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Back to School and Illness

by Beril Bayrak Bulucu, MD – August  2009

Fall, Back to School and Respiratory Illness in Children

As fall is approaching and the leaves are falling lots of children are preparing to go back to school. And unfortunately lots of viruses are preparing to infect them !  Not only them, the siblings at home, parents and other people around. School children usually serve as a portal which spreads around infections.

Why do most respiratory infections like colder weather?
Even though we do not know the exact answer to that the most accepted answer is t`hat The viruses that cause most of the respiratory infections replicate better in the cold. `Also during colder seasons people spend more time indoors, share more talks, hugs and of course droplets.

What is a cold? Is there  such thing as a common cold?
What we call a common cold is actually a viral infection. Cold, wind, temperature change does not really directly make anybody sick. It just makes easier for the viruses to replicate. After all it is an infectious agent that we capture from another person.

Which agents cause illness in the fall and winter months?
Approximately 80% of all the respiratory infections are viruses. Bacteria form a smaller percentage of the infectious agents. There are many different viruses. Some of them have been recently identified. Some of the names are Rhinovirus, coronavirus, RSV, Metapneumovirus, adenovirus, parainfluenzavirus and influenza virus. Each of these viruses have many different types and there are some additional ones as well so the list goes on and on.. Some of the bacterial causes of respiratory illness in winter are beta hemolytic streptococci,mycoplasma, pneumococci ( a lot less ,thanks to immunizations)

How many times cold or flu is normal?
A typical child gets  6-12 upper respiratory infections in a year. The child usually gets sicker a lot more often during the first few years of school as he is developing an immunity towards the infectious agents and actually each illness `trains` the immune system.

How many is abnormal?
The first few years of school some children get sick every month and that is normal. However If the illness is more severe like repeated pneumonias and underlying reason might have to be investigated. Some children get sick with fever every month and might have swollen tonsils and sores in their mouths. They might have an illness called PFAPA syndrome which might need to be investigated further. Children who have allergies or asthma seem to have more frequent respiratory and upper respiratory infections. Children who seem to be exposed to tobacco smoke get ill more often than those who do not.

What kind of upper respiratory illnesses effect children in the fall and winter?
The most common is namely common cold that is caused by rhinovirus or coronavirus. Usually mild, does not cause much fever. Usually gets better in few days. Upper respiratory infections may or may not cause fever. RSV virus usually causes upper respiratory illness in children and a cough that lasts a long time (sometimes weeks). In babies and young children RSV causes an illness called bronchiolitis which might sometimes cause wheezing and severe respiratory distress, and might result in hospitalization. Older children usually have a milder disease.

Agents such as parainfluenza, RSV etc also cause a clinical picture called croup. Croup is a cause of  barking cough and sometimes a scary sound called “stridor”. There is some narrowing of the upper airway near the vocal cords but it is usually not as scary as it sounds. Croup usually responds to cold fresh air and steam treatments.

Most of the upper respiratory infections are viral and do not need antibiotics for treatment.

How about lower respiratory illnesses?
Some of the lower respiratory illnesses are bronchiolitis, bronchitis and pneumonia.
Bronchiolitis mainly effects young children. It is the infection of the little bulbs adjacent to the bronchi, which are called bronchioli. The primary cause is RSV but there are other viruses to blame as well. Bronchiolitis might sometimes be severe and require intensive treatment especially for premature babies but for term babies usually heals without problems.

Is a viral illness and unless a secondary bacterial infection is added, treatment does not require any antibiotics.
Bronchitis is the infection of larger respiratory tubes called bronchi. It is usually mild unless the child has underlying asthma or allergies. For the most part bronchitis is viral, despite common belief. And it gets better on its own, with the help of symptomatic treatment.

A bacterium called mycoplasma is also a relatively common cause of bronchitis and pneumonia especially for school kids.

Pneumonia is a severe childhood illness, the incidence of which has dropped markedly with recent vaccination practices. Pneumonia is the infection of inner lung tissue, it might be caused by bacteria and viruses as well but when pneumonia is diagnosed an antibiotic treatment might be necessary as it is difficult to distinguish the two.

What is flu?
With the swine flu news  and bird flu, this topic stays quite hot. It seems flu viruses seem to be ahead of us and modify their structure constantly. Flu is different from common cold. People who have flu are febrile and sick. There is rarely flu without fever.

It is important to clearly diagnose influenza or flu both because there is antiviral treatment available and also as it would help avoid unnecessary antibiotics.

Is swine flu a very dangerous illness?
As demonstrated by the level 6 alert, swine flu is a very rapidly progressing illness but it is not necessarily more severe than regular seasonal influenza. For the most part swine flu is responsive to antivirals and the course and complication rate does not seem to be too much different from regular flu.

Flu shots?
Flu shots are a safe and effective way to prevent influenza. The effectiveness varies from year to year and is a bit luck of the draw. Flu shots are recommended for all age groups of children but especially important for kids below 2.

The situation about swine flu shots remains unclear but one thing that should not be forgotten is that it is an entirely new and quickly produced vaccine. Safety data will be clearer over time.

How to approach respiratory illness in children?

The approach changes with the age of the child and intensity of illness. A flu like illness with high fever may warrant an immediate doctor visit whereas a cough and cold with mild fever can be treated at home. For younger children the risk of complications is higher so there should be a lower threshold for medical attention. The most important issue is how ill the child looks. Also after a little while usually moms and dads develop a sense of how the child responds to illness. What kind of pattern and etc. This usually is very important to keep in mind.

Treating cough and colds
There has been lot of debate in the world medical community about the use of cough and cold medications in children. The consensus is that there is really no reliable data about their use in children below 2 and furthermore there is a lot of reports of incidents of accidental poisoning and side effects. Some countries such as the US now bring up the safety labels to age 4 and up.

When you search for daha about their efficacy for older kids the studies say that they are not at all effective even for symptom relief. As a matter of fact a recent study which compared cough syrups with honey found that honey was superior in relieving cough than the cough syrups.

In Turkey unfortunately lots of medications are used for treating coughs and colds in children and actually for the most part they do not do anything but only temporary symptom relief.

Natural medicines are safer and sometimes more effective than the synthetic ones. For example ginger has antihistaminic properties, natural honey is a cough suppressant, onions have antioxidant and and anti-inflammatory effects. Garlic also has almost antibiotic effects.

Salt and water is a lot more effecting in cleaning the nose than most syrups.

Cough and cold medications should never be used without the guidance of a physician especially for younger kids.

When do we use antibiotics?
Even though most upper respiratory and respiratory illness in children is of viral origin, sometimes bacteria might cause secondary infections and antibiotics will be needed to treat them. Also streptococcal phayngitis and pneumonias need to be treated with antibiotics. Antibiotics should be used carefully and with clear medical indications. Overuse of the antibiotics not only causes an antibiotic resistance in the person and in the community it also might have a relationship to the increase in allergic and autoimmune illness.

Any factors affecting immunity?
An infection is the most common factor which effects immunity in the first place. If a child has an upper respiratory infection, usually has lower immunity and is prone to more severe infections. Cigarette smoke at home is a factor. Also too much hygiene (eg excessive use of household cleaners) use of antibiotics all seem to be a factor in disturbed immunity. But for most health children colds and upper respiratory infections just make their immunity stronger.

What to do for protection?
Most of us know that especially if you have school children protection from illnesses going around might be a fantasy. Hygiene and hand washing are very effective to prevent spread of illness but unfortunately not so easy for younger kids. It is important to start talking about hand washing, as schools are about to start. Hand washing should be thorough and at least for 5 minutes. Hand sterilizing gels can be given to older children. Also `cover your cough or sneeze` is a good thing to teach and practice at home. Hand washing and sterilizants seem to be effective in preventing especially gastrointestinal infections and strep throats, a recent study showed. Not sending sick febrile kids to school is another important way to protect the rest of the class.

How about using supplements for protection? There is no good evidence about ecchinecia or vitamin C for long-term use for protection purposes however products containing probiotics seem to be more effective. A good balanced nutrition seems to be a very important factor. Also taking omega 3 seems to stimulate immune system as well as the memory. If a child does not have a good intake, taking fish oil and vitamin supplements could be of use.

I wish you all a beautiful and healthy fall with only a little bit of illness (as a little bit is necessary to stimulate immunity.)

Beril Bayrak Bulucu, MD FAAP

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