Is it the Flu?
Current guidelines for symptom management should be used based on the parents concern for their child. Illnesses caused by Influenza virus infection are difficult to distinguish from other respiratory pathogens based on symptoms alone. Young children are less likely to have typical symptoms such as fever and cough and infants are more likely to have fever and lethargy without cough or other respiratory symptoms. Use the FEVER PROTOCOL if there is only fever present. Use the other protocols for management of: COUGH, COLD, SORE THROAT, EARACHE, SINUS PAIN, WEAKNESS, RASH, DIARRHEA AND VOMITING as you currently do and prioritize accordingly.
As families become aware of the influenza in the community, seasonal or H1N1, the calls to be seen will sky rocket. The following are the highest risk groups:
Experience in the past seasonal outbreaks of influenza have identified that children less than 5 years of age, especially those children under 2 years and those with high risk medical conditions are at increased risk of influenza related complications. High risk medical conditions include: Asthma or other diseases of the lungs, Cardiac Disease, Diabetes Mellitus, Metabolic Disorders (e.g.MCAD, Urea cycle disorders, CAH), Immune suppression, Chronic kidney disease, Sickle cell disease, children on chronic aspirin therapy, and those with HIV/AIDS. Children with any condition that affects respiratory function including neurological conditions such as intellectual and developmental disability, cerebral palsy, spinal cord injuries, seizure disorders, metabolic conditions or other neuromuscular disorders are also at high risk. As the fall progresses other children who have experienced poor nutritional and fluid intake from gastroenteritis, pneumonia or other prolonged illnesses should be tightly triaged.
SYMPTOMS OF SEVERE DISEASE MAY INCLUDE:
Apnea, cyanosis, dyspnea, tachypnea, dehydration, altered mental status, extreme irritability
Triage to 911
Limp, weak or not moving
Unresponsive or difficulty awakening
Blue lips or gray skin color
Severe difficulty breathing
Sounds like a life threatening emergency to the triager
Triage to the hospital:
Child is confused
Severe or persistent vomiting
Bulging soft spot
Seizure with a fever
Child sounds very sick or weak to the triager
Triage to the office
Newborn (< 1 month old) who acts sick
Age < 12 weeks with fever > 100.4
Infants 3-6 months with fever > 102
Infants 3-24 months with fever > 24 hours and no other symptoms
Fast breathing/ trouble breathing (after cleaning out the nose)
Not drinking enough fluids
Not urinating as much as usual
Fever > 105
Fever returns after being absent for a day (un-medicated)/ a significant change in fever pattern
For the majority of patients home care is all that is needed and preferred to prevent spread of illness. Patients in the high risk groups may warrant more careful monitoring. Treatment with antiviral medications will be used sparingly and in accordance with recommendations put forth by CDC. As the disease is evolving resistance is emerging and antivirals may prove to be less helpful and decrease its effectiveness in high risk groups. Oseltamivir (Tamiflu) and zanamivir (Relenza) has been recommended. Oseltamivir can be used in children > 1 year and zanamivir in children > 5 years. During this pandemic, antevirals are to be used to treat those with severe illness (e.g. patients who are hospitalized and people who are in the high risk groups who are at risk to experience serious flu related complications.
Who is prioritized for treatment with influenza antiviral drugs?
Most people ill with influenza will recover without complications.
Some people are at increased risk of influenza complications and are prioritized for treatment with influenza antiviral drugs this season. They include:
- People hospitalized with suspected or confirmed influenza
- People with suspected or confirmed influenza who are at higher risk for complications
- Children younger than 5 years old (children under 2 years old are at higher risk for complications than older children)
- Adults 65 years and older
- Pregnant women
- People with certain chronic medical or immunosuppressive conditions
- People younger than 19 years of age who are receiving long-term aspirin therapy
Physicians may also decide not to treat some people in these groups and/or treat people who are not in these groups based on their clinical judgment.
Who is lower priority for treatment with influenza antiviral drugs?
Treatment with influenza antiviral drugs is generally not needed for people who are healthy and not at higher risk for complications or do not have severe influenza, such as those requiring hospitalization. However, any suspected influenza patient who presents with emergency warning signs (for example, difficulty breathing or shortness of breath) or signs of lower respiratory tract illness should promptly receive antiviral therapy. Doctors may treat some people who are not in a high risk group based on their clinical judgment. In addition, doctors also may decide that treatment is not needed for some who are in a high risk group based on their clinical judgment.
To be most effective antiviral medication should be initiated within 48 hours of illness onset. The diagnosis may be confirmed by rapid influenza testing for influenza A but not specifically for H1N1. Antiviral medication may reduce the severity of symptoms and shorten the duration of illness by 1 or 2 days. Post exposure prophylaxis and empiric treatment by phone will be restricted to high risk groups or situations and should be done in consultation with a provider only.
Web sites with Information for prevention and home care that are updated regularly:
2009 H1N1 flu (Swine Flu) and you
Taking Care of a Sick person
Antiviral drugs Q&A
American Academy of Pediatrics
H1N1 Flu Information
Frequently asked Questions
Massachusetts Department of Public Health
Flu facts video
Prevention and caring for family
Fever fact sheet
Symptom checklist and return to school criteria
Coping with stress
Criteria for School exclusion and readmission
Remove from school with fever and return to school 24 hours after fever resolves without fever reducing medication medication.