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Dr Tara Neumayr: Hi. I'm Dr. Tara Neumayr. I am a pediatric nephrologist and a pediatric intensive care doctor at Washington University and St. Louis Children's Hospital, and I am a mom doc.

Melanie Cole (Host): While respiratory infections occur year round, there's certainly an increase in these infections during the fall and winter months. Welcome to Mom Docs, the podcast from St. Louis Children's Hospital. I'm Melanie Cole. And Dr. Neumayr, I'm so glad you're here to talk to us about the difference between the cold, flu, croup, RSV and COVID-19. There's so much to discuss. So, as we get into this podcast, have you seen an uptick in RSV and these other respiratory illnesses as physical distancing and masks and such started going by the wayside? Tell us a little bit about that and the difference between all of these respiratory illnesses.

Dr Tara Neumayr: Yes, absolutely. And this is a really important topic right now. This year has been extremely different from years past. When we have formally expected that the various colds and flus would be seasonal in nature, so they tend to arise sort of in early to mid-fall and then last through the winter months, this year, ever since we've sort of eased COVID restrictions, the seasonality of the respiratory viruses has sort of gone away. And I think a lot of that has to do with simply that children generally will build up immunity to those viruses in those first months and years of life. But with two years of social distancing, masking, and COVID protocols, some of those children did not build that immunity in that timeframe, and so are susceptible to these new viruses whenever they encounter them.

So, unlike previous years, when we would expect these to sort of ramp up in those fall and winter months, this year, we have seen a very continual pressure on the system where lots of children are being hospitalized, even throughout the summer months and these early fall months. So right now, nationwide, there is a large pressure on pediatric hospitals in that many of them are very full with children experiencing what would otherwise be considered seasonal viruses.

And so before we've even hit the flu season, for example, we are seeing a number of children who are being hospitalized even in intensive care units with RSV and with rhinoviruses and enteroviruses. When you think about what is the difference between these viruses, there are a number of sort of distinguishing features, but they can be difficult to tell apart just by looking at your child at home. So when you think about rhinoviruses and enteroviruses, those are really associated with what we think of as the common cold. So for most people, those are going to be that you have congestion, a runny nose, maybe you have a sore throat, maybe you have a cough, maybe you just feel kind of rotten. Kids can have fevers with those. Kids who are younger or have other health problems can get very sick with rhinoviruses and enteroviruses, and they can need to be hospitalized. And usually, that will present with children who are breathing very fast or very hard, who can't breathe well through their nose because their nose is so congested. And they will look like they're really struggling and breathing fast.

In contrast to that, you have RSV, which is respiratory syncytial virus. That's usually a seasonal virus. It most profoundly affects the youngest children, and that's just because younger children have smaller airways. So, this is a disease that affects the lower airways, in the lungs themselves. And it can look a lot like asthma looks. They can be wheezing. They can breathe fast. They can breathe really hard. Those children, particularly the younger ones or the ones who have chronic lung conditions such as asthma or prematurity lung diseases, or kids who have cardiac diseases, so heart diseases, can get really, really sick with RSV and need to be hospitalized. And even healthy infants can get very sick with RSV and need to be hospitalized, including being in the intensive care unit. That one has historically been very seasonal, but we have seen it throughout the summer this year. Then, when you think about sort of the croupy illnesses, those are quite common. They affect children up until the age of about three to five years old most severely, and they tend to be illnesses of the upper airways.

And so, those are the ones that create those barky coughs, that create that sound when they try to breathe in. And those are the ones that tend to get a little bit better when you expose your child to a steamy shower or to cold air outside. Those sometimes need some intervention as well. They might need a trip to your pediatrician where you might get treated with steroids or with other medicines, or you might actually need to come to the hospital for special oxygen administration.

Putting all of those into one bucket, then you get into the seasonal flu. And I think this one is pretty confusing for people because we sometimes refer to the flu as being that kind of an illness where you have an upset stomach, maybe you have vomiting, maybe you have some diarrhea, and that's not really the flu, that's not influenza. That is what's called gastroenteritis. It can be caused by some of those enteroviruses that we talked about earlier. But the flu, seasonal influenza, is very much a respiratory illness, and so it really affects the breathing. They can have a really productive, nasty cough, like the way that people sometimes do with pneumonia. They can get very high fevers, body aches, have a real hard time getting enough water down to feel better. You can still have sort of that sore throat, congestion kind of feeling, but also that difficulty breathing and a need for supplemental oxygen.

This year, we expect that the flu season will be quite severe. And so, we would really, really encourage people to get your seasonal flu vaccine as early as you possibly can. That is in part because getting the flu vaccine will make sure that even if you get the flu, you have a milder version of it than you otherwise would. But think of it also in terms of the fact that the hospitals, the pediatric intensive care units, the pediatric hospitals around the region and around the nation are full to capacity right now and delays in care can be a consequence of overfilled hospitals as we saw during the COVID pandemic. So, we don't want to repeat that experience with seasonal flu. And resources for pediatric care tend to be more sparse than for adult care. So, you may not be able to rely on just your local community hospital to provide the kind of care your kid might need if they get severely ill. So, really getting that flu vaccine this year is more important than ever.

Similarly, COVID is still out there. It is still showing up in the hospital, making children quite sick. And we expect there to be another surge of COVID-19 over the course of the winter. And so, if your child is not vaccinated yet or not vaccinated and boosted according to the schedule recommended by the CDC, we strongly recommend that people get their children vaccinated for COVID19. My children are ages four and nine, and they are both vaccinated. My son is boosted, he's nine. My daughter is not yet available to be boosted because she has just completed her series in the summer. But when she is available, I will be getting her boosted as well. They both tolerated the vaccine extremely well and have had no side effects whatsoever. So, I would really encourage people to go ahead and get those vaccines completed to try to stave off any severe illnesses that we can sort of predict are on their way.

Melanie Cole (Host): That was such a comprehensive answer, Dr. Neumayr. So educational. And that co-infection aspect of all of these things, this twindemic that we are seeing, and as you describe, these hospitals being full to capacity can be a little bit daunting and scary for parents. So, I'm glad that you mentioned vaccines. Now, when you talk about all of these different things and the symptoms, when we take our children to the pediatrician with any of these symptoms, or we try and manage some of them at home, does it matter which one they have? Because they're all so similar. How do you guys tell the difference and what's the difference in treatment for these things?

Dr Tara Neumayr: Right. So, that's a great question. For the most part, when you are looking at your child at home, it doesn't matter a lot what virus they have if they're not severely ill. The exception to that would be, one, the seasonal flu, because if you catch it within the first 24 to 72 hours, your child can get what's called Tamiflu, and that can shorten and ease the course of the illness. So, if you suspect that your child may have seasonal influenza, maybe they're having really high fevers, maybe they're having those muscle aches, that would be an indication to talk to your pediatrician and say, you know, "Is this maybe something we should have tested?" and then, maybe get into a course of Tamiflu.

Similarly, especially if your child has underlying chronic illnesses, which includes asthma, if you think your child may have COVID-19, then you might want to call your pediatrician the minute that you experience any kinds of symptoms in case they would want to implement some of the treatments like remdesivir, which can again shorten and ease the course of the illness.

For the other ones, the main thing that you're trying to differentiate is does your child have severe illness to where they would need medical care? So, would they need oxygen or support for their breathing? And when you want to try to suss that out as a parent, you look to see if your child is breathing very fast. So, sometimes breathing right around 50 to 60 times a minute can be out of the range of normal, even for very small children. Whether your child is breathing very hard and so you can watch is their belly really pulling in a lot with each of their breaths or can you see their ribs as they're breathing? Those are kinds of indications where you'll want to have your child seen by your pediatrician or by an urgent care or an emergency room if it's after hours.

And then, the other sort of differentiating feature other than sort of how hard are they working to breathe, but is there concern that there may be a bacterial infection? And those can be really hard to tell the difference. So, a pneumonia versus an RSV can be very challenging to tell the difference. And so if you're concerned about that, it's a good idea to have your child see the pediatrician. RSV is a virus, but can often be followed by bacterial pneumonia, just based on the idea that RSV creates a lot of what's called secretions, so a lot of mucus and other things that can plug up little parts of your lungs that gives good sort of substrate for the bacteria to grow. So, what can start as RSV can become a bacterial pneumonia within a few days. And so, getting early consultation with your pediatrician can be really helpful as you're trying to think about how severely ill your child is and what you might need to be looking out for in the next few days.

Melanie Cole (Host): And before we get ready to wrap up, this is so educational for parents, what about some of the things that are over-the-counter? What about vitamin C or zinc or Airborne or the cough medicines, you know, Delsym and all of these different things? Are we supposed to be helping our children with these symptoms? Even if it's like fever, we've learned over the years as parents, that fever's supposed to be good. It helps our child, but it's still really, really scary. Do we want to get rid of those fevers? Tell us about symptom management and comfort measures, things that we can do to make our children more comfortable if they do develop any of these, and then certainly reiterate about vaccines.

Dr Tara Neumayr: Sure. The most important thing to remember about symptom management is that cough suppressant medicines, so things like cough syrups, and those sorts of things are not to be used in children younger than three. And so, they're generally marked that way on the bottle. But just remember that those are not for children younger than three. And that's just because the doses of some of the medicine in those cough syrups can make children under three more sleepy than they ought to be, and that can actually impair their ability to breathe. So, no cough suppressants in children under three.

Then, the kinds of symptom management that you're talking about, so some of these supplements like vitamin C, echinacea, zinc, all these things, they are thought to be supportive of the immune system and they're probably not harmful as long as you're not taking them in excess. But there's really no evidence that they shorten the length of an illness or reduce the severity of an illness. There's sort of these no harm, no foul kinds of supplements that you can give, but may not make a significant difference.

The other things are things like Tylenol. Tylenol is safe in all children and can be used to control fevers. If your child's fever is not causing them particular discomfort, you don't necessarily need to treat it. But if it's sort of getting into that realm where it's in the 101 range, 102 range, we recommend that you give them some Tylenol, encourage fluids, help them feel a little bit better. Ibuprofen is okay in children older than six months and should only be given to kids who are still able to drink well.

And then, the other kinds of symptom management that really seem to help best are things like using humidified air, giving them lots of fluids, so that they can really keep those mucus membranes moist and keep things cleared out of their nose and cough things out of their lungs.

So those are the kinds of symptom management that we generally recommend. And again, as I said, just preventive care of getting your vaccines, make sure you're up-to-date with your vaccines and get all of the vaccines that your pediatrician recommends. That's our strongest recommendation.

Melanie Cole (Host): It certainly is. Excellent advice. Thank you so much, Dr. Neumayr, for joining us again. And for more advice and articles, check out the Mom Docs website at childrensmd.org. That concludes another episode of Mom Docs with St. Louis Children's Hospital. Please always remember to share these shows with your friends and family on your social channels because we are all learning from the experts at St. Louis Children's Hospital together. I'm Melanie Cole.