It’s flu vaccine season. There have been shipping delays, but vaccine is starting to show up in doctor’s offices around the country. As soon as it’s available, get your family vaccinated!
Every year we have some sort of complication in trying to vaccinate our patients against influenza. This year is no different. Shipping delays have lead to problems this year. Of course it’s not new that pharmacies get their vaccine shipments before individual physician offices. Dr. Smith of Partners In Pediatrics wrote about this way back in 2013. She, along with many of us, remain frustrated year after year.
There is no preference over the injectable vaccine (inactivated vaccine) or nasal vaccine (live attenuated vaccine) as long as it is age appropriate. *Note: There is a significant shortage of the nasal vaccine, so do not wait for it. It is highly likely that you will not be able to find it this season.
There are now formulations of inactivated flu vaccines that have the same dose for everyone over 6 months of age. (Previously 6-36 months had a smaller dose and those 36 months and over got a larger dose.) This should make the availability of the dose your child needs more likely.
Children 6 months to 9 years of age who have received no previous influenza vaccine or only 1 dose before July 1, 2019, should receive 2 doses of influenza vaccine. Think of the first-ever dose in young children as a primer dose. A booster dose is needed every season. Everyone under 9 years of age getting vaccinated for the first time needs their primer dose and a booster dose at least 4 weeks later. Children who have previously received ≥2 total doses of influenza vaccine at least 4 weeks apart before July 1, 2019, require only one dose for 2019–20. The 2 doses of influenza vaccine do not have to have been administered in the same season or consecutive seasons. If they had only 1 flu vaccine before July 1, 2019, they need 2 doses this season.
Vaccines should be offered as soon as they become available and ideally will be given by Halloween. (I have concerns with this statement because of the shipping delays previously mentioned. If it is later than Halloween and your family has not yet been vaccinated, it is NOT too late. Get the vaccine – even if your family has already had the flu this year. You can get different strains in the same season!)
What’s the new with the flu vaccine season 2018-2019? Who needs the vaccine? Should you get the shot or nosespray? Which one is preferred by experts?
Every year the flu vaccine season throws us something new and challenging. The buzz this year is pediatricians questioning what to recommend with the new version of FluMist. So what’s new with the flu vaccine season 2018-2019?
If you tried to get a FluMist vaccine for the past couple of years, you know that it wasn’t available. It did not seem to be effective, so it was removed from use. It has been reconfigured to improve the efficacy. The CDC’s Advisory Committee on Immunization Practices (ACIP) is allowing it to be re-released for the 2018-2019 season.
There are many versions of the flu shot. Some contain 3 strains of flu protection, others have 4 strains. Use of each is dependent on age and other factors. There is only one version of nasal spray flu vaccine, the FluMist.
Flu Vaccine Season 2018- 2019 ACIP Recommendations:
Everyone over 6 months of age who does not have a contraindication to vaccination should get a flu vaccine.
No preference is given for one vaccine product over another, as long as it is age appropriate and there are no contraindications. (See Controversy for details on this.)
Children under 10 years of age who have never had a flu vaccine should get two doses this year.
If vaccine supply is limited, high risk people should get priority. This includes:
The CDC recommends starting to vaccinate as soon as it’s available (usually August or September) and to have the vaccine given by Halloween.
It’s not hard to see the logistical problems of vaccinating essentially everyone in the two months of September and October.
Some of the problems getting masses vaccinated:
Getting the vaccine itself. Recently flu shots have started to be delivered around the country. They seemed to show up first at big chain pharmacies before doctor’s offices. There aren’t any shortages this year so far, but not everyone can get all their vaccine orders at once.
The FluMist hasn’t been approved for shipping yet, so no one has that at this time. If you’re hoping to get it, you’ll have to wait. No approval date has been announced as far as I know.
I’ve heard that some Vaccine For Children (VFC) programs haven’t even opened up their ordering for the year. (Most flu vaccines are ordered in January or February for the next vaccine season, but VFC programs are state run and vary in rules.) If your child will require a VFC vaccine, you will likely have to wait until your clinic has them in stock, even if they have other flu vaccines.
Many years there are shortages. Those are hard to anticipate, but are another reason not to turn down a vaccine if it’s offered.
Having extra personnel skilled in giving flu vaccines available is difficult when they’re needed to perform typical work. Giving vaccines takes time. There’s a lot behind the scenes that needs to be done and documented in addition to the time of getting people prepared for the shot itself. And we all have seen the kids who put up a good fight, which means the nurse can’t quickly give the shot.
There are always time conflicts getting to a place that offers flu shots. Work, school and activity schedules are busy. It can be hard getting everyone in the family to a place that has the right vaccine for each person at a time that you’re not busy.
What if you aren’t vaccinated by Halloween?
There will be many who continue to be vaccinated in November and beyond. It is recommended to continue vaccinating until the vaccine supply is gone or the season ends. The flu season can possibly last through May in the Northern Hemisphere.
Will an early flu vaccine last long enough?
I’m asked this question often. I’ve been told by several parents that they want to wait to get the shot for their family until October to optimize the protection during flu season.
While this sounds good in theory, I’m afraid that some of these people may miss the opportunity to be vaccinated before the flu hits.
Although we say that it tends to hit in January in my area, it can hit at any time. I’ve already heard of one case of Flu A in another local pediatric practice.
All vaccines take time to become effective, so waiting until you hear that it’s in the community is already too late in some respects. We often have more than one peak of flu activity each year, so still get the vaccine!
The effectiveness of the flu vaccine does decrease over time, but it’s estimated to last about 6 months. Unfortunately our season can last up to 8 months, so there is no perfect time.
What if we got our flu shot later in the season last year? Is it still good?
Each year the strains in the flu vaccines are updated to reflect the anticipated strains of influenza that will circulate. It’s important to get a new flu vaccine each season. Even if your child got a flu shot in May 2018, he should get another this Fall or Winter.
Who needs a second vaccine?
It is not recommended to get a second flu shot later in the season for most people.
Children under 9 years of age getting vaccinated for the first time need their primer dose and a booster dose at least 4 weeks later. Children who have previously received ≥2 total doses of influenza vaccine at least 4 weeks apart before July 1, 2018, require only one dose for 2018–19. The 2 doses of influenza vaccine do not have to have been administered in the same season or consecutive seasons. If they had only 1 flu vaccine before July 1, 2018, they need 2 doses this season.
Grohskopf LA, Sokolow LZ, Broder KR, Walter EB, Fry AM, Jernigan DB. Prevention and Control of Seasonal Influenza with Vaccines: Recommendations of the Advisory Committee on Immunization Practices—United States, 2018–19 Influenza Season. MMWR Recomm Rep 2018;67(No. RR-3):1–20. DOI: http://dx.doi.org/10.15585/mmwr.rr6703a1
2. Will FluMist work?
Unfortunately, we won’t really know until the season is well underway. Every year we must wait to learn if the flu vaccine is effective. The effectiveness varies from year to year.
FluMist History
The FluMist was first approved in 2003. It was a welcome addition to the flu vaccine lineup because there are no needles needed. It seemed to be very effective initially. In 2014, the CDC’s Advisory Committee on Immunization Practices (ACIP) even gave it preferential status because it seemed to be more effective than the flu shot version.
The very next year ACIP reversed its decision due to very poor performance of the H1N1 strain in the FluMist in the United States. (This didn’t seem to be a problem everywhere.) FluMist was removed from the market for two years as scientists tried to figure out why it didn’t work well so they could remedy the problem.
This Year’s FluMist
Testing of the new version shows that the new H1N1 LAIV strain (A/Slovenia) performed significantly better than the 2015-16 strain (A/Bolivia). Does this mean that it will perform better this season? We really don’t know, but in February 2018, ACIP voted to bring back the newly formulated FluMist for the 2018-2019 season.
In years past it was recommended for anyone who had received the FluMist to avoid contact with immunocompromised people for 7 days. It is no longer considered to be a risk to most immunocompromised people to be around a recently vaccinated person. If the immunocompromised state is severe enough to require a protected environment, avoidance for 7 days after FluMist continues to be recommended.
Controversy
While most of the experts on the ACIP panel voted in favor to bring the FluMist back based on the study results, some members were not in agreement. They still worry that the FluMist may not perform well during the flu season.
The CDC official position states no preference between the FluMist and the shot version, as long as the vaccine is age appropriate and there are no contraindications, such as allergy or chronic disease. The shot is available for all ages over 6 months old, but the FluMist is only for 2 – 49 year olds.
The AAP (American Academy of Pediatrics) stance on the FluMist is that it should only be used when the shot version is refused or unavailable. They will continually monitor the flu vaccine effectiveness patterns and may change their recommendation. If your child is worried about giving the shot, check out ways to make shots less scary.
Interestingly, Dr. Paul Offit, one of our country’s leading vaccine experts, disagrees with the AAP.
So I think the AAP was wrong, frankly, to say that FluMist should only be used as a last-resort vaccine for influenza. Rather, they should have gone along with what the ACIP said, which was that these vaccines can now be used interchangeably for persons aged 2-49 years. ~ Dr. Paul Offit
3. What about egg allergy?
For several years now egg allergy is not considered a contraindication to flu vaccines. Despite this, people still think they cannot be vaccinated due to an allergy.
Severe allergic reactions to vaccines, although rare, can occur at any time, even in without a history of previous allergic reaction. The person giving flu vaccines should be able to identify and equipped to handle any allergic reaction.
Different influenza vaccines contain different amounts of egg components, so it is important to discuss the history of egg allergy with the person who will give the flu vaccine.
People with a history of egg allergy who have only had hives after exposure to egg should receive influenza vaccine. Any version that is age appropriate can be used.
People who have required epinephrine after eating egg or who have had angioedema, respiratory distress, lightheadedness, or recurrent vomiting are considered higher risk with influenza vaccination. They still may receive an age appropriate influenza vaccine, but it should be done in a health care setting, such as a medical clinic or hospital. They should not get the vaccine at a community drive, such as in a school or church setting. Vaccine administration should be supervised by a health care provider who is able to recognize and manage severe allergic reactions.
A previous severe allergic reaction to influenza vaccine, regardless of the component suspected of being responsible for the reaction, is a contraindication to vaccinating with that vaccine in the future. This does not include the typical reactions of redness at the injection site, fever, or muscle aches.
No observation period is recommended specifically for egg-allergic people. If there is concern, a 15 minute observation period after any vaccine can be done. This is commonly done in the adolescent age group due to their high risk for passing out after any needle – shots or blood draws.
4. What if you’re traveling internationally?
Influenza season varies by location. In the US, we tend to think of it as a winter thing, but it can happen during our summer months elsewhere. Flu is seen in the fall and spring in addition to the winter months in Kansas.
In the Northern Hemisphere it tends to hit between October and May. The Southern Hemisphere’s season tends to be April through September.
Even the types of influenza that circulates can vary by location. These types affect the type of vaccine that is used in that location.
It’s recommended to be vaccinated against influenza at least 2 weeks before traveling to any location during their flu season. This can be difficult if there is not any flu vaccine in your area. It can also be difficult to find the correct strains of flu vaccine in your location.
Talk to your physician or a travel clinic to see what is needed and available.
5. Doesn’t the flu shot cause the flu?
No. No it doesn’t.
Flu is a very dangerous illness that results in many people requiring hospitalization. Each year previously healthy children and adults die from influenza.
The symptoms people get after flu shots often could be explained by many viruses. They are not the flu. If they really are flu symptoms, it is because the vaccine didn’t have time to take effect or it was a strain not included in the vaccine.
There is no plausible way that the injectable flu vaccine can cause the flu. There is no live virus in the injectable vaccine that can lead to flu disease. Injectable flu vaccines are made in two ways. Either the vaccine is made with flu vaccine viruses that have been ‘inactivated’ and are not infectious or with no flu vaccine viruses at all.
The most common side effects from the influenza shot are soreness, redness, tenderness or swelling where the shot was given. Low-grade fever, headache and muscle aches also may occur, but interestingly these same symptoms occur with placebo shots too.
How do we know it doesn’t cause illness?
Studies like this one in adults have compared side effects of a flu shot to side effects of a placebo with saline (salt water). The only differences in symptoms was increased soreness in the arm and redness at the injection site among people who got the flu shot. There were no differences in terms of body aches, fever, cough, runny nose or sore throat. These all can occur during the time frame that the flu vaccine is typically recommended. It’s just a coincidence if you “get sick” after getting the vaccine.
Studies in children are lacking. Ethically it is difficult to study this, since it would require not giving some children a potentially life saving vaccine if they receive the placebo.
What about the FluMist?
The FluMist is a live virus. It can cause congestion and symptoms like a very mild case of the flu.
FluMist can cause mild illness, but it prevents (or hopefully will prevent) significant flu disease symptoms.
6. What if you get the flu?
I’ll write separately about how to treat the flu and flu-like symptoms.
7. Why bother, since the flu shot isn’t effective.
The effectiveness of the flu vaccine is never perfect, but it’s better than nothing. For more on this, see The flu shot doesn’t work.
This Flat Stanley spent time in our office one flu vaccine season. Given the paucity of good stock photos of people getting vaccines, I chose this one to highlight the point of few photo choices. And I think it’s fun.
Every once in a while we see a child whose school nurse says the child’s vaccines didn’t count and need to be repeated. This can be due to many things, usually inappropriate timing of vaccines. Some electronic health records now have intelligent vaccine recommendation abilities. These smart vaccine logic systems are catching kids who had incorrect spacing before this technology. Staying on the routine vaccine schedule and keeping all records in one place can help avoid extra doses due to inappropriately spaced vaccines.
One thing to remember if your child needs extra doses: you don’t need to worry. They’re safe!
What’s in this post?
First you’ll need to understand about the different types of vaccines to know why they are scheduled like they are. Some are given in a series to boost the initial response, but others need to be repeated to cover those who weren’t protected with a first dose.
Then we’ll do a quick review of the risk of the diseases to remind us why we vaccinate in the first place.
Hopefully after learning some basics, you’ll see why the timing of vaccines is so important and why we should all follow the recommended vaccine schedule.
Live attenuated vaccines are made from weakened virus that teaches the body to recognize the real virus but doesn’t cause the symptoms of the virus in healthy people.
Those with weak immune systems should talk to their physician before receiving a live virus vaccine. The amount of immune compromise and specific vaccine must be taken into account on an individual basis.
It’s usually okay to be vaccinated with a live virus vaccine if you’ll be around an immunocompromised person, but again, let your physician know the risk of exposure.
Examples of live virus vaccine:
rotavirus
measles
mumps
rubella
varicella
nasal flu vaccine (NOT the injectable flu vaccine)
Many people respond sufficiently to the first dose of these, but repeat doses are given to help those who missed the response the first time.
The second dose doesn’t boost the first, but it gives a person a second chance at making immunity.
Spacing between doses:
Because of the way these vaccines work, they must follow special separation rules. More than one live virus vaccine can be given on the same day, but they cannot be given on separate days that are closer than 4 weeks apart.
If one live virus vaccine is given, you must wait a minimum of 28 days to give another. If they’re given too close together, the body doesn’t make immunity as well to the second one given. This second vaccine wouldn’t count.
As an example, if the FluMist (nasal flu vaccine) is given on January 1 and the Varicella vaccine is given January 15 of the same year, the Varicella vaccine will not count and must be repeated.
Live virus vaccines are the only vaccines that are subject to this 28 day rule. If another vaccine type is needed, it is okay to give in a shorter time frame.
For example, if a child has the MMR at his 4 year well visit, it is okay to do an injectable flu vaccine at a flu clinic later that same month. (Note: the nasal flu vaccine is a live virus vaccine, so it is NOT okay to give the FluMist within the month before or after the MMR.)
If there is less than 28 days between live virus vaccines, the one that was given second must be repeated.
I see this quite frequently in kids who move to the US from other countries. It seems quite common elsewhere for kids to get the varicella (chicken pox) vaccine about 2 weeks after the MMR. When this happens, another varicella vaccine is needed.
Live virus vaccines aren’t recommended under 1 year… usually
Many parents worry that we don’t give live virus vaccines to infants because they’re less safe, but that’s not why at all.
Maternal antibodies (fighter cells from mom that got into baby during pregnancy) can inhibit the body from being able to build its own antibodies well against a vaccine.
Maternal antibodies are good because as long as they’re in the baby’s body, they fight off germs and protect the infant! They tend to hang around for the first 6-12 months of life.
If a disease has a low incidence, it is acceptable to let the maternal antibodies do their job for the first year.
By the first birthday most maternal antibodies have left the infant, so a vaccine can be used to build the baby’s immunity.
International travel increases risks
If there is a high risk of exposure it is recommended to give the vaccine as early as 6 months in case the maternal antibodies are already too low for infant protection. Many parts of the world have high measles rates so fit into this recommendation.
If the antibody levels are still high, the vaccine won’t work, but the baby should still be protected against the disease from mom’s antibodies.
At some point the maternal antibodies go away, we just don’t know when exactly, so the baby who gets the MMR early needs another dose after his first birthday to be sure he’s making his own antibodies once mom’s go away. This dose after the birthday is the first that “counts” toward the two MMRs that are needed.
The next dose of MMR can be anytime at least 28 days after the first counted dose, but we traditionally give it between 4-6 years with the kindergarten shots.
Yes, I realize there are some measles outbreaks in the US, but the experts have not said to start giving that extra dose to babies who are staying here yet. If you’re worried, talk to your doctor.
Inactivated virus vaccines
Inactivated virus vaccines are made by killing the virus and using it to make the vaccine.
They aren’t as effective as live virus vaccines, so several doses are needed to build immunity to these.
Examples of inactivated virus vaccines:
inactivated polio vaccine
injectable flu vaccines
hepatitis A vaccine
Subunit, recombinant, polysaccharide, and conjugate vaccines
Subunit, recombinant, polysaccharide, and conjugate vaccines use specific pieces of a virus or bacteria to make a vaccine.
Because these vaccines use only specific antigens, they give a very strong immune response that’s specific to the infectious particle and side effects are less common.
This type of vaccine is safe for nearly everyone, including people with weak immune systems.
One limitation of these vaccines is that you may need booster shots to get ongoing protection against diseases.
Subunit, recombinant, polysaccharide, and conjugate vaccines include:
Hib (Haemophilus influenzae type b) – not related to influenza vaccine at all
Hepatitis B
HPV
whooping cough
pneumoccal disease
meningococcal disease
Toxoid vaccines
Toxoid vaccinesprevent diseases caused by bacteria that produce toxins in the body.
The toxins are weakened into toxoids so they cannot cause illness and are used to make the vaccine.
When the immune system receives a vaccine containing a toxoid, it learns how to fight off the natural toxin.
Example of toxoid vaccine:
diphtheria and tetanus portions of the DTaP vaccine
Several shots are needed to build and continue immunity over time.
Passive immunization
Passive immunization is a bit different than any of the above.
Either catching a disease or getting any of the above vaccines stimulates your immune system to make memory cells to fight of that specific germ if it comes in contact with it.
Passive immunity results when a person is given someone else’s antibodies.
The protection offered by passive immunization is short-lived, usually lasting only a few weeks or months, but it helps protect right away.
Example of a passive vaccine:
Synagis (RSV) vaccine
Why are vaccines repeatedly given?
Vaccines interact with the T and B cells of our immune system to make memory cells.
If you want to learn more, see How Vaccines Work. It’s a really cool slide show from The College of Physicians of Philadelphia.
Some vaccines need several doses to help the body develop a strong immunity against the germs. Later boosters are required to maintain that level of protection.
Other vaccines require more than one dose to insure that most people develop the protection.
Age at time of vaccine matters
The CDC Immunization schedule allows for age ranges for many vaccines to be given. Many states allow a grace period around those ages, but not all do.
Some vaccines have been shown to work best at certain ages. Our vaccine schedule reflects the best ages to give vaccines so that they are safe and effective.
If a child receives a vaccine within the grace period of their current state, it might “count.” But if that child moves to another state, the vaccine might not count per the new state’s laws.
My office only gives the routine MMR, Varicella, and Hepatitis A vaccines on or after the first birthday to help prevent a child from moving to a location that does not have a grace period. This is despite the fact that Kansas does have a 4 day grace period.
We will give the MMR earlier under certain circumstances as discussed above, but it does not count toward the two needed after the 1st birthday.
Spacing matters
Many vaccines need to be separated by a minimum timeframe, often 4 weeks, but sometimes longer. The Hepatitis A vaccine has a minimum timeframe of 6 months between doses, for example.
If the vaccine doses are not separated by a minimum time, one or more will need to be repeated.
For spacing rules, see the CDC vaccine schedule at the bottom of this post. Click on “footnotes” to see the details for each vaccine.
Why not space them out further?
Many parents have come to believe the “too many too soon” theory. They believe this despite the overwhelming evidence that vaccines are safe and effective when given according to the CDC schedule.
The risks to waiting to give vaccines are many.
Increasing vaccine preventable disease rates
Young adults of today have grown up without seeing the suffering of vaccine preventable diseases. But we’re seeing an increase in these diseases where vaccine rates have fallen.
Infants who aren’t vaccinated are at risk of diseases that can lead to death. They are among the most vulnerable and need protection.
More trips = more exposure
Not only are underimmunized children more at risk for vaccine preventable diseases, but bringing them to a clinic more frequently to do one vaccine a time increases risk. Each time they visit the clinic, they’re exposed to all the common viruses. Why risk bringing them back again and again to get more exposures?
Giving the vaccines together has been shown to be safe and effective.
More visits = more stress
There are studies that show less overall stress to the body if vaccines are given together.
Studies have shown that the first injection causes a stress response measured by elevated heart rate, blood pressure, cortisol levels, and cry. Subsequent injections given at the same time do not increase as significantly the stress when compared to returning on different days to get further injections.
The immune system can handle it
Are you worried about “too many too soon” and that vaccines will overwhelm the immune system? Stop worrying. These fears are simply unfounded.
Current studies do not support the hypothesis that multiple vaccines overwhelm, weaken, or “use up” the immune system. On the contrary, young infants have an enormous capacity to respond to multiple vaccines, as well as to the many other challenges present in the environment. By providing protection against a number of bacterial and viral pathogens, vaccines prevent the “weakening” of the immune system and consequent secondary bacterial infections occasionally caused by natural infection.
Keep your child’s vaccine record handy
I see many kids who transfer to my office but I don’t have access to their vaccine records at the time of the visit. This makes it difficult to know which (if any) vaccines are needed.
Hopefully as we use Electronic Health Records with portals and vaccine registry databases more this will become a non-issue. At this time it’s still a problem.
This is one of the many reasons I prefer for all vaccines to be given at the same clinic. If you’re changing primary care providers, be sure records are transferred before your first visit.
Flu vaccines are especially troublesome.
Flu vaccines are commonly given in many locations: your primary care provider (PCP) office, a parent’s workplace, a local pharmacy, at a school flu vaccine drive. They need to be repeated yearly, so it’s easy to forget if each of your kids has had it this year.
It’s common for one parent to not know if their child got a flu vaccine already this season. That leads to a missed opportunity or vaccines given unnecessarily.
I have seen a few kids who couldn’t get their kindergarten vaccines at their well visit because they recently had a FluMist elsewhere. That requires another trip to the office for the family.
I have seen a few kids who did get the kindergarten vaccines inappropriately because the parent didn’t realize the other parent had taken them for a FluMist elsewhere. They needed to repeat the MMR and varicella vaccines, which didn’t make the kids happy!
FluMist is coming back to the US for the 2018-2019 flu vaccine season. It is not the preferred vaccine by many experts due to continued concerns about its effectiveness, but it will be preferred by many kids who hate needles. If your kids worry about shots, learn how to make them less painful.
Be sure to keep track if your kids get a FluMist – especially if they’re getting kindergarten vaccines around the same time!
Learn more about vaccine preventable diseases:
This comic book can teach kids and adults about viruses and how science works:
Dr. Paul Offit is one of the leading experts on vaccines. His many books can show how vaccines work and why they’re needed. He delves into the anti-vaccine movement in many of his books. He shows how delayed vaccine schedules are not effective or necessary in most of his books. I have many of these at my office available for patient families to check out. Just ask if you’re in my office. Otherwise, read about each on the links to see what best fits your needs.
Note: As an Amazon Affiliate Member, I will get a small percentage for the sale of the books if purchased from these links. This is at no additional cost to you.
How Math (and Vaccines) Keep You Safe From the Flu Simple (or not so simple) math shows how herd immunity works. Widespread vaccination can disrupt the exponential spread of disease and prevent epidemics.
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.
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.
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!
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.
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.
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
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.
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.
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.
Hello. This is Dr. Stuppy. I’m returning your call about…
That’s how my phone calls start, then they take various turns. Some are easy, some not so easy. I’d like to discuss what makes a phone call to the doctor’s office more productive, so we can help you better.
All examples are entirely fictitious, made up of 18 + years of phone call experiences.
Many calls start off like this:
Hi. This is Mary Sue. My son has a rash and I want to know what to do.
Me: ?????
I must ask many questions for more information.
Some callers don’t seem to know what to say, so they only answer direct questions. How old is your son? When did the rash start? What does it look like? Has it changed? Does it itch or hurt? Any other symptoms? What have you used to treat it? Did that help? Has he had any new ingestions, lotions, or creams? Does he have a history of allergies? Anyone else with a rash that looks like this?
On and on…
Other calls start like this:
Hi. Thanks for calling back. My son Jack is 3 years old. Well, really his birthday isn’t until next month, but he’s almost 3. He has had a fever for 2 days, maybe 3 days because he felt warm but he wasn’t acting funny or sick that first day he felt warm so I didn’t check his temperature. He actually was fussy last week, but I don’t think he ever had a fever then. I was thinking maybe he didn’t sleep well last week, but I don’t know why. His temperature was 100.3, that was on Tuesday around 7am. I gave Tylenol, and it went down to 97.9, but then 4 hours later it was back up to 99.7….
My thoughts so far: Get to the point.
Sorry, but that’s true. I care about my patients, but so far this phone call has taken me quite a bit of time and I really know nothing except this almost 3 year old has an elevated temperature (not even a true fever). I don’t even know what the parent’s main concern is.
just the facts, MA’AM.
When parents call, they need to summarize with pertinent facts. While they shouldn’t leave out important helpful information, they don’t need to mention every time they took a temperature.
Much like the evening news: they can’t do a play by play of every football game. There’s no time and it serves no purpose. A few highlights of the game and the score. That works well. People get a pretty good idea of how the game went.
It’s the same thing with phone calls to your doctor’s office or on call provider. We have thousands of patients. Not all call, but during peak cold and flu season, there are many calls all day and night. The phone nurse or on call provider simply can’t spend 15 minutes chatting about every detail. That’s for your friend and you to discuss over coffee.
During the cold and flu season, it’s not uncommon for me to be on the phone with one parent when another call comes in. This is at the same time I’m trying get groceries or do other things I need to do for my family on evenings and weekends. (Being on call after hours doesn’t mean that I don’t have to work during the day.) I really don’t want to sit and chat. I don’t have time for play by play action. Again, I really care about my patients, but I can do a better job at answering your questions if you are clear and concise.
Things that help us help you:
Know what’s going on.
When a parent calls and the child is at daycare or grandma’s so the caller doesn’t know details, we can’t really help. Yes, parents have called for advice when they’re on their way to daycare but don’t know any more than the child has to be picked up due to a symptom such as vomiting, fever or pink eye.
See your child first or have the person with the child call us. When you pick up the child, ask for details of their day. Learn how they ate/drank, how they acted, etc.
Sometimes you’ve been up several nights in a row with a sick child and things get jumbled in your head. It happens.
Write down the pertinent facts to get them straight if you need to.
Start with your child’s full name and birth date.
I can’t tell you how often parents jump right into their worries without stating who their child is. This is important not only for chart documentation of the call but also so we know how old your child is.
Include any significant past history, such as your infant was born at 28 weeks gestation, or your coughing 3 year old has a history of wheezing.
Give pertinent facts related to the concern.
If your child has a fever, give the number of days of fever, the maximum temperature, and how it was taken.
If you have given a fever reducer, share that.
Find a quiet place to talk.
When my kids were little they always wanted to be held when they were sick. I get it.
If you’re on the phone and they’re crying in your arms, it’s very hard to have a conversation.
Please find a safe place for your child to rest while we talk if possible.
If they won’t leave you or stay quiet, have another adult talk to us after they’ve been briefed about all the symptoms.
Summarize symptoms and treatments.
Briefly describe symptoms and what you have done to help them as well as how your child responded to the treatment.
Mention All treatments
If you use a vaporizer or saline for a cold, or have stopped dairy and used gatorade for vomiting, let us know. If you use a traditional home remedy, please let us know.
Let us know any medications your child typically takes in addition to ones you have tried for the current symptoms.
Signs and symptoms can be tricky to describe
When there’s a rash, it’s typically best for us to see it, but if you call about a rash describe it in terms of location, color, and size. Many find it helpful to relate to common objects, such as quarter-sized.
Note if there is a pattern to the symptoms, such as headache every day after school or barky cough only at night.
Summarize, don’t tell a novel
Leave out details that don’t help. Trends and generalizations work well.
If we want more details, we can always ask.
Avoid words that could be interpreted other ways, use facts.
Commonly misused words are “lethargic” and “fever.”
Lethargy in a medical sense is ominous. Many parents use it when their child is only mildly ill and tired. Describe what you’re seeing instead. Saying “Johnny won’t even wake enough to drink or hold his cup,” gives me the thought he is lethargic. Saying “Johnny wants to sit on my lap and read books instead of playing with his sister,” shows that he’s not well, but definitely not lethargic.
Fever is a temperature over 100.4 F. Many parents use the word fever if their child feels warm to touch. It’s more clear if you state that they’re warm to touch or what the thermometer says and how you took it.
I’m calling about Joe Smith, birth date 9.12.08. He has had a fever for 3 days, up to 101.3 under the arm. It comes down with ibuprofen, but is right back up in 6 hours. He also has sore throat and headache. He’s drinking well but not eating much for 3 days.
I know this child’s name, age, pattern of fever and associated symptoms. The only thing I need now is the parent’s concern – so far they’ve been doing everything right. What made them call today? What’s their question?
Describe
Sally Smith, birth date 9.12.17, has vomited 6 times in the past 12 hours. If I give formula it immediately comes up. She is now dry heaving and hasn’t had a wet diaper in 12 hours. There’s no fever but she looks tired and it is hard to wake her to drink. She doesn’t have diarrhea. Her older brother had the stomach flu a few days ago but is now better.
Again, I know the child’s name and age and main problem – especially the fact that she sounds dehydrated. The parent didn’t use this word, but described dehydration (no wet diaper in 12 hours and it’s hard to wake her to drink).
Include pertinent history
John Smith, birth date 9.12.17, was in the NICU for 2 months due to prematurity. He has been fussy all day and is now breathing fast and hard and is not able to drink more than a few sucks at a time. He doesn’t have a fever, but I’m really worried.
Here I know the child’s age and that he was significantly premature – a big risk factor. He’s distressed because he can’t feed. Note: I made this baby not have a fever on purpose. He’s sick even without a fever.
Getting More Information
Knowing where to get reliable information is important. There’s a lot of bad advice online. Fancy websites aren’t always reliable.
My office’s website, PediatricPartnersKC, also has many pearls of wisdom. Often when we give advice it’s already stated on our site. Parents sometimes call multiple times because they can’t remember what we said. This is frustrating on both ends of the phone. We wrote it down and made it easily available for a reason. Use our site! (For patients in other practices, check out your own pediatrician’s site.)
Things that cannot be done by on call providers – at least not well:
Prior authorization for an ER or urgent care visit that is already done.
Prior authorizations are not usually needed, but if they are required, we should talk to you to be sure the visit is necessary before you go.
If I didn’t send you to the ER, I can’t fill out paperwork saying I did. That’s lying and using my license inappropriately. Often I would have chosen another location or given home care instructions to get you through the night.
Of course if you do talk to me (or one of my partners) overnight and we do send you to an urgent care or ER, we are happy to fill out forms if needed by insurance.
You should ask their triage nurse who can make that assessment.
Refill medications.
I typically expect that your child is seen prior to most prescription refills for best medical care. If it’s urgent that your child have a refill, such as an inhaler, they should be seen to evaluate the concern.
There are exceptions to every rule, but don’t be upset if the on call provider or phone nurse refuses to call out a prescription.
This is in the best interest of your child, not to be difficult. It’s easier to just call in the script than it is to argue this point, believe me. But easier isn’t better care, and that’s what’s important.
Make a diagnosis.
We cannot see the ear, listen to the lungs, or feel the belly over the phone. A physical exam and sometimes labs or radiology studies are needed to make a diagnosis. If your doctor claims to be able to diagnose by phone to call out prescriptions, I would suggest that they’re not doing the best of care.
An example of a poor diagnosis by phone:
Just this week another child was seen in my office for a sore throat that wasn’t better on the amoxicillin prescribed by a telemedicine doctor through their insurance company. The exam clearly showed blisters on the child’s throat. The sore throat was from these blisters, which are from a virus, not a bacteria.
The antibiotic was never needed. In this case the child simply didn’t get better as expected with a presumed case of Strep throat, but fortunately she didn’t get diarrhea or have an allergic reaction to the antibiotic. Who knows if this contributed to more bacterial resistance and superbugs?
Not only did the family waste money on an unnecessary treatment, they also exposed their child to a treatment that could have caused harm.
I worry with the increasing use of telehealth that we will see more problems related to improper diagnoses and delay of proper diagnoses – some of which could be significant.
Swallowed poisons or medicine / drug overdose.
The United States has a great poison control system. They can give rapid advice that most doctors don’t have easily available.
Call (800) 222-1222 if you suspect your child has ingested something. PUT THIS NUMBER IN YOUR PHONE RIGHT NOW.
A visit’s better than a phone call for:
Difficulty breathing.
If a child is having difficulty breathing and you don’t have treatments at home that work, he needs to be seen as soon as possible.
Dehydration.
An infant who hasn’t urinated in 6-8 hours or an older child who hasn’t urinated in 12 hours might be dehydrated and should be seen as soon as possible.
Some fevers.
Temperature above 100.4 F in an infant under 3 months or in an under immunized child can be serious and should be seen as soon as possible.
Fevers lasting more than 3-5 days or with other concerning symptoms require an evaluation.
Fevers are scary and can make kids miserable. There is no “magic” temperature that we worry about more. Look at how your child is acting, not the thermometer, to determine if they are sick. Not every child with a fever needs to even be treated. There is benefit to letting the fever do its job!
Uncontrollable pain.
If you’ve used standard pain relievers and your child is still hurting, we cannot do anything by phone that will improve the situation. A careful exam might find a treatable cause of pain.
Most rashes.
Though these don’t necessarily need to be seen emergently unless there are other concerns, rashes cannot be evaluated on the phone and a physical exam is needed.
If your child is otherwise well appearing, treat the symptoms of the rash.
If he’s otherwise sick and you’re concerned, then he should be seen.
Chronic problems.
If your child has been dealing with anything for more than a few days, it might help to schedule a visit with your usual provider. This is especially true if it relates to a chronic condition, such as asthma, constipation, or other issue.
Many parents deal with a problem for months (or years) but have NEVER been in to discuss it specifically. They might mention it at another visit as an aside, but we never really talk about it in depth and give it the attention it deserves.
Diagnosis vs information.
If you want a diagnosis, we need to see your child. We cannot tell if the ear is infected or if your child has Strep based on symptoms alone.
If you want advice of what to do with symptoms, we can generally give advice. Remember that the websites above can be helpful with this type of information too!
Behavior problems.
These are best discussed with your usual provider, not an on-call provider who doesn’t know your child. Most of these build up over time and are not emergent issues.
If it is an emergent issue, such as a child is in physical danger due to his actions or if a child is threatening another person, call 911.
If your child is suicidal, call the suicide hotline at 1-800-273-8255.
Injuries.
If your child has a significant injury, they often require prompt evaluation. Call 911 before calling your doctor’s office if your child is seriously injured.
Lacerations must be repaired as soon as possible, so don’t wait until office hours the next day if there’s a gaping wound!
Minor bumps and bruises can be handled at home, but if you’re not sure, give us a call to discuss what happened.
Help me help you!
Let me know what else you need to know to be an educated caller.
I’d be happy to answer questions about when to call, what to ask, and what to expect.
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.
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.
Parents hear about fever seizures and are afraid the temperature will get so high that it will cause permanent brain damage. In reality the way a child is acting is more important than the temperature. If they’re dehydrated, having difficulty breathing, or are in extreme pain, you don’t need a thermometer to know they’re sick.
Fever is uncomfortable.
Fever can make the body ache. It’s often associated with other pains, such as headache or muscle aches. Kids look miserable when they have a fever. They might appear more tired than normal. They breathe faster. Their heart pounds. They whine. Their face is flushed. They are sweaty. They might have chills, causing them to shake.
Fever is often feared as something bad.
Parents often fear the worst with a fever:
Is it pneumonia? Leukemia? Ear infection?
Fever is good in most cases.
In most instances, fever in children is good. It’s a sign of a working immune system.
Fever is often associated with decreased appetite.
This decreased food intake worries parents, but if the child is drinking enough to stay hydrated, they can survive a few days without food. Kids typically increase their intake when feeling well again. Don’t force them to eat when sick, but do encourage fluids to maintain hydration.
Fever is serious in infants under 3 months, immunocompromised people, and in underimmunized kids.
These kids do not have very effective immune systems and are more at risk from diseases their bodies can’t fight. Any abnormal temperature (both too high and too low) should be completely evaluated in these at risk children.
Fever is inconvenient.
I hate to say it, but for many parents it’s just not convenient for their kids to be sick. A big meeting at work. A child’s class party. A recital. A big game or tournament.
Whatever it is, our lives are busy and we don’t want to stop for illness. Unfortunately, there is no treatment for fever that makes it become non-infectious immediately, so it is best to stay home. Don’t expose others by giving your child ibuprofen and hoping the school nurse won’t call.
Fever is a normal response to illness in most cases.
Most fevers in kids are due to viruses and run their course in 3-5 days. Parents usually want to know what temperature is too high, but that number is really unknown (probably above 106F). The height of a fever does not tell us how serious the infection is. The higher the temperature, the more miserable a person feels. That’s why it’s recommended to use a fever reducer after 102F. The temperature doesn’t need to come back to normal, it just needs to come down enough for comfort.
Fever is most common at night.
Unfortunately most illnesses are more severe at night. This has to do with the complex system of hormones in our body. It means that kids who seem “okay” during the day have more discomfort over night. This decreases everyone’s sleep and is frustrating to parents, but is common.
Fever is a time that illnesses are considered most contagious.
During a fever viral shedding is highest. It’s important to keep anyone with fever away from others as much as practical (in a home, confining kids to a bedroom can help). Wash hands and surfaces that person touches often during any illness. Continue these precautions until the child is fever free for 24 hours without fever reducers. (Remember that temperatures fluctuate, so a few hours without fever doesn’t prove that the infection is resolved.)
Fever is an elevation of normal temperature.
Normal temperature varies throughout the day and depends on the location the temperature was taken and the type of thermometer used. Digital thermometers have replaced glass mercury thermometers due to safety concerns with mercury. Ear thermometers are not accurate in young infants or those with wax in the ear canal. Plastic strip thermometers and pacifier thermometers give a general idea of a temperature, but are not accurate.
To identify a true fever, it’s important to note the degree temperature as well as location taken. (A kiss on the forehead can let most parents know if the child is warm or hot, but doesn’t identify a true fever and therefore the need to isolate to prevent spreading illness.) I never recommend adding or subtracting degrees to decide if it is a fever. You can look at a child to know if they’re sick.
The degree of temperature helps guide if they can go to school or daycare, not how you should treat the child.
Fevers in children are generally defined as temperatures above 100.4 F (38 C).
Fever is rarely dangerous, though parents often fear the worst.
This is the time of year kids will be sick more than normal. Kids get sick more than adults. With each illness there can be fever (though not always).
What you can do:
Be prepared at home with a fever reducer and know your child’s proper dosage for his or her weight.
Use fever reducers to make kids comfortable, not to bring the temperature to normal.
Push water and other fluids to help kids stay hydrated.
Teach kids to wash their hands and cover coughs and sneezes with their elbows.
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.
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 ofillness 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.
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. Then 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. Is vomiting from 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.
If they think a common cold or vomiting is from the flu, they’re mistaken.
They need to know that this isn’t the flu.
Cough is one of the most common symptoms of influenza, along with fever, sore throat, and body aches.
Common colds and vomiting are not 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.
Over the years I’ve written a lot about Tamiflu because I have strong feelings about its use. Here I’ll summarize what I’ve learned over the years because during flu season I get many requests for Tamiflu (oseltamivir). Understandably parents fear the flu once they see how miserable their kids are when it hits their house, but I don’t like to use Tamiflu because I just don’t think it works well and it has quite a few side effects.
The pressure’s on…
In recent years I’ve felt coerced into writing more prescriptions for Tamiflu due to the powers of the guidelines recommending it. It’s more common in my experience to hear negative feedback about side effects than it is to see patients get better faster. (Note: this is a very biased view, since those who are better would not call, but since so many call with side effects it seems fair to say I don’t like the drug.)
I am not alone in my dislike of Tamiflu. I follow a listserv of pediatricians around the country and many share my views. In a discussion of influenza and antivirals, one doctor suggested watching a TED Talk by Dr. Ben Goldacre: What doctor’s don’t know about the drugs they prescribe. Dr. Goldacre starts talking about Tamiflu specifically about 10:10, but the entire lecture is done in an entertaining and informative manner if you have the time.
I feel deceived.
When I practice medicine, I follow standard recommendations and guidelines that are based on peer reviewed articles and data. The question is, what important data is left out? There is a movement to solve this problem of unpublished studies. You can see updates at the Tamiflu Campaign of the British Medical Journal.
Summary of Influenza Antiviral Treatment Recommendations
Clinical trials and observational data show that early antiviral treatment can shorten the duration of fever and illness symptoms, and may reduce the risk of complications from influenza (e.g., otitis media in young children, pneumonia, and respiratory failure).
Early treatment of hospitalized adult influenza patients has been reported to reduce death.
In hospitalized children, early antiviral treatment has been reported to shorten the duration of hospitalization.
Clinical benefit is greatest when antiviral treatment is administered early, especially within 48 hours of influenza illness onset.
Antiviral treatment is recommended as early as possible for any patient with confirmed or suspected influenza who:
is hospitalized;
has severe, complicated, or progressive illness; or
is at higher risk for influenza complications.
Antiviral treatment also can be considered for any previously healthy, symptomatic outpatient not at high risk with confirmed or suspected influenza on the basis of clinical judgment, if treatment can be initiated within 48 hours of illness onset.
That last statement is what really gets me confused.
I know that influenza can be deadly.
And that we should try to do everything in our power to help prevent severe illness and death.
But to treat any healthy person with suspected flu with a medicine that hasn’t been shown to be very effective and has side effects seems unreasonable to me.
Because it’s a guideline, if a physician chooses not to give antiviral treatment and there is a bad outcome, they could be held liable.
Despite the research.
I think this option also encourages people to not get the vaccine because they think they can just treat it if they get the disease. It’s not that easy…
look at what a search for “unpublished tamiflu trials” shows.
For those of you unfamiliar with the Cochrane group: They are a well respected group that reviews all the studies within certain parameters on one topic to evaluate the overall findings of several independent studies.
These results are from a review of published and unpublished studies that they could find.
From the abstract:
“The authors have been unable to obtain the full set of clinical study reports or obtain verification of data from the manufacturer of oseltamivir (Roche) despite five requests between June 2010 and February 2011. No substantial comments were made by Roche on the protocol of our Cochrane Review which has been publicly available since December 2010.”
They found several problems with Tamiflu from the studies they were able to review:
Drug manufacturers sponsored the trials, leading to publication and reporting biases. One of the authors reported that 60% of the data was never published. This is over half of the research, and I suspect it didn’t support use of the medicine (remember the company that benefits from selling the medicine was doing the trials…)
There was no decrease in hospitalization rate for influenza in people treated with Tamiflu.
There was not enough evidence of prevention of complications from influenza. Design of the trials (again by the people who make the drug) did not report the prevention of complications from influenza, such as secondary infections.
There is not evidence in the trials to support that Tamiflu reduces spread of the virus. One of the main reasons people request the medication is after exposure to prevent illness! (Note: this might have changed because the indications on the package insert now say it can be used to prevent illness in those over 1 year of age and they were previously not allowed to mention prophylaxis.)
Tamiflu reduced symptoms by 21 hours. Yep. Less than one day of fewer symptoms. For the cost of the drug and the potential side effects, is feeling sick for 1 day less really worth it?
There was a decreased rate of being diagnosed with influenza in those randomized to get Tamiflu, probably due to an altered antibody response. The authors suspect a body becomes less able to make its own antibodies against influenza when taking Tamiflu.
Symptom duration decreased between 0.5 and 1.5 days, but only significantly reduced symptoms in 2 of 4 trials. That means in 2 of 4 trials there was no significant reduction in symptoms.
Prophylaxis after exposure decreased incidence by 8% of symptomatic influenza. This means for every 13 people given Tamiflu to prevent disease, one case will be prevented. Not great odds.
Treatment was not associated with an overall decrease in antibiotic use, suggesting it did not alter the complication of bacterial secondary infections.
Tamiflu was associated with in increased risk of vomiting. About 1 in 20 children treated with Tamiflu had an increased risk of vomiting over the baseline vomiting due to influenza.
There was little effect on the number of asthma exacerbations or ear infections by treating influenza with Tamiflu.
In the treatment of adults, oseltamivir reduced the time to first alleviation of symptoms by 16.7 hours, 29 hours in children.
There was no difference in rates of admission to hospital between treatment groups in both adults and children.
Oseltamivir relieves symptoms in otherwise healthy children but has no effect on children with asthma who have influenza-like illness.
Using oseltamivir had no significant effect on admissions to the hospital.
Oseltamivir causes gastrointestinal disturbances in both prophylaxis and treatment roles. In prophylaxis, it caused headaches, renal events (especially decreased creatinine clearance), and psychiatric effects.
So what do I recommend during the cold and flu season?
Get vaccinated! The influenza vaccines have been shown to help prevent influenza and are very well tolerated with few side effects. If you or your children are due for other vaccines, be sure to get caught up. Even if they aren’t a perfect match, some protection is better than none, and if more people get the vaccine herd immunity helps!
If you get sick, stay home until you’re fever free without the use of a fever reducer for at least 24 hours! Don’t spread the illness to others by going to work or school. The influenza virus is spread for several days, starting the day before your symptoms start until 5-7 days after symptoms start– kids may be contagious for even longer. You are most contagious the days you have a fever.
Wash hands well and frequently. If you can’t use soap and water, use hand sanitizer.
Cover your cough and sneeze with your elbow or a tissue.
Avoid close contact with people who are sick. But remember that people spread the virus before they feel the first symptoms, so anyone is a potential culprit!
Don’t share food, drinks, or towels (such as after brushing teeth to wipe your mouth) with others.
Don’t touch your eyes, nose, and mouth — these are the portals for germs to get into your body.
Keep infants away from large crowds during the sick season.
Frequently clean objects that get a lot of touches, such as keyboards, phones, doorknobs, refrigerator handle, etc.
Avoid smoke. It irritates the airway and makes it easier to get sick.
Remember that many germs make us sick during the flu season. Just because you’ve been sick once doesn’t mean you won’t catch the next bug that comes around. Use precautions all year long!
Because the guidelines recommend Tamiflu as above, I will probably be forced to prescribe it by worried parents who hope that their kids will feel better. (You’ve heard of defensive medicine, right?)
Key Point:
Influenza is a miserable illness. The key is prevention.
Influenza is not a just a bad cold. People sick with the flu can suffer from fevers, cough, sore throat and body aches. If you want to prevent this and more complications, don’t brush off getting the flu vaccine. There are many reasons to get the flu vaccine.
Complications of flu
Flu can lead to complications, many of them severe, and death.
Complications include pneumonia, ear infections, and sinus infections.
There’s good news though. There’s a vaccine to help prevent the flu.
Reasons to get the flu vaccine
There are many reasons people don’t get the flu vaccine, but many of those reasons deserve a second thought.
1. The flu vaccine doesn’t work.
While it’s true that the vaccine has variable efficacy, it’s important to get the vaccine each year. The more people vaccinated, the less likely the flu will spread through a community. Take a look at this really cool representation of how herd immunity works. How it was developed is described on IFLS.
No one claims that the vaccines against influenza work perfectly. The influenza virus can mutate by shifting and drifting.
Until there’s a universal flu vaccine, we must rely on experts to look at the viral patterns and predict the strains that will be most predominant in the upcoming season and make a vaccine against those strains.
Despite not working 100% of the time, the flu vaccine has been shown to lessen the severity of illness and decrease hospitalizations and deaths.
Even if there’s not a perfect match, it can still help those who are vaccinated have a lesser illness.
That’s worth something.
2. I got the flu from the vaccine.
The influenza vaccine that is currently available cannot cause the flu. Only live virus vaccines can lead to forms of the disease.
The vaccines available in the US this season are either an inactivated or a recombinant vaccine. These do not cause flu symptoms. The vaccines cannot mutate to cause symptoms. They simply don’t work that way.
There are many reasons you could have gotten sick after a flu vaccine that were not due to the vaccine.
You were exposed to influenza before the vaccine had time to take effect and protect.
You caught a strain of influenza that wasn’t covered in the vaccine.
You caught one of a number of other viruses that cause flu – like illness.
The vaccine did cover the type of virus you have but your body didn’t make the proper protection from the vaccine so you were still susceptible.
In each of these scenarios, you still would have gotten sick if you hadn’t had the vaccine, but if you recently had the vaccine it’s easy to understand the concern that the vaccine caused the illness.
The FluMist is a live virus vaccine, so it could cause mild symptoms of influenza viruses, but it is not recommended for use in the US this year.
3. I can prevent the flu by being healthy.
It is important to eat right, exercise, get the proper amount of sleep, and wash hands. All of these things help keep us healthy, but they don’t prevent the flu reliably.
We cannot boost our immune system with megadoses of vitamins. (Vaccines are the best way to boost our immune system.)
Organic and non-GMO
Organic and non-GMO foods don’t offer any benefit to our immune system over other healthy foods.
If these things did as some claim, people generations ago would have been healthier since they ate locally grown organic foods, got plenty of fresh air, and exercised more in their day to day life than we do these days.
One of the major causes of death historically (and still today) is from influenza, but it has been shown that the flu vaccine reduces the risk of death. Why not help your body prepare for flu season with the vaccine?
4. Flu vaccines shouldn’t be used during pregnancy — they’ve never been tested and can lead to miscarriage.
Pregnancy is considered a high risk condition for severe complications of influenza disease and the vaccine can help prevent those complications.
It is recommended that all pregnant women get vaccinated against influenza. If a pregnant mother gets the vaccine, it not only helps to prevent complications during pregnancy, but it also helps prevent influenza in newborns since they can’t be vaccinated until 6 months of age.
There are some who assert that since the package inserts state the vaccines have not been studied in pregnancy that they aren’t safe, but in the next breath they say that they aren’t safe because a study showed a high rate of miscarriage after the vaccine.
The first part of the argument is one of the many ways the package insert is misused.
Package Inserts – no big secret, but don’t misuse them
Think about it… you can’t argue that it’s never been studied and then quote a study. It’s been studied.
A lot.
The Vaccine Safety Datalink is a huge database designed to document adverse events associated with vaccination, allowing researchers access to a large amount of data.
The flu vaccine has been safely given to pregnant women for over 50 years.
Despite a recent small study suggesting a potential risk of miscarriage, the flu vaccine has been studied extensively around the globe and found to be not only safe but effective at decreasing the risk of influenza disease during pregnancy and beyond.
5. I have a chronic illness and don’t want to get sick from the shot.
People with chronic illnesses (including diabetes, heart conditions, and asthma) are more at risk from serious illness from influenza disease.
The influenza vaccine can prevent hospitalizations and death among those with chronic diseases. People with chronic diseases should be vaccinated, as should those around them to protect with herd immunity.
The flu shot cannot make anyone sick, even those who are immunocompromised.
You do not need to avoid being around someone who is sick or immunocompromised if you’ve recently been vaccinated.
6. If I get the flu I’ll just take medicine to feel better.
There is no medicine that makes people with influenza feel better reliably.
There is no medicine that decreases the spread of influenza to friends and family of those infected.
We can take fever reducers and pain relievers, but they don’t treat the underlying virus.
They suppress our immune system so we don’t make as much inflammation against the virus, which decreases the symptoms and our body’s natural defenses.
As for antiviral medicines, I have written about Tamiflu and why I rarely recommend it.
Megadoses of vitamin C or other vitamins, homeopathic treatments, essential oils, and other at home treatments have not been shown to significantly help.
It is important if you get sick, you should limit contact with others. This means missed school and work for at least several days with influenza. Prevention with the vaccine simply is better than trying to treat the symptoms.
7. I don’t like shots. (Or my child doesn’t like shots.)
I’m a pediatrician. Most of my younger patients hate shots.
Like really hate shots.
They cry, scream, kick, try to run and hide — you name it, they’ve tried it to try to avoid shots. They fear shots, but we can help them with techniques that lessen the pain, and they often say “it wasn’t that bad” afterwards.
In previous years there was a concern that people with egg allergy would have a reaction from the vaccine so it was not recommended, but it has been found to be safer and still appropriate to vaccinate with proper precautions.
People who have had only hives after egg exposure can safely get flu vaccines following standard protocols.
People who have symptoms of anaphylaxis with egg exposure that requires epinephrine (respiratory distress, lightheadedness, recurrent vomiting, swelling – such as eyes or lips) should still get the vaccine, but they should be monitored at the appropriate facility (doctor’s office, hospital, health department) for 30 minutes to monitor for reactions.
9. Vaccines are only promoted to make people money. Doctors are shills.
I often tell my own patients that I don’t care if they get the vaccine at my office, the local pharmacy, or at the parent’s office – whatever works for them best. I just want everyone vaccinated.
This in the end will decrease my revenue because they will not come to the office seeking treatments for a preventable illness.
But I am a pediatrician to take care of the health of children, not to make money.
Pediatricians are consistently on the bottom of the list of physician salaries.
If I was in it for the money, I would have gone into orthopedics or another surgical specialty.
There are many things to consider when addressing this argument and the Skeptical Raptor does it well, including links to more information.
Thimerosal was removed from the majority of childhood vaccines in 2001 due to lawmakers responding to constituent demands, not because it was shown to be a risk medically.
Since the flu vaccine is not only for children, there are multidose vials that contain thimerosal.
If that really bothers you, ask for a version without thimerosal.
But since it was removed because people thought thimerosal caused autism and the rates of autism haven’t gone down since it was removed, that’s pretty strong evidence that it never caused autism.
Flu Vaccine Information and Recommendations for the 2017-2018 Season
Both trivalent (3 strain) and quadrivalent (4 strain) vaccines are approved for use this year. There is no preference officially of one over the other, but the vaccine should be appropriate for age.
No FluMist Nasal Spray flu vaccine is recommended. The nasal spray did not work well in the last few seasons it was used in the US. Until it is understood why it wasn’t effective then how to make it effective, it will not be recommended.
Pregnant women should be vaccinated to protect themselves and their baby.
Everyone over 6 months of age should be vaccinated. Children 6 months to 8 years who have only had one flu vaccine in their past will need two doses this season. This is because the first dose acts as a primer dose, then a booster dose boosts the immune system. Once the body has had a boost, it only needs a boost each year to improve immunity.
Infants under 6 months of age can gain protection if their mother is vaccinated during pregnancy and if everyone around them is vaccinated. They cannot get the flu vaccine until 6 months of age.
People with egg allergy can be vaccinated. If there is a history of anaphylaxis to egg, they should be monitored for 30 minutes.
The CDC is encouraging everyone to be vaccinated by Halloween if possible, but it’s not too late to be vaccinated after that if not yet done this season. It takes up to 2 weeks for the vaccine to be effective. Flu season typically starts in January, but the peak can be as early as November and as late as March.
It is acceptable and encouraged to give the flu vaccine along with other recommended vaccines needed.
Fever is uncomfortable.
Be prepared at home with a fever reducer and know your child’s proper dosage for his or her weight.
