Flu Season Fears: What should you do?

Headlines are making everyone nervous about this year’s flu season. Schools are closing due to high flu numbers. Parents are worried that their child will be the next that dies.

Yes, the risk is real.

But there are things to do.

First: Prevent

Vaccinate

Vaccines are the one of the best inventions to prolong our lives. They really can help. I know the flu vaccine (or any vaccine) isn’t 100% effective, but it does help. Everyone over 6 months of age should get a flu shot.

I’ve heard from many pediatricians taking care of kids hospitalized with influenza, and none of the dying kids were vaccinated.

Kids who were vaccinated this season might get flu symptoms, but generally not as severe.

It does take 2 weeks for the vaccine to be effective, so get it ASAP. Kids under 9 years old who haven’t been vaccinated for flu previously will need 2 doses a month apart. Call around to see where you can get it.

If your kids (or you) are scared of shots, check out these tips.

Not convinced? Check out these 10 Reasons to Get the Flu Vaccine.

Wash hands

Wash hands often. This goes without saying. Whatever you touch stays on your hands. When you bring your hands to your face, the germs get into your body. Teach kids to wash hands well too!

Cover!
cough, cold, urgent care, primary care, medical home
Cover your cough!

Teach kids to cover their cough (and sneeze) with their elbow. This collects most of the germs in the elbow. Hands touch other things, so if you cover with your hands, you need to wash them before touching anything.

The only time I don’t recommend the elbow trick is if you’re holding a baby. Their head is in your elbow, so you should use your hands to cover and wash often!

You can get masks at the pharmacy to cover your nose and mouth to protect yourself from catching something and to prevent spreading an illness you have. We have masks available for anyone who comes to our office. We ask those who are sick to wear them, but those who are well can also put them on to prevent catching something!

In my office you’ll see that most of our nurses and clinicians have opted to wear masks when seeing sick kids even though we all have had our flu vaccine!

Avoid the T-zone

Avoid touching your face. It’s a horrible habit that most of us have. Be conscious of how often you wipe your mouth, eyes, or nose. Those are the portals to our body. Avoid touching them unless you can wash your hands before and after. Show kids how the eyes, nose and mouth make a “T” and teach them to not touch their T-zone.

Stay home when sick.

I’ve heard many angry complaints from parents about exposures. One mother was sick because she was exposed at work and then her illness spread to her family. She was especially upset because the exposure was from a child of a co-worker who brought the child to work because the child was sick and couldn’t go to school.

Keep sick kids home. If you’re sick: stay home.

If you’re sick with a flu-like illnesss, don’t
  • run to the store.
  • send your child to school with ibuprofen.
  • go to work.
  • go to your child’s game.

Stay home unless you need to seek medical attention.

Tamiflu and other anti-virals

My office is getting inundated with phone calls requesting us to call out Tamiflu. In some instances it’s appropriate for us to prescribe it for prophylaxis, but often we want to see your child first. If your child has flu-like symptoms, I do not want to prescribe a treatment without first evaluating your child. I don’t want to miss a more serious case that needs to be hospitalized. I don’t want to treat bronchiolitis or another condition as flu and miss the proper treatment. More on treatment with Tamiflu below.

Prophylactic uses

Tamiflu can be used for prophylaxis after exposure, but don’t rely on it. (If you follow my blog, you know I’m not a Tamiflu fan.)

Newborns

Some of the calls we are getting are from mothers with influenza who have newborns and their OB’s have recommended prophylaxis for the baby. If the baby is under 3 months of age, Tamiflu is not approved for prophylaxis. (See the chart and corresponding footnotes from the CDC below.) If you are sick, try these tips to prevent spreading illness to your kids.

Community exposures

Many calls are from parents worried about a classroom (or other) exposure in a child who is not high risk. Unfortunately we cannot and should not use Tamiflu for routine exposures. Tamiflu itself is not without risk and if overused it will not be available for people who might really need it.

Big event coming soon!

A big birthday party, a big test, a planned vacation, etc do not make your child high risk. We really shouldn’t use Tamiflu inappropriately just because flu will make life inconvenient. Remember that all treatments have potential side effects and if we use them indiscriminately they will not be available when really needed.

Tamiflu prophylaxis is recommended for high risk people who have known exposure.

High risk includes:

  • children under 2 years of age
  • adults over 65 years of age
  • persons with chronic lung (including asthma), heart (except hypertension alone), kidney, liver, hematologic (including sickle cell disease), metabolic disorders (including diabetes mellitus) or neurologic and neurodevelopment conditions (including disorders of the brain, spinal cord, peripheral nerve, and muscle, such as cerebral palsy, epilepsy [seizure disorders], stroke, intellectual disability, moderate to severe developmental delay, muscular dystrophy, or spinal cord injury)
  • persons with immunosuppression, including that caused by medications or by HIV infection
  • women who are pregnant or postpartum (within 2 weeks after delivery)
  • under 19 years of age receiving long-term aspirin therapy
  • American Indians/Alaska Natives
  • persons who are morbidly obese
  • residents of nursing homes and other chronic care facilities

Prophylactic and treatment options are summarized in this table from the CDC:

Antiviral Medications Recommended for Treatment and Chemoprophylaxis of Influenza
Antiviral Medications Recommended for Treatment and Chemoprophylaxis of Influenza

Finding Tamiflu

Right now it’s hard to find Tamiflu in many parts of the country, so you might not be able to get it after you’re exposed (or even if you’re sick with flu).

What’s better than Tamiflu?

Flu season can last through April, so taking it for 10 days now won’t help in 2 weeks when you’re exposed again. The flu vaccine protects more effectively and for a longer duration!

If sick: Treat

Most flu symptoms can be treated at home.
Fever and pain reducers

Use age and weight appropriate pain and fever reducers, such as acetaminophen and ibuprofen to keep kids comfortable. It is not necessary to bring the temperature to normal – the goal is to keep them comfortable. Don’t fear the fever – it is the immune system hard at work!

Offer plenty of fluids

Infants should continue their breastmilk or formula as tolerated. Older kids can drink water and it’s okay for them to eat. There is no need to avoid foods if a child wants to eat – I don’t know where the “feed a fever starve a cold” or other common myths started. Of course, appetite is usually down during illness, so don’t push foods. Push fluids.

Saline and suction

Saline and suction can go a long way to help relieve nasal congestion. Noisy breathing isn’t necessarily bad, but if the breathing is labored that’s another story. Check out the Sounds of Coughing to learn how to identify various breathing problems.

Cough medicine?

Pediatricians don’t recommend cough medicines due to high risk of side effects. Kids over a year of age can use honey. Some kids can get relief from menthol products. I’ve previously written all about cough medicines if you want to read more.

Natural treatments?

A lot of parents want to do natural treatments. Learn which have been shown to work and which haven’t.

For more…

For more on treating symptoms, visit my office website’s tips.

when not to go to the doctor

Not every person with influenza needs to be seen by a medical provider. I know we’re all scared, but in most cases there isn’t much doctors and other healthcare professionals can do to help.

Medical offices, urgent care clinics and ERs are overwhelmed with mildly sick people, which makes it harder for those who are really sick to be seen.

If your child is low risk (anyone who doesn’t meet the high risk criteria above) and is drinking well, overall comfortable with support measures, and doesn’t have any breathing distress, you can manage at home. Certainly if the situation changes, bring him in, but coming in before any signs of distress will not “ward off” the development of those symptoms.

When you should bring your child to be evaluated

If you think your child might have another illness, such as Strep throat, ear infection or wheezing, bring him in for evaluation and treatment.

When any signs of distress are noticed in your child: bring him in.

If your child is high risk (as described above) and has sick symptoms, he should be seen to determine if Tamiflu is appropriate. I do not recommend getting Tamiflu called in if a child is symptomatic. A child should have an exam to be sure there aren’t complications before just starting Tamiflu. I’ve seen several kids whose parents thought they had flu, but their exam and labs showed otherwise. They could be properly treated for Strep throat, ear infections, or pneumonias instead of taking Tamiflu inappropriately after an evaluation.

How can you tell if it’s the flu or another upper respiratory tract infection?

I have seen many kids who are brought in with a runny nose just to see if it’s early flu. No. No it’s not. Flu hits like a tsunami: fever/chills, cough, body aches, and fatigue. But the child was playing in the waiting room full of kids who do have flu, so you might recognize flu symptoms soon.

cold vs flu
From the CDC: How to tell if it’s a cold or the flu?

If your low-risk child had the flu vaccine, they may still get influenza disease. But if it’s mild, they can be treated at home. If symptoms worsen, they should be seen. Yes, there is a benefit to starting Tamiflu early, but we shouldn’t use it for low risk people who aren’t significantly sick. Even if you come in early, Tamiflu probably won’t be recommended if your child doesn’t meet criteria. Tamiflu has some significant side effects and is in short supply. We shouldn’t overuse it.

Flu testing

We currently have the ability to do a rapid flu test in the office, but there is a national shortage of the test supplies, so we might choose to not test your child if they don’t meet high risk criteria. I know at least one local hospital is out of rapid test kits and we probably won’t be able to get more this season if we run out.

Don’t come to the office or go to an urgent care or emergency room just to be tested.

Please don’t be upset if we do not test your child, especially if your child is not high risk and we wouldn’t recommend Tamiflu if they are positive.

If your child has classic flu symptoms, the guidelines don’t rely on test results for treatment, so if your child meets criteria for treatment, we can prescribe without a positive test.

Knowing test results doesn’t really help guide treatment when we have such high numbers of flu in the community. It does help early in the season to recognize when flu is coming to town, but we know it’s here. Pretty much everywhere in the US, it’s here.

Let’s work on stopping the spread.

Be healthy!


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The flu shot doesn’t work

I’ve seen a few kids this season who have influenza despite the fact that they had the vaccine. When the family hears that the flu test is positive (or that symptoms are consistent with influenza and testing isn’t done), they often say they won’t do the flu shot again because it didn’t work.

flu shot ineffectiveHow do they know it isn’t working?

Influenza can be deadly.

Most of the kids I’ve seen with flu who have had the shot aren’t that sick. Yes, they have a fever and cough. They aren’t well.

But they’re not in the hospital.

They’re not dying.

They tend to get better faster than those who have unvaccinated influenza.

Some kids still get very sick with influenza despite the vaccine.

That’s why there’s surveillance to see how it’s working.

When FluMist was determined to not be effective, it was removed from the market.

Studies are underway to make a new type of flu vaccine that should be more effective.

We know the shot isn’t perfect, but it’s better than nothing.

Maybe if you weren’t vaccinated you’d be a lot sicker.

Maybe you were exposed to another strain of flu and didn’t get sick at all.

I think it’s still worth it to get vaccinated each year (until they come up with a vaccine that lasts several seasons).

If everyone who’s eligible gets vaccinated against the flu, herd immunity kicks in and it doesn’t spread as easily. Historically only around 40% of people are vaccinated each year against influenza. We know that to get herd immunity we need much higher numbers.

Shot fears…

If your kids are scared of shots, check out Vaccines Don’t Have to Hurt As Much As Some Fear.

Don’t rely on Tamiflu to treat flu symptoms once you’ve gotten sick.

Tamiflu really isn’t that great of a treatment. It hasn’t been shown to decrease hospitalization or complication rates. It shortens the course by about a day. It has side effects and can be expensive. During flu outbreaks it can be hard to find.

Prevention’s the best medicine.

Learn 12 TIMELY TIPS FOR COLD AND FLU VIRUS PREVENTION.

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It’s not the flu!

I was at the gym today and an otherwise great instructor who seems to know a lot about health was sharing incorrect information about the flu with the class of about 40 people. She said that she had received several texts from other instructors asking her to cover their classes because they were vomiting. She went on to say that many at first thought it was food poisoning, but it’s spreading like illness, so it’s the flu, not food poisoning. She made a big deal that the flu is here.

That’s only partially right.

Yes…

There’s a stomach bug going around.

It’s not food poisoning.

Influenza is in town.

But this extreme vomiting is not “the flu”

Vomiting can be associated with influenza, but is not the main symptom.

The flu causes predominantly fever, cough, sore throat, and body aches for many days. It can cause vomiting and diarrhea, but those aren’t usually the predominant symptoms. And the flu doesn’t cause just a few hours of extreme vomiting like we’re seeing these days.

Why do I care if people call this stomach bug “flu”?

Runny nose is one of the symptoms of influenza.

The biggest reason I care is that it leads people to make other incorrect assumptions and to get the wrong treatments.

I hear all the time that people had the flu the year they got a flu shot, so they don’t want to get it anymore.

When probed about their illness, it’s usually not consistent with the flu. It was either a cold and cough or a stomach virus.

Cough is one of the most common symptoms of influenza, along with fever, sore throat, and body aches.

They need to know that this isn’t the flu. It wouldn’t be prevented with the flu shot. The flu shot has nothing to do with protecting against most cases of vomiting and diarrhea or most upper respiratory tract infections.

Of course there are people who got the flu shot (or FluMist when it was available) who did come down with the flu. They had a positive flu test and symptoms were consistent with the flu. But if they get influenza after the vaccine they tend to have milder symptoms. They tend to not end up in the hospital or dead if they’ve had the vaccine. Yes, even healthy young people can end up very sick from influenza. They can even die. (The FluMist didn’t protect well and was removed from the market due to this.)

We forget about all the times people did get the vaccine and they didn’t catch the flu even with likely exposure. Lack of disease is easy to fail to acknowledge.

We know the flu vaccine is imperfect. But if the majority of people get vaccinated, we can slow the rate of spread and protect us all against influenza most effectively.

We don’t have great treatments for influenza, so vaccinating and using other precautions is important!

Menthol for Sore Throat, Colds and Coughs… Should we use it?

I am often asked about the use of Vick’s Vapo Rub (or other menthol products and refer to all brands in this post).

We see menthol for vaporizer dispensers, in cough drops, and the good ole jar of rub that mom used on our chests when we were sick.

But should we use it?

Cough drops

Menthol is a mild anesthetic that provides a cooling sensation when used as a cough drop. The menthol is basically a local anesthetic which can temporarily numbs the nerves in the throat that are irritated by the cold symptoms and provide some relief. (Interestingly, menthol is added to cigarettes in part to numb the throat so new smokers can tolerate the smoke irritation better. Hmmm…)

Menthol cough drops must be used as a lozenge and not chewed or swallowed because the menthol must slowly be exposed to the throat for the numbing effect. They are not recommended for young children due to risk of choking. Since science lacks strong evidence, but the risk to most school aged children is low and it is safer than most other cough medicines, I use the “if it seems to help, use it” rule for children not at risk of choking. Do not let any child go to sleep with one in his mouth. First, he might choke if he falls asleep with it in his mouth. Second, we all need to brush teeth before sleeping to avoid cavities!

Vaporized into the air

When it is put into a vaporized solution, menthol can decrease the feeling of need to cough. It should never be used for children under 2 years of age. They have smaller airways, and the menthol can cause increased mucus production, which plugs their narrow airways and may lead to respiratory distress. Infants can safely use vaporizers (and humidifiers) that put water into the air without any added medications.

The rubs for the skin

We’ve all seen the social media posts supporting putting the menthol rubs on the feet during sleep to help prevent cough. That has never made sense to me, and the link provided discusses that it is not a proven way to use the rubs.

Menthol studies show variable effectiveness. It has been shown to decrease cough from baseline (but the placebo worked just as well) and did not show improved lung function with  spirometry tests (but people stated they could breathe better) in this interesting study.  In other words, people felt better, but there really was no objective improvement.

Putting menthol rubs directly under the nose, as opposed to rubbing it on the chest, may actually increase mucus production according to a study published in Chest. In children under age 2, this could result in an increase in more plugging of their more narrow airways. There might be a concern with putting any petrolatum based product in or near the nose. There is a more recent study that does show children ages 2-11 years with cough sleep better with a menthol rub on the chest.

Note: There is a Vick’s BabyRub that does not contain menthol. Its ingredients have not been proven to be effective and some of the ingredients have their own concerns, but that does not fall into this discussion.

Cautions

Menthol products should never be used in children under 2 years of age. It can actually cause more inflammation in their airways and lead to respiratory distress.

Photo source: Angel caboodle at English Wikipedia [CC BY-SA 3.0 (https://creativecommons.org/licenses/by-sa/3.0) or GFDL (http://www.gnu.org/copyleft/fdl.html)], via Wikimedia Commons 

If a child ingests camphor (another ingredient along with menthol in the rubs) it can be deadly. It has been known to cause seizures in children under 36 months when absorbed or ingested in high concentrations. Menthol rubs sold in the US contain camphor in a concentration that is felt to be safe if applied to intact skin in those over 2 years of age. Mucus membranes absorb medicines more readily than intact skin, so do not apply to nostrils, lips, or broken skin. Do not allow children to handle these rubs. Apply only below their necks to intact skin.

Many people using the menthol rubs experience skin irritation. Discontinue use if this happens.