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When to Call Your Pediatrician – COVID-19 Edition

As pediatricians encourage kids with cold symptoms to stay home, it becomes important for parents to know when to call their pediatrician.

Parents should always feel that they can call their pediatrician when their kids are sick, but that call might not get you a quick visit now that we are concerned about COVID-19.

Why not?

Folks realize that this doesn't actually include a test for COVID-19, right? They are just going to tell you that you have the symptoms of COVID-19 after you tell them your symptoms. As we all start using telemedicine visits more and more in the next few weeks and months, you are still best off scheduling a video visit with your own health care provider. — Folks realize that this doesn’t actually include a test for COVID-19, right? They are just going to tell you that you have the symptoms of COVID-19 after you tell them your symptoms. As we all start using telemedicine visits more and more in the next few weeks and months, you are still best off scheduling a video visit with your own health care provider.

Although we don’t think that kids typically develop serious COVID-19 symptoms, they probably do still get sick and can be contagious to others.

That makes it important to keep them home if they have any symptoms of COVID-19, which unfortunately, can mimic most of the other viral infections that kids get.

When to Call Your Pediatrician – COVID-19 Edition

As more and more pediatricians limit who they will be seeing in their offices, it becomes even more important that parents learn to recognize when their kids have mild symptoms that can safely be treated at home and when they might have urgent problems that need medical attention.

Many pediatricians are encouraging patients with fever and respiratory symptoms (URI, cough, runny nose, difficulty breathing) to stay home and are instead providing phone/virtual consultations.

Fortunately, while many parents have gotten used to running to their pediatrician as soon as their kids have a fever, sore throat, diarrhea, or cough, most of these symptoms are caused by viral infections that go away without treatment.

And parents should understand that their pediatricians are still available! Most of us likely won’t be able to see everyone as quickly and easily as we usually do, but the kids who get triaged to stay at home without being seen will almost certainly be those who don’t need to be seen.

Recognizing the signs of a more serious infection will also help you trust your pediatrician’s judgment on home care so that you don’t rush to an urgent care, where they might not be triaging kids with COVID-19 symptoms and are seeing everyone who comes in.

So how do you know if your child has a mild viral infection or if it is something more serious?

Ultimately, you might need to call your pediatrician, but it might help to know that:

fever itself is not a disease and how high a temperature gets doesn’t tell you how sick your child is. Unless you have an infant under 2 months old with a rectal temperature at or above 100.4°F (38°C) – which is always a medical emergency – your otherwise healthy (no chronic medical problems) older child with a fever doesn’t necessarily need treatment or a visit to the doctor, as long as they are drinking and aren’t irritable and aren’t having trouble breathing etc.
a sore throat with a runny nose and cough is typically caused by a virus and not strep throat. On the other hand, if your child has the sudden onset of a sore throat and fever, with red and swollen tonsils (tonsillitis), possibly with white patches (exudate) and small, red spots (petechiae) on the roof of their mouth, and tender, swollen lymph glands in their neck, then they might have strep and should have a strep test.
the flu, although it can be a life-threatening disease, especially in those who are high risk, typically goes away on its own after 5 to 7 days of fever, runny nose, and cough. Unless they are at high risk for flu complications, kids don’t necessarily need a flu test or Tamiflu, so don’t necessarily need to visit their pediatrician when you think they have the flu.
a runny nose, even if it is green or yellow, doesn’t mean that your child has a sinus infection and needs antibiotics, unless the symptoms are lingering for ten or more days or the child has severe symptoms
ear pain doesn’t mean that your child has an ear infection and even when your child does, a 2-3 day watching period before starting antibiotics is becoming the standard of care because the great majority of ear infections go away on their own
a cough, even if has been lingering for a week or two, doesn’t mean that your child needs antibiotics, as most kids with coughs simply have bronchitis, which will eventually go away
diarrhea can be a sign of a food intolerance or an infection, typically a stomach virus. Either way, you can likely treat your child at home, unless your child has high fever and bloody diarrhea or is dehydrated.
vomiting, especially when it is accompanied by diarrhea, is also often associated with gastrointestinal infections, and can respond to proper rehydration techniques

Of course, if your child has a chronic disease, like diabetes, asthma, or cystic fibrosis, etc., then even mild symptoms might put them at high risk for serious disease and you shouldn’t hesitate to call your pediatrician any time they get sick.

What are some other “red flag” type things parents should look for? In general, you should seek quick medical attention if your child has viral symptoms and:

is truly lethargic, which means that they are hard to wake up and not that they are just sitting on the couch watching Netflix instead of running around the house
has vomiting or diarrhea that has led to dehydration – dry mouth, few tears, only urinating a few times a day, etc
has vomiting with severe stomach pain
is breathing fast and hard, which could be a sign of pneumonia
has a fever and a purplish rash
is not at all playful or consolable
is not eating or drinking anything

On the other hand, even if your child has a fever, runny nose, cough, and sore throat, if they are also sometimes playful and drinking, then you likely have less reason to need an immediate visit to the doctor.

What if it’s COVID-19?

Again, most kids are not at big risk to get severe COVID-19 symptoms, so the main reason to see your pediatrician about COVID-19 would be to get tested to help know if you need to quarantine your child. Unfortunately, as most people are aware, testing is still very limited. Your pediatrician likely does not have the ability to test kids yet.

What about well checks and vaccines and other visits to your pediatrician?For that info, you will have to call your pediatrician.

And see if they are set up to do telemedicine yet.

Does Your Child Need an RSV Test?

It is hard to avoid RSV season, but a lot easier than you think to avoid an RSV test.

A lot has changed since this Kansas City RSV outbreak back in 2013.

Your toddler has a cough and runny nose and there is a notice that RSV is going around at daycare…

Do you need to rush to your pediatrician?

Does your child need an RSV test?

Like many things, it depends on who you ask.

For example, the folks at your child’s daycare might push for a visit and an RSV test, thinking it will help them keep the virus from spreading to other kids.

It won’t.

Does Your Child Need an RSV Test?

If an RSV test is available, why not do it?

“Our study showed that a simple nasal swab, while less painful for infants than NPA, failed to detect about one third of cases that were RSV positive by nasopharyngeal aspirate.”

Macfarlane et al on RSV testing in bronchiolitis: which nasal sampling method is best?

For one thing, the test isn’t that accurate, especially when done with a nasal swab, the most commonly used method. And while less invasive than a nasopharyngeal aspirate, if done correctly, sticking a nasal swab up your child’s nose, rotating it around a few times, and then getting a sample isn’t exactly something kids enjoy.

Mostly though, since there is no treatment for RSV, what are you going to do with those test results, whether or not they are positive?

Remember, RSV is a very common respiratory virus that can cause a cold, bronchiolitis, or pneumonia. But testing positive for RSV doesn’t mean that your child has bronchiolitis or pneumonia. Those are typically diagnosed clinically, based on the signs and symptoms that your child has, such as wheezing and trouble breathing.

Similarly, testing negative for RSV doesn’t mean that your child doesn’t have bronchiolitis or pneumonia.

“Clinicians should diagnose bronchiolitis and assess disease severity on the basis of history and physical exam.

When clinicians diagnose bronchiolitis on the basis of history and physical examination, radiographic or laboratory studies should not be obtained routinely.”

AAP on the Clinical Practice Guideline: The Diagnosis, Management, and Prevention of Bronchiolitis

Is there ever a role for RSV testing?

RSV testing might be a good idea when an infant has apnea or other uncommon symptoms.

And if a child is getting monthly Synagis injections and has a suspected case of RSV, it is a good idea to confirm that they actually have RSV.

Why?

If they really do, then you can stop getting Synagis injections, as they are unlikely to get RSV again in the same season.

“In the event an infant receiving monthly prophylaxis is hospitalized with bronchiolitis, testing should performed to determine if RSV is the etiologic agent. If a breakthrough RSV infection is determined to be present based on antigen detection or other assay, monthly palivizumab prophylaxis should be discontinued because of the very low likelihood of a second RSV infection in the same year. Apart from this setting, routine virologic testing is not recommended.”

AAP on the Clinical Practice Guideline: The Diagnosis, Management, and Prevention of Bronchiolitis

That’s pretty clear.

The American Academy of Pediatrics guidelines say that routine RSV testing is not recommended.

Need another good reason to avoid routine RSV testing?

Do you know how long kids with RSV shed the virus or can test positive after having an RSV infection?

“People infected with RSV are usually contagious for 3 to 8 days. However, some infants, and people with weakened immune systems, can continue to spread the virus even after they stop showing symptoms, for as long as 4 weeks.”

CDC on RSV Transmission

Apparently, it is a long time, which means that your child might have a new respiratory infection, but still test positive for RSV because they had it a month ago.

You might actually be “diagnosing” an old infection and not the virus that is causing your child’s current symptoms.

Do you still want an RSV test anyway? Talk to your pediatrician.

Did someone order an RSV test, but you are now wondering if it was necessary? Talk to your pediatrician.

Remember that an RSV test won’t change your child’s treatment (breathing treatments and steroids are no longer routinely recommended when infants have RSV), won’t help predict how sick your child might get, and won’t tell you if your child can return to daycare.

What To Know About RSV Tests

You likely won’t be able to avoid RSV season, especially if your kids are in daycare, but you can avoid RSV testing season.

It’s Not Always the Flu When You Get Sick During Cold and Flu Season

Flu isn’t the only virus that is going around during cold and flu season. Many others can cause flu-like illnesses, croup, bronchiolitis, or just a cold.

We hear a lot about flu season.

It typically starts in late fall, peaks in mid-to-late winter, and can continue through early spring.

Cold and Flu Season Viruses

It’s important to understand that a lot more is going on, and going around, during flu season than just the flu.

That’s why it is likely more appropriate to think of flu season as just a part of the overall cold and flu season that we see during the late fall to early spring.

During cold and flu season, in addition to the multiple strains of the flu, we see diseases caused by:

respiratory adenovirus – can cause bronchitis, colds, croup, viral pneumonia, pink eye, and diarrhea
Human metapneumovirus (HMPV) – can cause bronchiolitis, colds, and viral pneumonia
Human parainfluenza viruses (HPIVs) – can cause bronchiolitis, bronchitis, colds, croup, or viral pneumonia
rhinovirus – the classic common cold
Respiratory syncytial virus (RSV) – can cause wheezing and bronchiolitis in younger children, but colds in older kids and adults
seasonal coronavirus – can cause colds, bronchitis, and viral pneumonia
norovirus – diarrhea and vomiting
rotavirus – diarrhea and vomiting, was much more common in the pre-vaccine era

That there are so many different respiratory viruses that can cause bronchiolitis, colds, croup, and flu-like illnesses helps explain why some kids get sick so many times during cold and flu season.

It also helps explain why some folks think they might have gotten the flu despite having been vaccinated, especially in a year when the flu vaccine is very effective.

Is It a Cold or the Flu?

So how do you know if you have the flu or one of these flu viruses during cold and flu season?

Signs and symptoms of the flu vs a cold.

While the symptoms can be similar, flu symptoms are usually more severe and come on more suddenly.

Can’t you just get a flu test?

While rapid flu tests are fast and easy to do, they are likely not as accurate as you think.

“This variation in ability to detect viruses can result in some people who are infected with the flu having a negative rapid test result. (This situation is called a false negative test result.) Despite a negative rapid test result, your health care provider may diagnose you with flu based on your symptoms and their clinical judgment.”

CDC on Diagnosing Flu

If your pediatrician is going to diagnose your child with the flu because of their symptoms, even if they have a negative flu test, then why do the test?

Rapid flu tests are usually invalid if they are positive for A and B, but many folks are told that they have both. — Rapid flu tests are usually invalid if they are positive for A and B, but many folks are told that they have both flu virus strains.

Can you test for all of the other viruses that are going around during cold and flu season?

Tests can be done to detect most cold and flu viruses.

Sure.

The real question is should you.

Like the rapid flu test, many pediatricians can do an RSV test in their office. But like many other viruses, there is no treatment for RSV and the American Academy of Pediatrics actually recommends against routine RSV testing. Whether your child’s test is positive or negative, it is not going to change how he or she is treated.

And the other viruses? Not surprisingly, there are respiratory panels that can test for most or all of these viruses. They also usually include flu and RSV.

The problem with these tests is cost. They are not inexpensive, and again, in most cases, the results aren’t going to change how your pediatrician treats your child.

And they all involve sticking a nasal swab far up your child’s nose…

What About Strep?

While strep throat can occur year round, it does seem to be more common in the winter and spring.

And while you can certainly have two different infections at the same time, such as strep throat and the flu, it is important to remember that the rate of strep throat carriers is fairly high. These are kids who regularly test positive for strep, even though they don’t have an active group A strep infection.

During cold and flu season, if kids routinely get a “strep/flu” combo test, it is possible, or even likely, that many of the positive strep tests are simply catching these carriers.

Remember that a cough, runny nose, hoarse voice, and pink eye are not typical symptoms of strep throat and are more commonly caused by cold viruses. Adenovirus is especially notorious for causing a sore throat, fever, pink eye, runny nose, with swollen lymph nodes = pharyngoconjunctival fever.

Kids who are likely to have strep throat usually have a sore throat, with red and swollen tonsils, and may have swollen lymph nodes, fever, stomach pain, and vomiting, but won’t have typical cold symptoms.

Why does it matter?

Viral causes of a sore throat don’t need antibiotics, while a true strep infection does.

And remember that none of the other cold and flu viruses need antibiotics either, unless your child gets worse and develops a secondary bacterial infection.

What to Know About Cold and Flu Season Viruses

Flu isn’t the only virus that is going around during cold and flu season. Many others can cause flu-like illnesses, croup, bronchiolitis, or just a cold.

Treating the Flu and Hard to Control Flu Symptoms

In addition to basic symptomatic care for your child’s flu symptoms, including the fever, cough, and runny nose, etc., Tamiflu can be an option to treat high risk kids with the flu.

It is much easier to prevent the flu with a flu shot than to try and treat the flu after you get sick.

Unfortunately, like most upper respiratory tract infections, the flu is not easy to treat.

What are Flu Symptoms?

While a cold and the flu can have similar symptoms, those symptoms are generally more intense and come on more quickly when you have the flu.

These flu symptoms can include the sudden onset of:

fever and chills
dry cough
chest discomfort
runny nose or stuffy nose
sore throat
headache
body aches
feelings of fatigue

And more rarely, vomiting and diarrhea.

In contrast, cold symptoms come on more gradually and are more likely to include sneezing, stuffy nose, sore throat, and mild to moderate coughing. A cold is also less likely to include a headache, fatigue, chills, or aches. And while either might have fever, it will be more low grade with a cold.

As with other infections, flu symptoms can be very variable. While some people might have a high fever, chills, body aches, constant coughing, and can hardly get out of bed, others might have a low grade fever and much milder symptoms.

That variability also applies to how long the flu symptoms might last. Some people are sick for a good 7 to 10 days, while others start to feel better in just a few days.

Treating Flu Symptoms

Although there aren’t many good treatments for the flu, that variability in flu symptoms makes it hard to even know if any you try really work.

For kids older than 4 to 6 years and adults, you could treat symptoms as necessary, including the use of decongestants and cough suppressants.

And of course, almost everyone might benefit from pain and fever relievers, drinking extra fluids, and rest, etc.

Treating the Flu

In addition to symptomatic flu treatments, there are also antiviral drugs that can actually help treat your flu infection.

These flu medications include oseltamivir (Tamiflu), zanmivir (Relenza), and peramivir (Rapivab). Of these, oral Tamiflu is the most commonly used. It can also be used to prevent the flu if taken before or soon after you are exposed to someone with the flu.

“If liquid Tamiflu is not available and you have capsules that give the right dose (30 mg, 45 mg or 75 mg), you may pull open the Tamiflu capsules and mix the powder with a small amount of sweetened liquid such as regular or sugar-free chocolate syrup. You don’t have to use chocolate syrup but thick, sweet liquids work best at covering up the taste of the medicine.”

FDA – Tamiflu: Consumer Questions and Answers

Unfortunately, these flu drugs are not like antibiotics you might take for a bacterial infection. You don’t take Tamiflu and begin to feel better in day or two. Instead, if you take it within 48 hours of the start of your flu symptoms, you might “shorten the duration of fever and illness symptoms, and may reduce the risk of complications from influenza.”

At best, you are likely only going to shorten your flu symptoms by less than a day. And considering the possible side effects of these medications and their cost, they are often reserved for high risk patients, including:

children who are less than 2 years old
adults who are at least 65 years old or older
anyone with chronic medical problems, including asthma, diabetes, seizures, muscular dystrophy, morbid obesity, immune system problems, and those receiving long-term aspirin therapy, etc.
pregnant and postpartum women
anyone who is hospitalized with the flu
anyone with severe flu symptoms

That means that most older children and teens who are otherwise healthy, but have the flu, don’t typically need a prescription for Tamiflu. The current recommendations don’t rule out treating these kids though.

“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.”

Antiviral Agents for the Treatment and Chemoprophylaxis of Influenza – Recommendations of the Advisory Committee on Immunization Practices (ACIP)

There is a lot of controversy surrounding the use of Tamiflu and other anti-viral flu medications, with some studies and many experts thinking that they should rarely be used, if ever, stating that they are not as useful as others claim. Others state that while they not perfect, they are all we have, and there is enough evidence to recommend their use.

Treating Hard to Control Flu Symptoms

Instead of learning about treating hard to control flu symptoms, which might require medical attention, it is probably much more important to learn how to recognize these severe flu symptoms that might be hard to control.

Your child’s flu might be getting worse and require quick medical attention if you notice:

fast or hard breathing
complaints of chest pain
that it is hard to wake up your child
irritability to the point that your child is not consolable
signs of dehydration because your child won’t drink any fluids
that your child is complaining of being dizzy or is feeling lightheaded

You might also need to seek medical attention if your child with the flu was getting better, but then worsens again, with the return of a fever and more severe coughing, etc.

What to Know About Treating the Flu and Flu Symptoms

In addition to basic symptomatic care for your child’s flu symptoms, including the fever, cough, and runny nose, etc., Tamiflu can be an option to treat high risk kids with the flu.

And remember that it is recommended that everyone who is at least six months old should get a yearly flu vaccine.

More Information on Treating Hard to Control Flu Symptoms

Treating Hard to Control RSV

RSV is never really easy to control for infants and toddlers, as there is no treatment or cure, but fortunately, most kids do not have severe symptoms that require hospitalizations.

With a cough, wheezing, and trouble breathing that can linger for weeks, all RSV infections probably seem like they are hard to control, especially since up to 2% of kids, mostly high-risk infants, with RSV require hospitalization.

Still, it’s important to remember that for many kids, RSV is just a cold.

Understanding RSV

Since there is no cure or treatment, it is best to learn to protect your kids from RSV.

The first thing to understand about RSV is that it isn’t a disease.

Instead, RSV, or the respiratory syncytial virus, can cause many different kinds of upper and lower respiratory infections, ranging from the common cold and croup to bronchiolitis and viral pneumonia.

And almost all kids get sick with RSV at some point during the first few years of their life, especially if they are in daycare.

Fortunately, although RSV can cause life-threatening infections, especially in high-risk infants, the great majority of children get over their symptoms without any special treatments.

And infants who are the most high risk, including premature babies who were born at less than 29 weeks, can get five monthly doses of palivizumab (Synagis) during RSV reason to reduce their chances of getting sick. Infants with hemodynamically significant heart disease or chronic lung disease of prematurity can also get palivizumab.

Treating RSV

Many of the classic treatments for RSV have now fallen out of favor with pediatricians. In fact, the American Academy of Pediatricians now advises against using albuterol breathing treatments, epinephrine, steroids, or chest physiotherapy (CPT) for infants with RSV bronchiolitis.

What’s left?

Not much, except pushing your child to drink and treating cold symptoms as possible.

The AAP even advises against routinely testing kids for RSV. That makes sense, since there is no treatment, kids can sometimes be contagious for 3 to 4 weeks, long after they have returned to daycare without symptoms, and other viruses can cause similar symptoms.

Instead, if your child has symptoms of RSV, especially if she was around someone else with RSV symptoms about two to eight days ago or is simply in daycare during RSV season (usually November to April), then it is safe to assume that your child has RSV.

Also understand that antibiotics have no role in the treatment of uncomplicated RSV infections. RSV is a virus. Antibiotics do not work against viral infections.

Going to Day Care with RSV

Since many kids who get RSV are in day care, the million dollar question often becomes, when can my child with RSV go back to day care?

“Most minor illnesses do not constitute a reason for excluding a child from child care, unless the illness prevents the child from participating in normal activities, as determined by the child care staff, or the illness requires a need for care that is greater than staff can provide.”

AAP Red Book 2015

Although I once had the manager of a day care argue with me that a child needed to test RSV negative before being allowed back into her day care, kids can usually go back, even if they still have cold symptoms, as long as they:

don’t have a fever for 24 hours
don’t have any trouble breathing
are not fussy or irritable

Since these kids will likely be contagious, the AAP recommends that “In child care centers, good hygiene practices should be used by the staff and the children, including frequent and thorough hand washing.”

Treating Hard to Control RSV

If your child has RSV symptoms and isn’t getting better, ask yourself these questions and bring the answers to your pediatrician or seek quick medical attention:

“Some youngsters with bronchiolitis may have to be hospitalized for treatment with oxygen. If your child is unable to drink because of rapid breathing, he may need to receive intravenous fluids.”

American Academy of Pediatrics

Do you think your child’s symptoms are hard to control, not because they are getting worse, but rather because they are lingering for several weeks, which can be normal when young kids have RSV?
Does your newborn or infant under two or three months have a fever (temperature at or above 100.4F/38C)?
Is your child having trouble breathing, such as breathing fast or hard, with chest retractions (chest caving in), nasal flaring, trouble catching his breath, or a non-stop, continuous cough?
Do you see any signs that your child isn’t getting enough oxygen, including that “his fingertips and the area around his lips may turn a bluish color?”
Is your child dehydrated, with less urine output, dry mouth, or no tears?
Does your child have any medical problems that put her at higher risk for a severe RSV infection, including extreme prematurity, having complex heart disease, chronic lung disease of prematurity, or immune system problems?
Is your child lethargic, which doesn’t simply mean that he is just playing less, but rather that he is actually hard to wake up and is maybe skipping feedings?

If your child with RSV is getting worse, although there aren’t any special treatments to make the RSV infection go away, supportive care is available to help your child through it, including IV fluids and supplemental oxygen. Those who are most sick sometimes end up on a ventilator to help them breath, and tragically, some infants with RSV die.

What To Know About Treating Hard to Control RSV

RSV is never really easy to control for infants and toddlers, as there is no treatment or cure, but fortunately, most kids do not have severe symptoms that require hospitalizations.

More Information About Treating Hard to Control RSV

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Tag: cold symptoms

When to Call Your Pediatrician – COVID-19 Edition

When to Call Your Pediatrician – COVID-19 Edition

More on Calling Your Pediatrician – COVID-19 Edition

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