'It-snot" a drill!

Fall is here—pumpkin patches, crisp air, colorful leaves, and… the return of the schoolyard sniffles. As backpacks get filled with sharpened pencils and lunchboxes, they also seem to bring home an endless supply of runny noses, coughs, and the occasional wheeze. It’s almost like every classroom comes with its own invisible “sharing station” for germs (though, unfortunately, hand sanitizer isn’t quite as popular as trading snacks).

For many families, back-to-school season means more than just new routines and after-school activities—it often marks the beginning of “respiratory illness season.” From the common cold and RSV to the flu and even asthma flare-ups triggered by fall allergens, kids are especially vulnerable this time of year. And while most of these illnesses are part of growing up and building strong immune systems, they can still leave both children and parents feeling worn down.

In this month’s blog, we’ll break down the most common respiratory illnesses children face in the fall and what you can do to help your child stay healthy and recover faster when the inevitable sniffles strike. Here to help is Dr. Erin Spees, MD. Dr. Spees started her work in pediatrics in 2011 and has been an outpatient pediatrician since 2014. She works in a clinic setting, seeing infants and children from birth to age 21.

Dr. Spees, let’s start from the beginning. What is a respiratory illness, which ones circulate in our community, and for how long?

A respiratory illness is an infection, often caused by a virus, that affects the respiratory tract. If it affects the upper respiratory tract, we often call those the common cold. If it affects the lower respiratory tract, we call that pneumonia.

In our community, we often see the bulk of respiratory illnesses from October to April, the colder months. This is when we see viral infections like RSV (respiratory syncytial virus) and influenza (flu), but also viral infections that are less commonly known, like rhinoviruses, enteroviruses, adenoviruses, and parainfluenza viruses, which are the most frequent causes of the “common cold”.

What do the symptoms of these illnesses look like and how do I know which one my child has?

One of the difficulties with these respiratory infections is that the symptoms overlap so much, it can be difficult to tell which one you are dealing with.

• Flu is characterized by fever and crushing fatigue. Some people will also notice that their eyes look a bit red, not as red as they would be with pink eye, but more inflamed than usual.
• RSV has a very consistent course. It starts out mild, with a light cough and congestion for the first 2 days. Then between days 3-5 those symptoms worsen significantly, this is often when the fever starts. After day 5, the symptoms gradually improve over the next 4-6 weeks. It can be a very long recovery period.
• Adenoviruses tend to combine respiratory symptoms and GI symptoms (nausea, vomiting, diarrhea).
• Rhinoviruses are the most frequent cause of the common cold, they’re characterized by cough, congestion, sore throat, fatigue, loss of appetite, and sometimes fever.
• The remaining upper respiratory viruses, including covid, tend to have similar symptoms. It’s often difficult to identify which virus you have, specifically.

The good news is, it doesn’t matter a lot which one you have, because they’re all generally treated the same way. The exception would be flu, which does have a possible treatment, if your child has the flu symptoms described above, you might want to bring them in over the first 2 days to have them tested, to see if they warrant that treatment.

How do I treat their symptoms at home?

In my opinion, one of the most under-utilized tools for treating the common cold is saline nasal spray. We have data that suggests that starting a nasal rinse at the onset of a new viral upper respiratory illness can decrease the length of that illness by as much as 25%. It can also help decrease congestion, and it may help decrease secondary infections (like ear infections) that show up the week after a cold starts.

Ibuprofen can help with body aches, acetaminophen can help alleviate headaches, and both can help decrease fevers. If they’re having trouble sleeping, diphenhydramine at bedtime can help them get some rest at night.

In cold weather, using a humidifier can help to keep mucus membranes moist, which can make you more comfortable, especially when your nasal passages are partially obstructed with mucus.

Children older than 6 years are able to take over-the-counter cold medicines. Guaifenisin and dextromethorphan are active ingredients that can help with cough. For toddlers older than 12 months, you can use honey. Children of any age can use demulcents, like pectin and gelatin. If you are using combination cold medicines, be sure that you aren’t combining them with acetaminophen, since it’s already included in many of the combination products.

When do I need to bring them to a provider?

As with all medical advice, I’ll start by saying that if you ever have concerns about your child, regardless of the recommendations that you get online, trust your instincts and bring them in to their pediatrician to be seen. We may have more medical information, but parents can always tell when their child is not acting like themselves.

That aside, if your child is just starting to have symptoms of a respiratory infection (like cough, congestion, maybe fever, fatigue, and decreased appetite) you can probably monitor them at home in most cases.

There are 3 things to watch for in kids, that would be a good reason to bring them in.

1. Signs of respiratory distress. If they seem like they’re working hard to breathe. I don’t mean they are necessarily making a lot of noise when they breathe, because that could just be from mucus in their airway (and if they’re making a lot of noise, it means that they’re actually moving a lot of air, which is what we want). But if they’re using their head or shoulders, or their or chest or abdominal muscles to breathe, and it’s getting gradually and progressively worse, that is definitely a reason to have them seen.
2. Signs of dehydration. In infants, if they were to stop drooling, or making tears when they cry, that might be a sign that they’re starting to get a bit dry. In older kids, one of the best ways to track hydration is with serial weights. If you have a bathroom scale, weigh your child when they’re starting to get sick, and then twice a day after that. If you start to notice the number going down, give your pediatrician a call, they can let you know how much weight they can lose, based on their size, before we’d start to recommend getting IV fluids. Tracking urine output in children isn’t always the best way to track hydration, because they have healthy kidneys that are good at recycling fluids.
3. Signs of a secondary infection. Secondary infections that we often hear about include ear infections, pneumonia, and sinus infections. We usually see them in the second week, after you’ve already been sick for at least a few days. They’re bacterial infections, that you can be more susceptible to as a result of having a viral infection. If your child has been sick for a few days, and it seems like they’re getting better, and then they suddenly get worse, start feeling more tired, have a new fever, have a change in the character of their cough, or new ear pain, that’s a good reason to bring them in.

What about antibiotics? Can my kid just get a prescription and be done with it?

Antibiotics can be very helpful, even life-saving, in the right context. But they’re not stronger treatments that we’re just saving until someone gets sick enough to warrant them. They just kill bacteria. If your problem isn’t caused by bacteria, then they won’t help you. Instead they just put you at risk for side effects, and kill your healthy flora. Since respiratory illnesses are caused by a virus, they aren’t the answer.

What about vaccines? Which illnesses can we vaccinate against and when should we do it?

We have had a vaccine for flu since 1945. It is very effective at preventing hospitalization and death, especially in children. It is less effective at preventing flu. This is because flu has a short incubation period, meaning that there is only a short period of time from the time you are exposed to the virus, to the time you become symptomatic. It is so short, that there isn’t enough time for your immune response to be activated before you start to get symptoms from the virus. If you get a flu vaccine, then your immune system is pre-activated, and ready to fight the influenza infection, and so can be activated quickly enough to decrease the impact of the infection. Without a vaccine, your immune system has to start from the beginning in order to fight the infection, and so the virus has more of a chance to replicate before your immune system can start to fight back effectively.

Because the flu vaccine is so effective at preventing severe infection, we recommend that everyone over age 6 months get a flu vaccine every fall season.

The first year you get a flu vaccine, a 2-part series will be recommended, with the doses separated by at least 28 days. If this is the first year your child is getting a flu vaccine, we would recommend that they get their first vaccine in late September/early October, to allow them to get the 2nd dose before the infection rates start to increase around early December. They should have developed full immunity around 2 weeks after their 2nd dose.

We also have a vaccine used for the prevention of RSV. We refer to this as the “RSV vaccine” for the sake of simplicity, but it is really a monoclonal antibody, which means it functions differently to protect you from infection. This new vaccine, Nirsevimab, is given one time, to infants in the first year of life. This helps prevent severe RSV infections, at the time of their life when they are most vulnerable.

We also have a Covid vaccine available to all children above 6 months of age. The availability and insurance coverage, as well as the recommendations for who should be advised to receive this vaccine, are currently being debated. My family will all be getting a flu vaccine, and will attempt to get a covid vaccine if it is available this fall.

Can I do anything to keep respiratory illnesses out of my house all-together?

As always, proper hand washing is helpful in preventing the spread of germs, especially in children, who are more likely to be putting their hands in their mouths. It’s also a good idea to avoid close contact with anyone who is in the first few days of a new viral illness, which is usually when they’re most contagious. But the unfortunate truth is that we don’t have a definitive way of preventing children, or adults, from getting upper respiratory viruses. Once they’re endemic in the community, they can be difficult to avoid.

If you have one sick kid, do your best to isolate them from other kids in the home. Try to avoid letting them share cups/water bottles. Many respiratory infections are spread by droplet, and so keeping healthy kids out of the immediate airspace around the sick kids can be helpful. But keep in mind, it’s not easy to keep infections from spreading within a household, so if everyone else in the house does get sick, try to cut yourself some slack.

Top 3 things to remember:

1. When your child starts to get sick, start a saline nasal spray. It’s the best thing you can do to help them to not only feel more comfortable in the moment, but also to decrease the length of their symptoms.
2. The flu vaccine doesn’t necessarily help to prevent you from acquiring the flu, it does help to ensure that if, or when, you do get exposed to it, that the symptoms will be mild, and much more tolerable.
3. Vaccines don’t weaken your immune system, they strengthen it. They don’t do the work for you. They just give your immune system a hint, so that your immune system can do the work in advance, before the virus is in your body causing infection.