The community burden of influenza has been staggering, as has the outpouring of near-hysterical parental concern, thanks in part to sensationalistic coverage provided by media modalities, e.g. newspapers, magazines, radio and television. Calls have been at an all-time high and clinics experience wait times often up to three hours. Here at Brooks Kids, we have been forced to refer patients to Emergency rooms on some days when patient volume exceeds our capacity to handle.

Here are some facts about novel H1N1 (“Swine flu” or nH1N1):

First and foremost, nH1N1 is a new strain of a familiar fiend, influenza. Every year I recommend people get their influenza vaccines because this virus is no fun, and can have complications. There are treatment options with anti-viral medications, but they are not great and should be reserved for patients with conditions or factors that put them at increased risk of complicated influenza illness.

Let’s talk about the illness first. What is common? What should we expect to happen with routine influenza illness? Influenza is predominantly a respiratory illness that attacks the upper and sometimes lower respiratory tract. If the host has not previously encountered the strain, the illness can be pretty unpleasant and commonly results in any combination of the following: Fever (any height, often high), malaise (feeling of being unwell or sick), myalgias (muscle and body aches – these can be quite intense), fatigue (children will sleep more and mope about), cough (can be very unpleasant and keep you and yours up through the night), runny nose, sore throat, congestion (enough to make feeding a chore), headaches, chills and often children with have vomiting (the worst symptom in my opinion) or even a little diarrhea (less common and usually not a lot). Influenza illness typically lasts three to five days. Few are shorter and some last a couple days longer.

Now let’s talk about complicated influenza disease. Most influenza makes you FEEL like dying, but very very few actually succumb to the disease, but deaths DO occur. The death toll that is plastered across the news is not a new concept. Every year 30,000 to 50,000 deaths are attributed to complicated influenza illness in the United States. Most of these are people who have risk factors for complicated influenza, but a small number will not. Seasonal flu and nH1N1 flu both seem to have the SAME propensity to cause complicated disease. This means nH1N1 is no more aggressive than seasonal flu and vice versa. So what is complicated disease, you ask? Essentially influenza can cause full-blown viral pneumonias that are tough to treat. Occasionally the insult to the lungs will cause swelling in the lungs called “pulmonary edema”. Such a process interferes with the lungs ability to exchange gases and the host then begins to have labored breathing and shortness of breath. Dropping oxygen levels can cause shock (poor grayish-blue color, cold, clammy and sweaty extremities, and disorientation). Other complications involve opportunistic infections. Opportunistic organisms, specifically bacteria like Streptococcus pneumonia, take advantage of the host’s defenses being knocked down by the primary influenza infection. These infections will often result in a compounded sick appearance of the host or similar symptoms as described above.

A person suffering from complicated influenza will usually demonstrate some of the following symptoms: Protracted fever lasting over 6-7 days, increasingly productive cough, especially if accompanied by chest pain and/or breathlessness (infants in distress will breathe fast, hard and often the skin between, above and blow the ribs will tug inward slightly with inspiration – these are called “retractions”), refusal to drink fluids, grayish color, cold and clammy extremities and in very poor situations confusion, disorientation or combativeness. Infants in trouble may refuse to be cuddled or touched. These symptoms would warrant a call to the office during office hours or a trip to the ER after hours or weekends.

What treatment is there for influenza? Remember that influenza is a virus and therefore antibiotics have absolutely no place in the treatment of simple, common flu illness. Important measures include rest and pushing fluids. Over-the-counter ibuprofen and acetaminophen are useful to ease the aches and pains. Cool mist is nice for soothing the inflamed airways and thin mucous to promote drainage. Cough remedies tend to work the same as placebo, can have side effects and drain the wallet a few bills.

Who should be treated with antiviral medications? Should everyone with flu symptoms be treated or given prophylactic medications? Many physicians are prescribing these medications this way, but I disagree because, anti-virals are not recommended for treatment of common flu illness in patients without risk factors for complicated influenza illness. If these medications are over-used, resistant virus strains could emerge, more patients will experience side-effects, and the stock of available medication will (already has) dwindle or become unavailable for the patients who really need it. Patients who should receive prophylaxis or treatment are those over 12 months who have persistent asthma, chronic lung disease, congenital heart disease, taking chronic aspirin therapy, diabetes or immuno-suppression from chemo, medications or disorders. These children are at notably higher risk of serious, complicated influenza disease.

What do anti-virals do? They slow the virus down and may trim about 24-36 hours off the duration of the illness if started within 48 hours of illness. In my experience, many insurance companies do not cover these medications. A course of Tamiflu is about $80. Side effects can be notable. In studies, 10-15% of children experience nausea and vomiting from the medication. These side-effects are tolerable if the benefit outweighs the risk, as in the high-risk individuals.

If your questions and concerns have not been addressed, consider calling the office or paging after hours if concerns are emergent.