants under 8 months after birth.

In both cases, the supply has been severely limited, and many babies remain at risk. Once they catch RSV, we only have symptomatic treatment. Antibiotics won’t help. Antivirals aren’t available. These babies are miserable and their parents are fraught. Again, it’s especially heartbreaking this year because of the promise of effective preventions.

Let’s first look at the big 3 viruses that are circulating to get an idea of the numbers, then at how to manage these at home and when to seek medical attention.

What’s going around?

COVID-19

Yes, we are still seeing COVID-19. The public emergency has ended, but infections continue. Most acute infections are mild, but about 1000 people in the US die from COVID-related infections each week still and many more have long term symptoms following infections.

From biobot, you can see rates have increased over the last 6 months, as is anticipated for the time of year. The Midwest is at the top of the curve - which is not great for this ranking.

Influenza

We’ve had several patients with positive Influenza A tests, but our area has yet to see the peak of the season.

Bronchiolitis - RSV and other viruses

As mentioned above, bronchiolitis is in our area now. Testing is not done in most cases, since most people have a mild cold with RSV. Even infants who have trouble eating and breathing are not always tested due to the cost of the test and the fact that it doesn’t change how it’s managed. There is no specific treatment (unlike COVID and flu, for which antivirals are sometimes used).

Pictured below is a year to year graph of hospitalizations, which is reflective of rates. You can see the hospitalization rate for kids 0-4 years is rapidly rising this year in the US.

Strep throat

We’re still seeing some Strep throat, which always rises at the start of each school year. The good news is that this is a bacteria, so antibiotics can treat it.

Unfortunately, most sore throats now are viral, not bacterial. Your child should have a throat swab and test to be sure they would benefit from antibiotics before giving them.

Pneumonia

Both viral and bacterial pneumonias are being seen in our community. If your child is having rapid breathing, chest pain, or shortness of breath, they should be evaluated. Treatments vary based on the underlying cause.

Ear infections

Ear infections often complicate upper respiratory infections. A majority of them are viral and will self-resolve, but some may need antibiotics.

Pain management with acetaminophen or ibuprofen is helpful.

If you can’t keep pain under control or if symptoms last more than a few days, have the ears get checked and discuss if antibiotics would be helpful.

See my past blog All about Ear Infections for more.

When are you contagious and how is it spread?

A big question on everyone’s mind with upcoming holiday travels is how long someone’s contagious and how long symptoms will last.

Please do not travel or go to friend or family gatherings if you’re sick. Even if it’s mild - what’s minor for one person can be life threatening for another. Really. Very young, elderly, and people with chronic conditions may get sick and suffer. If you must travel (or go to work or school) at least help others by wearing a quality mask (KF94, KN95, or N95).

It is great to see everyone, but horrible to get them sick. If you start to feel sick once you’re there, put on a quality well fitted mask and avoid others as much as possible.

COVID-19

People can be contagious before symptoms even start with COVID-19. They are most contagious during the first 5 days of illness and most people are no longer contagious after 10 days of symptoms. Some (especially those with significant infection or who are immune compromised) can be contagious for over a month.

The best way to know if you are no longer contagious is to have two negative rapid COVID tests 24 hours apart.

How long symptoms of illness last varies based on severity. Some people seem to improve, only to have resuming or new symptoms weeks later due to long covid.

Flu

Flu is also spread through droplets, but doesn’t survive on surfaces as long as RSV. (Good old hand washing and wiping down surfaces is still recommended though!)

People with flu are most contagious in the first 3-4 days after symptoms begin, but infants and people with weakened immune systems who are infected with flu viruses may be contagious for a longer time.

Symptoms typically begin 1-4 days after infection. It is possible to spread the infection before symptoms develop. Some people can be infected with flu viruses and have no symptoms, but may still be able to spread the virus to their close contacts.

For most people with influenza, most significant symptoms typically resolve within a week, but cough and fatigue can persist for 2 - 3 weeks. Take it easy during recovery! If symptoms worsen after the first few days, seek medical attention to look for secondary infections, such as pneumonia.

Immunization against the flu may lessen symptoms, but does not prevent spread to others who may be more at risk of severe symptoms.

RSV

RSV is spread through droplets often spread with coughs and sneezes.

It can survive for many hours on hard surfaces and then infect when a contaminated hand touches eyes, nose, or mouth. Frequent wiping down of commonly touched surfaces and handwashing is helpful.

Our kids often cough and sneeze directly into our face, so wearing a mask and eye covering can help prevent direct spread.

Adults infected with RSV are usually contagious for 3 to 8 days and may become contagious a day or two before they start showing signs of illness.

Infants and people with weakened immune systems can continue to spread the virus up to 4 weeks, even after they stop showing symptoms.

Symptoms tend to worsen over the first 3-5 days then improve, but the runny nose and cough can linger for weeks. Many weeks.

What are the symptoms?

The symptoms of COVID-19 vary widely from person to person. Many have very few symptoms, but others struggle with fever, sore throat, cough, headache, vomiting, diarrhea, dizziness and many other symptoms ranging from mild to severe.

Primary symptoms of Influenza are fever, chills, fatigue, sore throat, cough, body aches, headache, and sometimes vomiting & diarrhea.

Primary symptoms of RSV are runny nose and cough. It can appear very mild in older kids and adults, but be VERY CAREFUL to not share with anyone who is around young children. It can cause severe respiratory distress in at risk people.

Treatments

The good news is for most viruses, specific identification does not change the at home treatments you can start right away. Identify symptoms and treat those accordingly.

If your family member has symptoms of one of these viruses, you do not need to have them seen unless they are high risk for severe infection (infants or those with chronic disease that can cause severe respiratory infections).

Sometimes we see kids early in their illness and they only need home based care. Unfortunately, some will have worsening of symptoms over time, but coming in early won’t head this off. I often hear parents say they come in to “prevent” things from getting worse, but I do not have the power to prevent symptom progression. That’s why I am such an advocate to vaccinate against all infections that have vaccines available. Prevention is most helpful before exposure. Once you’re sick, it’s your immune system’s job to fight off the infection. If the immune system is primed to fight, the infection will generally be more mild.

Risk of exposure to a different virus is very possible whenever you visit a medical facility, so weigh the risks and benefits of running in to be seen. If you do need to come to the clinic or visit an urgent care or emergency room, wearing a quality mask can help limit your exposure (and protect others if you are sharing a virus).

Certainly if you are worried about how your child is acting, they should be seen. This may include any difficulty breathing, signs of dehydration, or discomfort not controlled with usual comfort measures.

Any child at risk of severe infection should be monitored very closely for signs of increasing distress and get seen if there are concerns. If you have an infant or child under 2 years of age, they are higher risk - the younger the child, the more risk. Kids with a history of asthma, diabetes, or other chronic condition that increases risk with respiratory viruses also should be watched closely.

If your child is able to be managed at home with treatments discussed below, there is no benefit to being seen.

If you are not able to keep them comfortable, if they have few tears or aren’t urinating like normal, or if they seem to be struggling to breathe, they should be evaluated for further treatment. We are seeing ear infections and pneumonias that may benefit from antibiotics.

Treatments used for all respiratory infections:

I always say, “water, water, water” is the best treatment for cough and colds.

Water in the air.

Water (saline) in the nose.

Extra water to drink.

Water to wash hands frequently.

• Saline can be more helpful than many imagine. For infants, use a nasal spray available at your pharmacy. For older kids and adults, sprays can also work, but washes are even better! I wrote about using nose sprays previously - see the “For more” section for information about washes.

• Honey has been shown to help coughs but can only be used over 12 months of age.

• Older kids can use cough drops if they aren’t at risk of choking.

• Anyone with a history of asthma should use their Action Plan to step up therapy. Make sure you have all the medications and equipment needed to treat symptoms. If you don’t, schedule a visit to update the Action Plan and get refills that are needed.

• Use fever reducers to make kids comfortable, not to bring the temperature to normal.

• Push water and other fluids to help kids stay hydrated. They can eat foods if they feel up to it, but fluids are important!

• Help kids rest when sick.

• If the fever lasts more than 3-5 days, your child looks dehydrated, is having trouble breathing, is in extreme pain, or you are concerned, your child should be seen. A physical exam (and sometimes labs or x-ray) is needed to identify the source of illness in these cases.  A phone call cannot diagnose a source of fever.

• Any infant under 3 months or immunocompromised child should be seen to rule out serious disease if the temperature is more than 100.5.

• For children over 3 months, there is NO MAGIC TEMPERATURE that we worry more about. Look at your child, not the thermometer.

• If there are signs of difficulty breathing (rapid breathing, sucking in ribs or at the bottom of the neck, grunting, or looking scared) seek medical attention.

• Signs of dehydration include lethargy/very tired, no tears, dry tongue, and decreased urine output. If this occurs, your child should be seen. (Note: if there is high urine output and other signs of dehydration this is a sign of diabetes and your child should be seen.)

• If your child has ear pain, treat the pain. Most ear infections are due to a virus, but if your child is under 2 years, the symptoms persist more than 3-4 days, or if the symptoms are not manageable, antibiotics may be considered. Learn more about ear infections here.

Things that are not helpful:

• Cough and cold Medicines. There are no cough or cold medicines approved by the FDA for children under 6 years. None have been shown to help people of any age. They are not safe and can cause serious side effects. See my post on cough medicines for details.

• Allergy Medicines. They are not helpful unless your child also has nasal allergies. Nasal sprays with corticosteroid (Flonase, Nasocort, Nasonex) can help with nasal congestion more than antihistamines.

• Antibiotics. Antibiotics are not helpful for viruses or colds. They may lead to side effects or allergic reaction, so should only be used when the benefit outweighs the risk. Antibiotics may be used if your child gets an ear or sinus infection, though many of those are also from a virus, so talk with your prescriber about the need for antibiotic. At this time there are shortages of the antibiotics typically used for sinus and ear infections and pneumonia, so we must be especially cautious to only use them when needed.

• Menthol on the feet. This is a popular online suggestion. I don’t know why it’s so popular. Some menthol products may help, but not on the feet. Learn more on Menthol for coughs and colds.

Bronchiolitis

There are no medications used to treat RSV other than a lot of saline (with suctioning) and acetaminophen or ibuprofen. All of these are available over the counter.

If a child is wheezing we will often try a breathing treatment with a bronchodilator (albuterol). This doesn’t help in every case, but if it does, this can be continued at home or in the hospital.

There is no vaccine (yet) for RSV but there is a preventative injection given monthly during RSV season to high risk infants. If your baby has congenital heart disease, Down Syndrome, a neuromuscular disorder, or was born at or before 35 weeks gestation, talk to your doctor to see if they would qualify for this treatment.

Flu

As with RSV, standard comfort measures and at home treatments are used for managing influenza.

Flu vaccines are an important preventative measure. You cannot get the flu from the injectable vaccine because it is not a live virus vaccine. The nasal spray vaccine is an attenuated live virus, so may cause mild symptoms and should not be used in certain people. It is possible to be infected with the flu after vaccination (as with any infection you’re exposed to) but generally the illness is more mild and vaccines help keep people out of the hospital.

Antivirals can also be used and are recommended for those in high-risk categories. They do have side effects, which need to be considered in the risk to benefit decision making process of whether or not to use them. Unfortunately, every flu season they become hard to find in pharmacies so I recommend only people who have risk factors take an antiviral. Learn more here.

COVID-19

Antiviral medications are sometimes recommended for people with COVID-19, but none are approved for young children or those with medical conditions that make the antiviral contraindicated. Talk to your prescriber if you are interested in antivirals to see if your child qualifies.

There are many unproven (and often dangerous) treatments for COVID-19. Be cautious of where you find treatment recommendations. Talk to your pediatrician before giving treatments other than the standard recommendations listed above.

Prevention is key!

• Stay home when sick to keep from spreading germs. It's generally okay to return to work/school when fever - free 24 hours without the use of fever reducers unless you know you are still in the contagious window, such as the COVID rapid test is still positive.

• Protect your family from spread of the infection within the home, regardless of what is causing it. No one likes to be sick and we have many ways to prevent spread, including:

  • Encourage everyone able to wear a mask to wear a quality well fitted mask, such as a KN95 or KF94 (kid sizes available!). The person who is sick is the most effective mask wearer, but if your child is too young or uncomfortable to wear a mask, your mask can help protect you.

  • Filter the air.

    • You can make an effective but less expensive HEPA filter box fan with these DIY instructions. 

    • Clean Air Stars has this helpful spreadsheet to help choose the right filter for your needs.

    • Run your heater or AC fan all the time by changing from “Auto” to “On” to help filter your air through the home’s HEPA filter.

  • Open windows to improve ventilation if weather permits.

  • Wash hands and surfaces frequently.

  • Isolate the sick family member as much as possible from others.

  • Stay up to date on all vaccines and boosters. This can help protect against serious illness.

For more:

Here’s a great toolkit on staying healthy before gatherings from the People’s CDC.

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