Flu can be miserable, but how do you know if it's serious?
When should you treat at home and when should you be seen?
My last post talked about the flu and RSV that are going around. Since that post we continue to see a lot of sick patients.
A lot.
We’re seeing some kids more than once and taking many phone calls from worried parents. Several keep calling back to be sure they’re doing everything they can.
Many parents seem surprised at just how sick their kids look when they have flu. They are frustrated that we can’t offer something that will make them feel better faster.
How do we know it’s the flu or RSV or COVID or allergies or just a common cold? The only way to know for sure is if there’s a positive test for one of the viruses, but symptoms can suggest one or the other diagnoses. As we’ve all heard, a negative test is not as helpful. It could be done outside the testing window or there could be a problem with the collection or test supplies, so there is a possibility that the virus is the culprit but isn’t showing up on the test.
The good news is that most of these things can be treated with similar supportive measures, which will be discussed further below. You can use symptoms to guide the most likely cause.
Flu can be miserable.
Flu is not just another cold. Influenza viruses can lead to significant infections, sometimes requiring hospitalization. Thousands of people die from influenza every year, including previously healthy children and adults.
Thankfully, most people are able to manage symptoms at home, but they still look and feel miserable.
Influenza can cause significant fevers. Many times the fever is accompanied by shaking chills. You can use age and weight based doses of fever reducers for comfort, but the goal is not to bring the temperature to normal. The goal is comfort. The fever has a purpose: it’s trying to fight the virus. If your child is hot but comfortable, there’s no reason to bring the temperature down. For this reason you don’t need to keep rechecking the temperature with a thermometer. That usually just makes parents more anxious. Watch your child, not the thermometer.
Headaches, body aches, sore throats - lots of things hurt. I’ve heard it described as feeling like you’re hit by a train. Use pain relievers based on age and weight to help manage the aches and pains.
Some people are lucky and have mild cases. Others have mild cases because they’ve been vaccinated, which helps their body fight it off without as much fever, muscle aches, cough.
Not everyone with flu-like symptoms needs to be seen.
During peak times of flu season, going to any clinic, urgent care, or ER might increase risk more than be helpful.
Why?
These places are full of all kinds of sick people. You will be exposed to more than one thing when there, which could lead to additional symptoms and prolong recovery. If you wear a quality well-fitted mask, that can help decrease your exposure, but the risk is not zero in a high risk location like a waiting room.
The benefits of getting seen are to make sure your body is able to handle the infection. Medical professionals can assess your oxygenation (which can now be done at home for non-infants and small children). They can perform an exam, including listening to your lungs and looking in your ears, to see if there’s anything that is concerning.
Viral testing can be done, but results often don’t change the treatment plan.
Antiviral medications and antibiotics aren’t the mainstays of treatment, but do require a prescription. I feel that any time a prescription is given, it should be done only after a visit to discuss the indications, risks, and benefits. If you want a prescription, you should be seen, but if you’re going in just to try to get a prescription, think how worthwhile that really will be. Keep reading for more on that.
Who should be seen?
Those with significant symptoms
Although most symptoms can be managed at home with the treatments described below, some kids should be seen quickly due to severe symptoms.
A physical exam (and sometimes labs or x-ray) is needed to identify the source of illness in these cases. A phone call cannot fully assess these concerns.
What are the symptoms to be concerned about?
Some fevers.
Any fever that lasts more than 3-5 days could signify a bacterial infection and should be assessed.
Any infant under 3 months or immunocompromised child should be seen to rule out serious disease if the temperature is more than 100.5.
For children over 3 months, there is NO MAGIC TEMPERATURE that we worry more about. Look at your child, not the thermometer.
Difficulty breathing, such as rapid breathing, sucking in ribs or at the bottom of the neck, grunting, or looking scared. If you have rescue medicine for asthma at home, you can follow your Action Plan and come to the office during regular business hours if symptoms improve sufficiently after hours.
Dehydration. Signs of dehydration include lethargy or being very tired, no tears, dry tongue, and decreased urine output. If this occurs, your child should be seen.
If there is high urine output and other signs of dehydration, this may a sign of diabetes and your child should be seen. Viruses, such as influenza and SARS-CoV2, can trigger the onset of diabetes in susceptible people.
Ear pain. If your child has ear pain, treat the pain, don’t rush in to be seen. Most ear infections are due to a virus, but if your child is under 2 years, the symptoms persist more than 3-4 days, or if the symptoms are not manageable, antibiotics may be considered. Learn more about ear infections here.
If your child has leg pain or weakness that limits their ability to walk, they should be seen as soon as possible. This can start even a few weeks after influenza if it is post-viral myositis.
If symptoms start to resolve then return or if they’re worsening, an assessment should be done. This can be due to a new infection back-to-back with the initial infection, but it also could indicate a secondary bacterial infection.
First 1-2 days of infection in at risk people
Influenza can be treated with antiviral medications if they are started early in the course of infection, generally within the first 48 hours of symptoms. Starting later significantly decreases their effectiveness.
I try to reserve these medicines for those who are higher risk, because if everyone uses them, they won’t be available for those who really need them. Risks can include being under 5 years of age, diabetes, asthma and other lung conditions, heart conditions, immunodeficiencies, neuromuscular disorders, and obesity. Pregnant women, elderly, and those who live with high risk people are also high risk.
There are four approved antivirals for influenza in the US, but they’re hard to find now. These medicines include
oseltamivir phosphate (generic available, trade name Tamiflu®, available in liquid and tablet form, approved for 14 days of age and up)
zanamivir (trade name Relenza®, inhaled medication approved for people 7 years and up without breathing problems)
peramivir (trade name Rapivab®, intravenous medication approved for 6 months and up)
baloxavir marboxil (trade name Xofluza®, available as a single dose in liquid or tablet form, approved for 5 to 12 year olds who do not have any chronic medical conditions and for all 12 years and older)
Oselatamivir (Tamiflu) has never been a favorite medicine of mine. It has many side effects and isn’t that effective. I’ve written a lot about it before, so won’t repeat everything here, but if you want to know why I’m not a fan, see Tamiflu: The not-so-great influenza treatment. I will recommend Tamiflu for young infants who have been exposed to influenza or early in their infection, since their risks of influenza are quite high, especially if they have not had flu vaccines.
I’ve heard great things about baloxavir marboxil (Xofluza) in the community, but haven’t used it much personally. This is due to many factors, including the timing of when I see patients- it must be started early, the age ranges for which it is approved- high risk kids under 12 (including asthma) should not take it, unavailability, and cost.
Relenza and Rapivab are medications I have no experience using.
Treatments commonly recommended:
Most people with influenza can be treated at home.
I always say, “water, water water” is the best treatment for cough and colds.
Water in the air.
Water (saline) in the nose.
Extra water to drink.
Water to wash hands frequently.
Saline can be more helpful than many imagine. For infants, use a nasal spray available at your pharmacy. For older kids and adults, sprays can also work, but washes are even better! I wrote about using nose sprays previously - see the “For more” section for information about washes.
Honey has been shown to help coughs but can only be used over 12 months of age.
Older kids can use cough drops if they aren’t at risk of choking.
Anyone with a history of asthma should use their Action Plan to step up therapy. Make sure you have all the medications and equipment needed to treat symptoms. If you don’t, schedule a visit to update the Action Plan and get refills that are needed.
Use fever reducers to make kids comfortable, not to bring the temperature to normal.
Push water and other fluids to help kids stay hydrated. They can eat foods if they feel up to it, but fluids are important!
Help kids rest when sick.
Things that are not helpful:
Cough and cold Medicines. There are no cough or cold medicines approved by the FDA for children under 6 years. None have been shown to help people of any age. They are not safe and can cause serious side effects. See my post on cough medicines for details.
Allergy Medicines. They are not helpful unless your child also has nasal allergies. Nasal sprays with corticosteroid (Flonase, Nasacort, Nasonex) can help with nasal congestion more than antihistamines.
Antibiotics. Antibiotics are not helpful for viruses or colds. They may lead to side effects or allergic reaction, so should only be used when the benefit outweighs the risk. Antibiotics may be used if your child gets an ear or sinus infection, though many of those are also from a virus, so talk with your prescriber about the need for antibiotic. At this time there are shortages of the antibiotics typically used for sinus and ear infections and pneumonia, so we must be especially cautious to only use them when needed.
Menthol on the feet. This is a popular online suggestion. I don’t know why it’s so popular. Some menthol products may help, but not on the feet. Learn more on Menthol for coughs and colds.
Prevention is key!
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. Be kind and wear a mask for a few weeks after infection to prevent spread to friends, family member, and co workers. This also helps to protect you, since after infections your body might not be able to fight off new infections as easily.
Protect your family from spread of the infection within the home, regardless of what is causing it. No one likes to be sick and we have many ways to prevent spread, including
Encourage everyone able to wear a mask to wear a quality well fitted mask, such as a KN95 or KF94 (kid sizes available!). The person who is sick is the most effective mask wearer, but if your child is too young or uncomfortable to wear a mask, your mask can help protect you.
Filter the air.
You can make an effective but less expensive HEPA filter box fan with these DIY instructions.
Clean Air Stars has this helpful spreadsheet to help choose the right filter for your needs.
Run your heater or AC fan all the time by changing from “Auto” to “On” to help filter your air through the home’s HEPA filter.
Open windows to improve ventilation if weather permits.
Wash hands and surfaces frequently.
Don’t touch your eyes, nose and mouth. These are germ portals into your body!
Isolate the sick family member as much as possible from others.
Stay up to date on all vaccines and boosters. This can help protect against serious illness. Even though they don’t completely stop infections, they make a difference! Influenza has many strains, so even after a flu infection it is recommended to get the vaccine if you have not yet had it for the season. This year’s flu vaccine has 4 strains to protect you against serious infections.