It's Flu Season!

image from wikimedia.org

It is flu season (and has been since December)! The media tells us that influenza (flu) is on the decline. Maybe so--but there is still plenty of it out there. 

Friday in the office I evaluated 8-10 children with flu-like symptoms: sudden onset of high fever, cough, body aches, headache, runny nose, sore throat, and fatigue. They all looked miserable, with fever and sometimes chills, slightly glassy and reddish eyes, cough, and exhaustion.

Flu looks different from a cold. Kids with the flu are not usually smiling and perky in the office. Sometimes there is vomiting and loose stools--but these are just part of the whole picture, not the main symptoms.

Flu vaccines ARE helping this year--though we have had a few break through infections even in those who were immunized. Overall, the majority of children with confirmed influenza have not had their flu shots. Even if the vaccine did not completely prevent the flu, the symptoms in the immunized have been less severe and lasting for a shorter amount of time.

The high fever, cough, body aches, headache, runny nose, sore throat, and fatigue that come with the flu often last for a full week. It is important to be sure the patient gets enough fluids throughout their illness so they do not become dehydrated. Rest is also important. People with flu and fever should not go to school or other activities. Even if the fever comes down with some ibuprofen or acetaminophen the patient is still contagious to others and needs to rest to achieve a full recovery.

Medication for the flu includes Tamiflu, an antiviral antibiotic. In cases of influenza, if started within the first 24-48 hours of the symptoms, it can reduce the severity and length of the symptoms. Unfortunately, Tamiflu suspension tastes terrible and it has been quite difficult for parents to get their young children to take it. In addition, sometimes Tamiflu can be hard to find in the community. Tamiflu is not as good for flu as amoxicillin is for strep throat--it's definitely not an instant cure. Although pediatricians are encouraged to prescribe it for flu patients, I have found parents have a very difficult time getting it into their children. I tried it with my own kids a few years ago, and it is not a happy memory (as the doctor did not succeed in getting her own children to take it!).

Get a flu vaccine for your children if you are able to do so. Keep your children at home, resting, and drinking lots of fluids if they have the flu. Go to the doctor's office early in the illness if you think your child might benefit from Tamiflu. Good luck, I hope it's over soon!

Babies Coughing and Wheezing: Does Your Baby Have RSV?

It's late.  Your baby is coughing and wheezing.  Everything seems worse in the middle of the night.  What kind of cough is it?  What is going around this time of year?  What should you do?

A common virus has really taken off in the last month or two.  You have probably heard of it:  RSV.
RSV stands for Respiratory Syncytial Virus.  For older kids and adults it usually just causes a bad cold.  However, infants and toddlers can be hit hard by this virus.  RSV causes a lot of mucous drainage.  This is hard for babies because they greatly prefer to breathe out of their noses.  The infection causes wheezing and congestion in the lungs of small children.  RSV can cause a fever and may lead to ear infections and prolonged cough.

Sometimes I have called this "baby bronchitis."  Although that comparison helps people understand the condition a little better, bronchiolitis is not actually the same thing as bronchitis.  Bronchitis affects the larger airways in the lungs (the "bronchi") and leads to a significant productive cough.  Bronchiolitis affects the smaller airways, deeper in the lungs.  These flexible, narrow airways are called bronchioles.  They collect mucous and then tend to tighten up with each breath.  This leads to wheezing and a painful sounding, tight cough.

Here are some examples of the symptoms of bronchiolitis.  You will hear wheezing (both with inhale and exhale) and see retractions.  When the skin sucks in above the sternum (breastbone) or between the ribs with each breath, these are retractions. 

This video shows a baby with bronchiolitis who has retractions in her neck (called suprasternal retractions), wheezing with inhaling and exhaling, nostrils flaring with each breath, and a tight little cough (at the end of the video).  Although the dad mentions during the video that she has croup, actually this is a better video of bronchiolitis.




The next video shows a baby with head bobbing.  It is a sign of difficulty breathing in young infants.  Because he is using his neck muscles to help him breathe it pulls his head forward with each breath.




Here is a pretty good example of a bronchiolitis cough.  It starts about 20 seconds into the video.  You might also notice that the baby seems to cough up mucous into her mouth, which she then chews on for a while before she swallows it.  Sometimes babies with bronchiolitis gag on the phlegm and actually throw up after coughing.




RSV bronchiolitis can be mild, moderate, or severe.  Mild bronchiolitis causes wheezing and coughing, but babies can still smile, laugh, drink, and eat.  More severe bronchiolitis can cause rapid breathing, significant retractions, pale or bluish skin tone, prolonged coughing spells, gagging and vomiting with cough.

In another blog post I will discuss some home treatment for RSV bronchiolitis, and what can be done for a child in the office, emergency room, or hospital.  Please remember that my blog is not intended to substitute for the advice of your own personal pediatrician!  Words on a page cannot replace your own observations, or those of the doctor who knows your child.

Flu and Flu Symptoms

High fever? Chills? Cough? Body aches? Glassy, filmy, reddish eyes? Sore throat? Runny nose? If you have all or quite a few of these symptoms you might have "the flu." Flu, or "influenza" is a respiratory illness that makes people feel really sick. It is not to be confused with gastroenteritis (what many people call "stomach flu"), a completely different kind of infection. Flu shots help protect against influenza, but not against gastroenteritis.

Influenza is "going around" right now. We have seen quite a few cases in our office in the last two weeks. Children look miserable, listless, flushed, and weak. They cough, have high fevers, and complain of sore throats, body aches, and chills. The infection comes on pretty suddenly and hits hard. Most of the cases we have seen in the office have been in children who did not receive a flu vaccine. However, this week I have had two patients with confirmed influenza A who were vaccinated last fall. While this does not seem fair, it does happen sometimes.

The treatment for flu is almost always supportive care, which means making your child as comfortable as possible by controlling the fever and ensuring adequate fluid intake. In addition, monitoring for signs of bacterial complications of flu (such as an ear infection or pneumonia) is important. A high fever can persist for 5 to 7 days. Sometimes there is nausea and vomiting, although these are not the main symptoms of influenza.

Clear liquids, especially Pedialyte given 1 tsp at a time every ten minutes, are the best home treatment to prevent dehydration when a child is vomiting. Acetaminophen (Tylenol) or ibuprofen (Advil or Motrin) will help keep a fever more manageable and a feverish child more comfortable. In my experience these medications often do not bring a high fever down to normal. Remember that the fever is not harmful to your child and is actually helping her body fight the infection. However, it makes the sick person feel awful and look terrible, so it is usually worth the effort to treat a fever.

In general it is safest to use one medication to control a fever--either acetaminophen OR ibuprofen. For a limited period of time (less than 24 hours) and a very high fever (over 103) I sometimes recommend alternating these two medications. However, too much medicine on an empty stomach CAN make things worse (nausea and vomiting, for example).

Cough and cold medications (especially decongestants such as pseudoephedrine or phenylephrine, as well as cough suppressants such as dextromethorphan) are NOT recommended for children under age six because research shows they do not work any better than placebo (fake medication), and because there have been a number of overdose cases due to the use of combination products (medicines with acetaminophen plus cough and cold products) in young children.

I sometimes recommend the night time use of the antihistamine diphenhydramine (Benadryl) alone for a smaller child with a bad runny nose and cough. Even this can cause problems such as irritability and wakefulness. At my own home I am likely to use home "remedies" to clear a congested nose and make sleep easier. These would include a steamy shower, saline nose drops, elevating the head of the bed a bit, and clear liquids to drink.

If your child looks really ill, and ibuprofen or acetaminophen do not "perk him up", then we should evaluate him in the office. Similarly if he is appearing dehydrated, (with a dry mouth, lack of tears, sunken eyes, absent or severely decreased urine output, cold hands and feet) then we should also evaluate in the office. If the high fever persists beyond 7 days, we need to see your child. And if you are very worried about your child, or there are concerning symptoms other than those I have described then you should call or bring your child in to be checked. Please remember that my blog is intended to be informational, and cannot take into account every individual situation, or replace the personal attention of your own doctor.

There are medications to treat influenza (not stomach "flu", remember?). In reality we use these only sometimes, as they carry their own risks of side effects, are not palatable (Tamiflu liquid tastes terrible), must be started very early in the illness, and are not extremely effective. Primarily we use medications like Tamiflu for children with underlying medical conditions (at risk for severe complications of flu) to either treat flu in the early stages or prevent flu in cases of household exposure. Hopefully all of these children with severe underlying illness have already been vaccinated for flu!

How do you distinguish influenza from strep throat? Strep is the other illness that is "going around" right now. The classic symptoms of strep throat are sudden onset of fever, sore throat, headache, and stomachache, usually in the absence of cold symptoms such as cough or runny nose.

I have previously written blogs about both strep throat and flu, so you could check those out for more information. And remember, you are the expert when it comes to your child. This blog is here to be helpful in providing general information to you, it is not designed or intended to diagnose or make treatment recommendations for specific children, illnesses, or situations. That kind of individual attention can only come from your own personal pediatrician!

Croup and a Croupy Cough

It's easy to be scared when you wake up in the middle of the night to hear your baby or young child coughing with a deep, loud, barky cough and making raspy sounds when she breathes. Chances are this is croup!

It's important to hear what croup sounds like. The following videos are from YouTube. All give a pretty good idea of the distinct barky, croupy cough. It sounds like a barking seal.

CROUPY COUGH
A croupy cough sounds loud and barking, like a seal's bark:





STRIDOR
Raspy breathing, also known as stridor, is another characteristic of croup:



This next link is to a video that demonstrates a significant case of stridor, just click on the link to go to YouTube (the video did not allow itself to be embedded):
http://www.youtube.com/watch?v=Z1_uKqmPyLA


Croup is usually caused by a virus (a common one is parainfluenza virus). It causes cold symptoms (runny nose, stuffy nose, cough, fever) and it likes to settle in the upper airway. It causes swelling in the upper airway and vocal cords, giving the funny sounding cough, causing raspy breathing, and a hoarse voice (laryngitis). The barky cough and raspy breathing are always worse at night.

Croup often sounds much worse than it is. In two of the videos above, the ones demonstrating stridor, you can see completely happy babies who have raspy breathing. They look pink, are smiling or talking, and are not bothered by the "trouble" they are having with their breathing. Croup can be serious, and require a trip to the emergency room. However, usually it is manageable at home.

For a croup attack, first sit your child up, and then calm him down. Sitting up usually helps the airway stay open. Crying and panicking tend to make the airway close even more. Take your child into a steamy bathroom. To do this--run the hot water in your shower and don't turn on the fan. Sit in the bathroom and sing to your child, rock her, read to her. Try this for about fifteen minutes at a time. If it works, you can put your child back to bed--then repeat the treatment as needed through the night.

Another home treatment is taking your child outside into the cold night air (assuming it is cold outdoors!). The point is to try the opposite of hot steam, if the steam wasn't working for her. You can also put a cool mist vaporizer into your child's room.

If a croup attack is very severe, your child can't breathe despite home treatments, or is looking quite pale, bluish, or lethargic, you should go to the emergency room. There your child can receive breathing treatments (to temporarily open the airway), oxygen (if required), and steroids (to reduce swelling in the airway). Remember, however, that croup can look and sound much worse than it really is--so if your child is happy and playful, able to nurse or drink from a bottle or sippy cup pretty well, it's unlikely that you need to go to the emergency room for croup.

If you make it through the night, but had a rough time getting to morning (needing recurring steam or outdoor treatments) you should bring your child to the office the next morning. Symptoms may appear to be gone in the daytime, but croup comes back each night for a few nights before it turns into a regular cold.

After a few days of the croupy stage the cough will change into a phlegmy, wet cough. This almost always happens with croup, and is a sign that the croup is starting to clear up. However, when the cough changes into something else, every parent worries that it is turning into something more serious. When it changes, watch your child closely. If she is sleeping better, is more playful, more hungry, and the fever is mostly gone, then your child IS improving and you can handle the rest of the croup illness at home, like you would for the average cold virus.

Croup is contagious in the way a regular cold is contagious. It is spread by respiratory droplets (mucous, cough, sneezing), and is most contagious in the first 2 to 3 days of the illness. If there is no fever, and the child is sleeping pretty well at night, croup is not a reason to keep kids out of daycare or school.

As always, my blog is designed to give you general information about your child's health and illness. One of the main reasons I posted this topic is to provide the links to videos of a croupy cough and stridor. My advice here is not meant to replace the more personal advice you can receive from your child's own pediatrician.

Lots of information about croup is available on the web. Here are some possible links, if you want more information:

http://www.askdrsears.com/html/8/t084200.asp

http://www.healthychildren.org/English/health-issues/conditions/chest-lungs/Pages/Croup-Treatment.aspx

Post updated 1/26/2014 (a new video added to replace one no longer available, two links replaced with embedded videos).