Ask the Pediatrician: Dr. Molly

Category: Cold and flu

Tamiflu: Is it really good, necessary for everyone?

Tamiflu shortages are everywhere. Pharmacies are having to take the capsules meant for adults and compound them into a liquid version safe for younger children. I've had parents who have had to call multiple pharmacies to find which has the medication and can prepare the liquid version.

It is frustrating on many levels, not the least of which is that the patients for whom I prescribe Tamiflu are high-risk kids.

I suspect some pediatricians are giving even otherwise healthy kids with milder illnesses the medication and this is resulting in the relative shortage. The problems with doing this are many.

First, using Tamiflu for everyone with flu-like symptoms is very likely to result in a huge growth in Tamiflu resistance. This is the same phenomenon that occurs when lots of kids in daycare or preschool are on amoxicillin for infections. Eventually, the bugs that cause the illnesses get resistant to the amoxicillin and it doesn't work anymore. Last summer, a camp in North Carolina had a widespread outbreak of H1N1 and decided to put every camper on Tamiflu to prevent the flu from spreading. One case of person-to-person transmission of Tamiflu resistant flu appeared as a result. What that means is that this virus can change and then Tamiflu will stop working. Not a good thing!

Second, using Tamiflu for everyone with flu-like symptoms is resulting in a shortage of the medication so that when kids who are high risk, such as those with asthma, really need it, little is available.

These reasons sound like a big deal, but when I tell parents of otherwise healthy children who have swine flu these are the reasons I'm not writing a prescription for their child, it doesn't really seem to matter to them. They have a sick kid in front of them and just want to help their child get better and decrease the child's risk of complications.

Third, and more convincing, is that Tamiflu has a lot of side effects. About half of all kids who take it will throw up, have stomach aches or diarrhea. A small percentage of them will have nightmares or even hallucinations. It isn't a benign medication to use and is very expensive (about $100 per course) for families without good prescription coverage.

Lastly, and also somewhat convincing, is that the rate of transmission in households is only 15 percent-25 percent at best, which means if you have a child infected there is only a small chance other members of the household will come down with symptoms. Treating the child isn't going have much benefit for the rest of the family and because Tamiflu has significant side effects, unless the child is high risk or very, very sick, it just isn't worth it.

Category: Cold and flu

H1N1 testing helps determine treatment, use of scarce vaccine

H1N1 has hit Michigan hard. The CDC identified Michigan as one of the states with widespread disease. Luckily, most of the cases have been mild, but even so, many children have been hospitalized and a few in Michigan have died. What's maddening is that despite the media's focus on the illness and importance of getting the vaccine, the supply of vaccine remains limited. Thousands of people are waiting hours, sometimes in the cold and/or rain, to get their children vaccinated. Thousands more search in vain to find a place to get it.

My office has been swamped with calls and office visits for feverish kids whose parents worry their kids are infected with the swine flu virus. Many of these kids turn out to not have H1N1 and the ones who did haven't been terribly sick. Still, when I say the words "probable swine flu" there is always a look of panic on the parent's face.

In most doctors' offices, we can only do the rapid influenza test that doesn't differentiate between the swine flu and other seasonal flu strains. In fact, because well more than 99 percent of all influenza in hospitalized patients is the H1N1, it is a very safe bet that child with a positive test at this point has H1N1 influenza. The other rub has been that the office- based test is not foolproof. About 30 percent-40 percent of the time the test will be negative even when the child has the H1N1 strain.

All of this worry and inaccuracy of the test makes the decision about whether or not to start Tamiflu that much more difficult. The CDC recommends only high-risk children (those under 2 years or with chronic medical conditions like asthma, cerebral palsy, diabetes, etc.) need Tamiflu treatment because the vast majority of otherwise healthy kids are weathering the illness easily.

So what am I doing in my office? I am primarily testing those kids with whom I am considering using Tamiflu and the others in my office who are tested are done so if they look particularly sick. If a high-risk child looks really sick, even if the test is negative, I am prescribig Tamiflu. For otherwise healthy kids, unless they look incredibly sick, I am not initiating treatment.

That begs the question about why even do the test. I do it because at this point in the season if a child tests positive, whether I treat them or not, chances are this is the H1N1 virus and they will be immune and not need the vaccine when it finally does become widely available. The CDC still recommends all children who have not had their flu strain typed to know for sure it is H1N1 should receive the vaccine. However, in this climate of limited availability and the lack of other influenza strains, I feel comfortable that my patients with positive rapid influenza tests do indeed have H1N1 and need not get the swine flu vaccine. If a child has had a flu-like illness but tested negative for influenza or wasn't tested at all, that child should still get the vaccine when it is available.

This epidemic of sorts has tested the public and private health sectors and their ability to not only implement a disaster plan of sorts, but also has helped me fine tune how I communicate with my patients to minimize unnecessary office visits and phone calls. Offices that have recorded information when you call, Web sites that are frequently updated or e-mail lists for patients have been able to run their offices more smoothly despite the worry and frenzy surrounding the swine flu epidemic.

Category: Cold and flu

H1N1 update: Michigan is being hit hard now

Iinfluenza has really started to hit our area hard. The following Q&A will help you understand who needs to be seen, when testing should be done and who needs Tamiflu treatment:

Q: When do I suspect my child has influenza? What are the symptoms?
A: Fever higher than 101.5 degrees along with sore throat and body aches is the first sign followed by headache, congestion and cough. The kids look very sick, down and out and are not interested in playing, eating or even really watching TV.

Q: What's the difference between H1N1 and seasonal influenza?
A: The symptoms are the same and both can give illness that ranges from mild to severe. Deaths in healthy and high-risk children occur with both, but early information indicates because none of us has immunity to the new H1N1 virus, lots more kids are getting sick with it.

Q: What if there's a case at my child's school - should I keep him home or what should I do?
A: I would not keep your healthy child at home. This situation will be the case every day for the next few months and unless you plan to homeschool your child this year, he should go. We will not be putting high-risk kids on Tamiflu when the only exposure is a classmate. Only 20 percent to 30 percent of household contacts will get the flu when exposed within the family, so the risk is even smaller for contact with classmates.

Q: When do I need to take my child to the doctor's office?
A: If your child is at high risk for complications from influenza you should take your child in within 48 hours of the start of symptoms. If your child is low risk, you should bring him in if the fever lasts more than three days to make sure there is not a secondary bacterial infection, or if the fever goes away for a full day and then returns at 101 degrees or higher.

Q: How do I know if my child is high risk?
A: High risk kids are those younger than 5 or any child with asthma, diabetes, heart conditions requiring daily medication, cystic fibrosis or any condition that affects ability to breathe easily (cystic fibrosis, very low muscle tone, etc.).

Q: What if I have a child who is high risk but it is the sibling of that child who is sick?
A: In that case, take the sick child to the doctor for assessment. High-risk siblings of likely influenza cases will need medication to try to minimize their chance of getting the illness or lessening the symptoms.

Q: Are you going to test for influenza in the office?
A: Most offices have a rapid test for influenza available. All high-risk kids (or siblings of high-risk kids) should be tested, but the test is not foolproof. About 30 percent of the time the test will be negative even with influenza present. So even if the test is negative, your high-risk child should be treated with Tamiflu to be on the safe side if the clinical presentation is consistent with influenza.

Q: Should all kids who have a positive test be treated with Tamiflu?
A: No. Only those children at high risk for complications should be treated. For the vast majority of children, the illness will be uncomfortable but not dangerous. To discourage the H1N1 virus from morphing and becoming resistant to Tamiflu, it is not recommended that otherwise healthy children receive it.

Q: How do you know that the influenza cases you are seeing now are H1N1? Can you do the test to know for sure?
A: Only hospitalized cases are being tested specifically for the H1N1 strain. Across the nation, more than 98 percent of all of the influenza seen and typed is H1N1 so it is safe to assume every case seen now is the swine flu. This will get tricky in late December or January when the seasonal flu will start to get mixed in, especially because the seasonal flu is not made better with Tamiflu because it is resistant to it.

Q: What if my child was exposed to another child with influenza during a sleepover or other intense and prolonged contact? Should he receive the medication to help minimize the chance he will get sick?
A: Only if he is high risk.

Q: We stood in line to get the H1N1 vaccine at the health department clinics last weekend. When can we get the seasonal vaccine?
A: When your child can get the seasonal vaccine depends on the type of H1N1 vaccine he received. If he received the live virus intranasal vaccine and you want to get the intranasal seasonal vaccine, you will need to wait two weeks. If you got the intranasal vaccine but are willing to get the seasonal flu shot, you can get that at any time. If you got the H1N1 vaccine as a shot, you can get either the intranasal or the shot for the seasonal flu vaccine at any time. Remember, the intranasal vaccine can only be given to children older than 2 without a history of wheezing or asthma and cannot be given when an infant younger than 6 months or anyone with an immune-compromising illness is in the household.

Q: Should we be taking our kids to CVS or Wal-Mart to get the seasonal vaccine?
A: Retail-based pharmacies will not administer the vaccine to anyone younger than 4 years of age and because the seasonal flu is still a ways off, I think it is more than safe to wait and get the vaccine at your doctor's office when it comes in.

More information is available on the CDC flu site as well as the Michigan Department of Community Health site. You can also read my other blog posts on seasonal and H1N1 flu, too.

Category: Cold and flu

Croup season is here!

It is 2 a.m. and you hear your 3-year-old in her bedroom awake and coughing. This cough doesn't sound like any cough you have heard before.

Your child is agitated, sounds like she is gasping for air and even when she is just breathing you can hear her air moving in and out. When you look at her chest and neck they seem to cave in oddly as she tries to breathe more deeply. Her voice is hoarse and she may even have a fever. The amount of distress you are seeing as she breathes is very concerning and you call your doctor who encourages you to calm her down and perhaps take her outside where the cool air can help her swollen airway.

Once you calm down and she does, too, her breathing is still noisy. When she coughs it sounds like a seal barking, but otherwise the distress and agitation are improved and both of you can return to sleep.

This is the classic presentation of croup. Croup is caused by swelling in the airway just below the vocal cords in response to a viral illness or more rarely a bacterial illness. Occasionally croup swelling can be the result of allergy, but this, too, is very uncommon. The fall viruses, parainfluenza viruses and adenovirus, and the winter influenza and RSV are the most common causes of croup. I am seeing a fair amount of it and I suspect adenovirus is the cause.

When the virus causes swelling, the airway that is usually wide open (like a wide hose) gets constricted to a narrow tube (like a straw) and as a result there is a lot of distress, noise and work to get the air through the smaller tube into the lungs. If you suck hard on a straw, especially if you are having a milkshake, the tube will collapse due to the negative pressure. When croup causes swelling, the airway doesn't collapse but it takes a lot more negative pressure to move the air past the area that is narrow. This work to breathe deeply is what causes the distress and the retractions seen as the chest seems to cave in against the narrowed airway.

The swelling of the airway is worse at night (isn't everything?!) and as a result, kids will appear to have a hoarse voice and a cold during the day, but at night the symptoms escalate. Older kids and adults who get infected with these viruses get laryngitis and a very sore throat along with a harsh cough, but because the airway is much wider to begin with, the swelling doesn't compromise the air movement as much. Older kids and adults report the sore throat feels like they have swallowed glass and unfortunately there is little more than pain relievers, cool liquids and time to cure this illness.

There are lots of strategies to use when the symptoms get bad at night to relieve the symptoms of croup: steamy showers, going outside in the cool air and running humidifiers. Few of these actually make much difference. What is the biggest help is remaining calm and helping your child relax. Sometimes cool air or steamy air can help and they are not harmful so try those, too, but getting your child to relax and realize she can breathe is most important. It may take up to an hour to calm down your child enough to return to sleep, but hang in there; calming and soothing and most often the cough and agitation will lessen and you can all rest again. You may need to go to the ER during the night if your child is turning blue or cannot seem to relax despite your help and the breathing distress continues.

After a bad night and the noisy breathing is still present during the day, even if the child isn't agitated, I know it will be even worse at night so I often will prescribe a three-day course of an oral steroid to help shrink the swelling in the airway more quickly.

The good news is that croup symptoms are bad for only about three nights and then within 10 days the cold symptoms that accompany it are gone and the child feels back to normal.

Croup is contagious and as such if kids have fevers or are having really rough nights due to the cough, they shouldn't go to school or daycare the following day.

Category: Cold and flu

H1N1/swine flu on pace to kill more kids than seasonal flu

The H1N1 (swine flu) virus is hitting many states hard, but lucky for us Michigan has yet to see widespread infection. As predicted, children are the most likely to have complications. In the last week, 19 deaths were reported among children with the infection.

Of the more than 75 children in the United States that have died of the illness thus far, 20 percent were otherwise healthy children with no risk factors. If the number of children dying of this virus remains at this pace, the H1N1 virus will surpass the seasonal influenza in deaths among children this year. Over the last several years, the number of children who have died as a result of the seasonal influenza have ranged from 46-88 deaths each year.

The good news is that so far all of the influenza seen this fall is H1N1 and remains very susceptible to the antiviral medications. More good news is that the Michigan Department of Community Health will begin distributing the vaccine in the coming weeks and we may be one of the few states that will be able to get most people vaccinated before the illness takes over. The H1N1 vaccine is highly recommended for all people 6 months-24 years of age, pregnant women and adults with chronic health conditions.

What about squalene?
Previous blog entries have addressed the safety of the H1N1 vaccine, its formulations and side effects, but one more question has been posed by several patients: what about squalene? Squalene is a naturally occurring substance that is made by all of us in our livers and used as an adjuvant in the vaccine to boost immune response. The squalene in the vaccine is culled from ocean fish and purified. Squalene has been well studied and is a safe and desirable way to boost response to the vaccine.

• Michigan gets first batch of swine flu vaccine

Category: Cold and flu

Making the case for H1N1 (swine flu) vaccine

In my office I have had a lot of families very willing and eager to have their kids get the seasonal flu vaccine but questions and concerns linger about the safety of the H1N1 vaccine (aka swine flu) and whether it is really necessary given the mild nature of this strain of influenza thus far. There is a lot of misinformation and fear-mongering about this year's vaccine and I hope to set the record straight.

Q: I've heard this swine flu strain results in a pretty mild illness, so why should I have my kids get the shot if they are otherwise healthy?
A: It is true that the novel H1N1 virus has resulted in fewer severely ill cases so far, but the illness still takes its toll. Fever is high (102-104 degrees) and is lasting on average about three days. Body aches and fatigue along with headache and cough are significant. Although fewer people are needing hospitalization or dying from this virus compared to the seasonal flu viruses, the illness is no picnic. In addition, the people most apt to die or have severe, complicated illness are children and pregnant women. For these reasons I recommend vaccination against the H1N1 strain.

Q: I am nervous because this is such a new vaccine and hasn't been tested. I don't want my kid to be a guinea pig but I am also concerned about the illness. What should I do?
A: Actually, this vaccine has been tested in the same way the seasonal vaccine is each year. As a matter of fact, if this strain had been identified just a couple months earlier in the spring, it would have been integrated into the seasonal flu vaccine. The steps taken to make this vaccine and the ingredients in it are no different than the seasonal version except for the virus-specific antigens. In other words, the risk with the swine flu vaccine is no different than the seasonal vaccine. It has been tested as well and this testing is part of the reason this vaccine is being distributed two months later than the seasonal vaccine. Just as the seasonal vaccine undergoes testing before distribution, this one has, too, and proven safe. Looking across the globe at other countries that don't have as rigorous a vaccine approval process as the United States, the rate of side effects from the H1N1 vaccine is no different than the seasonal flu vaccine, as would be expected. All flu vaccines throughout the years have carried a very small risk of Guillain-Barre syndrome, a neurologic complication, and that rate remains unchanged at 1 in 1 million doses. The risks of complications from influenza, even this milder strain, is much higher than that as is the death rate. Receiving the vaccine is safer than getting the illness.

Q: I don't want to put toxins like mercury or thimerosal into my child's system. Aren't those in the H1N1 vaccine for kids?
A: There are three formulations of the H1N1, two of which contain no preservatives: the nasal spray contains a much weaker version of the virus and in children confers better immunity plus a shot form as well. There is a third version in a shot form that does contain preservatives and is safe for older children and adults.

Q: Do I really have to have my child get both vaccines? Can't I just get the seasonal vaccine and ride out the illness if he gets the H1N1 strain?
A: That is not what I would advise. Even though the seasonal viruses were more severe last season, the seasonal and H1N1 viruses weren't around together for any long stretch of time. It is presumed that as they co-mingle, they will share genes and that the H1N1 is likely to become more severe as the season progresses.

Q: If my child gets the H1N1 flu, can't I just have her take Tamiflu and she'll be fine?
A: Tamiflu currently does work well against almost all of the H1N1 viruses recovered in labs, but to keep that sensitivity to Tamiflu alive, giving the medication to everyone with suspected H1N1 is not a good idea. As a matter of fact, only high-risk children (those under 2 or with high-risk conditions such as asthma, diabetes, etc.) should be given Tamiflu. The chances are if your healthy child gets it, she's on her own.

Category: Cold and flu

So I think my kid has the flu - what now?

Wondering when to take your sick child to see her doctor and what kind of treatment to expect? Here are a few cases of flu-like illnesses and how they turned out.

Case 1
Otherwise healthy 8-year-old came in with a one-day history of fever up to 104 degrees, mild headache, head congestion, cough, fatigue and body aches. Dad is concerned this may be the swine flu and wants him assessed. This child's exam is consistent with a flu-like illness and he looks pretty miserable.

In this case, because the child is low risk, I suggested we not bother with the rapid influenza test because it would not change my management, but the father really wanted to know if this was influenza or not. I did the test and it was negative. The dad was relieved, but actually more than 30 percent of the time the H1N1 virus will not be detected by rapid screens so it is still possible this child had influenza. He was sent home with instructions to drink lots of fluids, take Tylenol or Motrin as needed, avoid all aspirin products because of the risk of Reye's syndrome and rest. He was told to return if the fever is still present on day four of illness, if the fever goes away for a day or more and returns or if the child is looking dramatically sicker. I advised that he could return to school once his fever is gone for a day or so and he's feeling better.

Case 2:
An otherwise healthy 10-year-old girl with a baby brother at home comes in with two days of fever to 103, runny nose, cough, fatigue and body aches. Exam reveals nothing more than the cold symptoms she describes.

In this case, I did a rapid test in the office because this child has a sibling who is a high risk. Again the rapid test was negative, but in this case, I sent a second specimen to the lab and put the child on Tamiflu. I instructed the parent to keep her away from everyone until the fever is gone for at least a day and that everyone in the household needs to wash their hands well to avoid spreading this virus to the baby.

Case 3:
It is Dec. 28 and the seasonal and H1N1 viruses are circulating. An unvaccinated 3-year-old comes in with symptoms of fever to 103 degrees for four days, runny nose and cough. The exam reveals an ear infection along with the viral upper respiratory symptoms. Mom is wondering if this is the swine flu.

In this case, even if it is influenza, it is too late to initiate treatment with Tamiflu, so no test was done. Tamiflu needs to be given within the first 48 hours of fever and after that time is no longer effective. We discussed the pros and cons of treating the ear infection with antibiotics and decided to treat her because her fever has been present for so many days.

Case 4:
It is January and seasonal and H1N1 strains are circulating. A 14-year-old with a history of asthma who is on maintenance medications in the winter months comes to the office with a two -day history of fever to 102.5 degrees, significant body aches, fatigue, headache, dizziness and runny nose. Cough has just begun that day. Exam reveals a head cold but no wheezing in his lungs.

In this case, a rapid flu test is done and is positive. Because the rapid test cannot differentiate between H1N1 and the seasonal flu, I cannot know whether or not Tamiflu will help. All of the seasonal strains are highly resistant to Tamiflu but H1N1 remains susceptible to this antiviral (at least for now). Given this child's high risk status due to his asthma, I put him on Tamiflu and hope it is the H1N1 strain that is causing his illness.

In all of these cases, knowing when to do the rapid flu test and when to use Tamiflu to treat is murky. The guidelines make it all seem so clear but the reality of office life rarely follows the absolutes of guidelines. If you suspect your child has influenza but is otherwise low risk, chances are he will not be put on Tamiflu so getting a rapid test done seems unnecessary to me. Whether it is influenza or one of the other winter viruses won't affect treatment. If your child is high risk though, seeking care early will leave more options open.

Category: Cold and flu

When a fever means 'swine flu' and what to do

We all know that the H1N1 virus is ramping up. School is back in session and kids clustered together means germs spread. Parents (and teachers) are worried about this novel virus and as such the phone calls and e-mails to my office are on the rise. The challenge is that many illnesses with fever will not be H1N1 influenza - so how is a parent to know? Here are some tips:

H1N1 influenza, commonly known as the swine flu, presents most often on day one with high fever, sore throat, body aches and headache. By day two, the head cold symptoms (runny nose and cough) are present and some kids will even have diarrhea or vomiting. On the third day, fever is still present and the other symptoms are progressing. The fever will last up to five days (although usually just two-three) and the head cold, cough, fatigue and body aches will last about seven-10 days all together.

This sounds pretty straightforward, but in reality, each person experiences the symptoms differently and lots of these symptoms occur in other noninfluenza illnesses. Because bacterial illnesses such as strep throat can present with fever, sore throat, headache and vomiting, the overlap is huge. Other routine viruses that cause fall colds can also cause all of these symptoms, too, so knowing when to seek care can sometimes be hard to determine.

If your child is considered at high risk to have complications if this febrile illness is influenza, going into the office on day one or two of the illness is essential. High-risk kids are those younger than 5; with asthma, chronic conditions such as diabetes, heart or kidney problems;children with immune-compromising conditions, and siblings of infants under 6 months of age. If your child is not in one of these high-risk categories, it doesn't matter if this illness is influenza or one of the other fall viruses because the management is the same: plenty of fluids, rest and fever reducers. Only children at high risk for complications will qualify to receive the anti-viral medication Tamiflu so making a definitive diagnosis of influenza is only important for those children. The rest of the kids with influenza will have to let nature do its job while parents treat the symptoms.

Got a fever? Who needs to be seen by a doctor:

• Any high-risk child with fever and influenza symptoms should be seen on the first day or two of the illness.
Any child with fever lasting more than three days should be seen.
• Any child with fever and sore throat for a couple of days without head cold symptoms should be seen to rule out strep throat.
• Any child who had fever that went away for a day or more but in whom the fever has returned should be seen.
• Any child who is listless, refusing to eat or drink, dehydrated, or acting very sick should be seen.
• Children at low risk who have fever and flu-like symptoms for fewer than three days do not need to be seen by a doctor.
• Because fever itself is not dangerous, even if your child's temperature is quite high (up to 104 degrees) but your child is drinking and can be made comfortable with fever-reducing medications, he or she doesn't need to see a doctor unless the fever lasts more than three days.

Category: Cold and flu

H1N1 influenza vaccine update

Now that the kids are back in school, the incidence of influenza-like illness is on the rise and parents are asking a lot of questions. Here's what you need to know:

Q: When will the "swine flu" shot be available?
A: In early October, 3 million doses of the nasal mist form of the vaccine will be distributed to state health departments, which will then distribute them to local health departments and physicians offices. The shot form of the vaccine will be available later in the month.

Q: My child hates shots but I will have him get it if need be. Is the nasal mist as good?
A: Actually, the nasal mist confers better immunity in children than the shot version. I would always prefer to give the nasal mist as long as the child doesn't have asthma or significant congestion.

Q: Is the "swine flu" vaccine safe?
A: Yes. The vaccine has undergone the same scrutiny that the seasonal flu vaccine goes through each year before coming to market. It has been tested well and no significant adverse reactions have occurred.

Q: What about the risk of Guillan-Barre (a temporary paralysis seen with the 1976 version of the vaccine) - has that been seen with this version of the "swine flu" vaccine?
A: Any flu vaccine carries a small risk of this, including the seasonal vaccine, but the rate is 1 in 1 million doses and the likelihood of getting influenza and then having serious complications is much higher, so the benefit of the vaccine strongly outweighs the risk.

Q: Does the "swine flu" vaccine contain mercury or other preservatives?
A: Some versions of the vaccine do while others are preservative-free. Children under 3 will receive preservative-free vaccine and older child can on a first-come, first-served basis.

Q: Can family members of an infant younger than 6 months of age get the FluMist (intranasal vaccine)?
A: No. FluMist - whether the H1N1 or seasonal flu version - should not be given to older children if a young infant is in the house. The Flumist is a live virus vaccine and there is a small but real chance of spreading the virus to the baby.

Q: I heard that only one shot will be needed now, is that right?
A: Probably not. Although one shot may be sufficient for adults (the data is still be assessed) for children, especially children under 9, expect to have to receive two doses of the vaccine, each dose given a month apart.

Q: Can the H1N1 vaccine and the seasonal flu vaccine be given on the same day?
A: Yes.

Q: Do we really need the seasonal vaccine or should we just get the H1N1 vaccine?
A: You really do need both to decrease the chances that the seasonal influenza strains will run rampant and have the opportunity to mix with the H1N1 strains to mutate into a more virulent virus.

Q: Can pregnant women get the H1N1 vaccine?
A: Yes - and they should. Pregnant women are at the greatest risk for complications (including death) from this virus. They should also get the seasonal vaccine.

Q: Can the "swine flu" vaccine be given at the same time with other routine vaccinations?
A: Yes.

Q: Can the "swine flu" vaccine be given when the child is sick?
A: As long as your child has been without fever for 24 hours, he or she can get the vaccine. If your child is very congested or has a runny nose, the FluMist cannot be given but the shot can be. The same is true for the seasonal flu vaccine.

For more information and updates on the flu, check out www.flu.gov.

Category: Cold and flu

(Probable) swine flu hits home

Over the weekend I experienced firsthand the H1N1 influenza virus.

It started Friday when I was much more tired than usual despite a good night's sleep. By the evening, I was feverish and had a very upset stomach. All night Friday I tossed and turned with fever and getting up to run to the bathroom. My head was pounding and my nose felt like it was swelling on the inside. By Saturday morning, I knew this was not a normal illness. You see, I don't get sick very often. As a pediatrician for 19 years I have already been exposed to every possible illness and have the immune system of a giant. I get my flu shot every fall religiously, so when I felt like I had been run over by a train Saturday morning I knew something was wrong.

Being a doctor has advantages though, so I went to my office and ran a rapid influenza test on myself. It was quickly positive. This alone doesn't mean I have the swine flu, just that I have influenza of one type or another. This time of year, Influenza B is still all around and even some non-H1N1 strains of Influenza A are circulating, so a positive rapid test alone doesn't mean this is the swine flu. However, knowing I had a flu vaccine last fall and it was very effective at preventing the run of the mill seasonal A and B strains of the influenza virus, chances are this is the swine flu.

I had three confirmed cases of H1N1 in my practice and a fourth probable case so the timing was right, too. The incubation period is about three-five days and my first case was diagnosed about a week before my symptoms started and the next two about four days before my symptoms began.

Given that I am now a probable case, the next question is whether or not I should be treated with Tamiflu. Because I am a health care worker and have asthma I met a couple of the criteria to be treated, so I started the medication Saturday. Even with H1N1, most people don't meet the criteria for treatment. Only people with underlying health conditions such as asthma or diabetes, children under 5 or older adults over 60, essential workers such as health care providers and EMS personnel, or people so seriously ill that hospitalization is likely need treatment. The plan is to let the rest of the infected folks fight through it without using the antiviral medications in the hopes of preventing the medications from becoming ineffective against this strain.

The next issue to confront was my immediate family: Should they be put on Tamiflu to prevent them from getting it because they have a household contact who is (probably) infected? As it turns out, only about 20 percent of household contacts are contracting a flu-like illness from someone with H1N1. So although contagious, it isn't a done deal that everyone will get it. As such, using the same criteria as those used to determine who requires treatment, my kids qualified for prophylaxis because they have asthma, too. I quarantined myself in the guest room and offered my husband the option of prophylaxis. He doesn't have any risk factors, but did decide to take it. Not a perfect medical decision but a real one.

It is now two days into the Tamiflu for me and I can see the light at the end of the tunnel. I am no longer feverish and my fatigue, congestion and body aches are the most significant symptoms. According to the Centers for Disease Control and Prevention, I should stay home from work for a week(!), but that is completely unrealistic for me, a solo practitioner, so I will limit my schedule, keep taking the Tamiflu, and wear a mask for the next few days.