How to tackle a pediatric ‘tripledemic’

Around this time of year, our pediatric staff will often hear, “Winter is coming!” It strikes fear in all of us as we prepare for the coming onslaught of snotty noses, febrile children, coughs and more. Well, this year winter came early, it came swiftly and it came with a ferocity that we haven’t seen in some time. Respiratory syncytial virus (RSV), which has been unpredictable since the COVID-19 pandemic began, showed up first this season — now stronger than ever. Influenza didn’t wait, coming right on the tails of RSV, causing an early “twindemic.” Of course, we can’t forget about COVID-19, which is still a player in this game and does not want to be forgotten (and shouldn’t be forgotten), leading to worries of an evil “tripledemic” in pediatrics this fall and winter.

RSV is not a new virus. It has been around for a long time, but you are no doubt hearing more and more about it this year for several reasons. There are more cases in the community this year as we have resumed many typical pre-COVID activities while also losing our masks and social distancing practices. It turns out the methods we used to combat COVID-19 worked even better on our typical seasonal respiratory viruses. It is also theorized that community immunity has waned since RSV hasn’t been as predictable regarding seasonality or severity since the onset of the COVID-19 pandemic.

We have seen significant RSV spikes the last two summers, but the incidence this fall has pushed many children’s hospitals to the brink. While this serious virus may cause a cold in older children and adults, it can be severe in infants and young children. It can cause respiratory distress and lead to the need for significant respiratory support. It is a leading cause of hospitalization and even death in infants, however, due to waning immunity, we are seeing more severe illness even in typically low-risk populations.

When you have RSV your respiratory tract produces copious amounts of mucus, which makes it harder to breathe. It is easy to see how a small infant less than 6 months of age and/or with

co-occurring respiratory or cardiac conditions may have difficulties with this virus. Unfortunately, there is no medication to treat RSV and antibiotics are not helpful against it since it is a virus. Supportive measures such as suctioning, warm showers, humidifiers and fluids are the main treatments to help one get over this virus. Some patients may go on to develop ear infections or pneumonia during the course of illness or worse respiratory distress, which could mean hospital or intensive care admission. Even infants who do well may have a prolonged cough, which often causes parental concern, but eventually almost all infants will recover with supportive care.

Fortunately, it seems in some areas that RSV has spiked and may be declining, although this will vary by region. It may rear its ugly head again at any time.

Not to be outdone, influenza has also presented itself as a worthy challenger. While it seems that many areas of the country have been hit hard by the flu, Tennessee seems to be at the center of the current surge. Several counties have closed their schools in attempts to keep children healthy and safe. It’s important to remember that the flu can still cause severe illness and even death in children. The flu can cause cough, fever, fatigue, muscle aches, headaches, congestion and more. Again, most children will do well, but certain groups, especially those with underlying respiratory conditions

such as asthma, may be at high risk. Generally, children need supportive care, but we do have anti-viral options that can reduce the symptoms and can be used in certain circumstances. As with RSV, some children may need respiratory support requiring hospital or ICU admission, and some children may develop other complications such as pneumonia. It has been widely reported that this flu season is the worst since the 2009 H1N1 swine flu pandemic. A total of five pediatric deaths due to the flu have been reported by the Centers for Disease Control and Prevention (CDC) so far this season. As we often said with COVID-19, no child should die from a preventable illness, and we should work to immunize children and keep them safe and healthy. Most children who die from the flu are unvaccinated, but the flu vaccine can make the course less severe, limiting the need for hospitalization or other complications.

RSV, flu and COVID-19, oh my! It seems as though we’ve been picked up and put down in an unfamiliar world. But this is what pediatricians are seeing in our offices and hospitals all across the country. Fortunately, we have a yellow brick road of sorts on how to navigate the situation.

First, get yourself and your child vaccinated against flu and COVID-19. It takes about two weeks after the flu shot for your body to build up immunity to get the full benefit from the shot, so it’s best to get it as soon as possible. Those who haven’t gotten their primary series of the COVID-19 vaccine should get it now and those who have should check to see if they are eligible for the new bivalent boosters now available.

Also, practice good hand hygiene, stay home when sick, cough or sneeze into your elbow and make sure your body is getting enough sleep, adequate nutrition and physical activity.

Once again, we can make it through this winter together. While there’s no place like home, don’t let the volume of patients keep you away from your doctor’s office or hospital if you need it. You can often call your pediatrician first to see if your child can be safely cared for at home.

The American Academy of Pediatrics has asked for support and resources, while noting that we are still in the midst of a mental health emergency as well. Be patient but be vigilant. We have the tools to fight. Let’s put them to use and keep our children healthy throughout this battle.

Carlenda Smith, MD, FAAP is vice president of the Tennessee Chapter of the American Academy Pediatrics.

Jason Yaun, MD, FAAP, is president of the Tennessee Chapter of the American Academy Pediatrics. Follow him on Twitter: @JasonYaunMD