Each fall, classrooms full of kids become smoldering hotpots of colds, flu, stomach viruses, and germs that fester and spread. Doctors expect this; in fact, it’s how young bodies build immunity against these illnesses. But last year was an astonishing exception, with common respiratory illnesses vanishing as the pandemic forced children in the U.S. and other countries to give up their team sports, restrict their play dates, and learn in isolation from home.
So, what will this year’s cold and flu season be like?
Doctors can’t say for sure how a lost year of immunity-building will change things, but many are preparing for what could be an extremely busy season. “From a clinician’s point of view, we might, all of a sudden, have a higher volume of children than usual coming in with all these illnesses,” says Carlos Oliveira, MD, PhD, a Yale Medicine pediatric infectious diseases specialist. In normal years, even if a child isn’t infected with a virus, exposure to it can make their immunity to that virus stronger—and some children who would have started daycare last year have had little to no chance to build immunity, he says.
Of course, all sorts of factors could impact how the upcoming season will go. For instance, it’s difficult to predict how many children will get their annual flu vaccine—preliminary estimates suggest flu vaccination uptake in the 2020-21 season was lower among U.S. children than in the previous season, according to the Centers for Disease Control and Prevention (CDC).
Another question is how many children will wear masks in school at a time when not every jurisdiction is mandating them. And then there is the challenge of diagnosing sick kids when the highly contagious COVID-19 Delta variant is causing symptoms similar to other respiratory viruses.
We asked Yale Medicine doctors for advice on how to keep children healthy in the coming months.
1. Is it the flu, COVID, or something else? When to call the pediatrician
Diagnosing a respiratory illness in a child can be challenging when COVID-19 is circulating along with other viruses and illnesses like bronchitis, strep throat, and pneumonia (which can be a complication of the flu).
A surprising concern this year has been the rise of respiratory syncytial virus (RSV), a virus that usually causes cold-like symptoms in children. It has landed up to 60,000 children in the hospital in pre-pandemic winters—the season when it is most common—but seemed to disappear last winter. RSV then resurfaced in the Southern Hemisphere. This past spring, the CDC issued a health advisory about increased inter-seasonal RSV activity across parts of the Southern United States. By the summer, off-season cases were spiking in places like Brooklyn, New York. “We’re learning about this along with everybody else,” says Dr. Oliveira.
All of these illnesses share at least some symptoms. In the case of flu and COVID-19, the CDC has a list of common symptoms, and they vary from person to person: Some children have no symptoms at all; others have cases that range from asymptomatic to mild to severe. Flu symptoms can appear anywhere between 1 to 4 days after infection—so parents often have no idea if a child has been with someone who is contagious. People who have been infected with COVID-19 usually don’t experience symptoms until about 5 days after infection, but symptoms can surface anytime between 2 and 14 days, according to the CDC.
Symptoms common to flu and COVID-19 include:
- Fever or feeling feverish/having chills
- Shortness of breath or difficulty breathing
- Fatigue (tiredness)
- Sore throat
- Runny or stuffy nose
- Muscle pain or body aches
- Vomiting and diarrhea
- Change in or loss of taste or smell, although this is more frequent with COVID-19
It may be unrealistic to consult the pediatrician about every cough or sneeze, but parents can assess the situation and take the appropriate steps, says Magna Dias, MD, a Yale Medicine pediatrician and chair of pediatrics for Bridgeport Hospital.
“What you should do, if your child doesn’t look alarmingly sick, is bring them home, isolate them from other family members, if possible, and call the pediatrician's office,” says Dr. Dias. The pediatrician may direct you to get your child tested for COVID-19. “If it is COVID-19, that isolation period is going to be much longer, potentially, than the few days that the child may have symptoms,” she says. Before the pandemic, it was reasonable to send a child back to school once symptoms subsided. “You can't do that anymore,” she says.
Mild colds or viruses may start to get better in a few days, but if symptoms get worse, the doctor might want to test your child for the flu, which may benefit from treatment; or consider testing for RSV. Dr. Dias says testing for RSV is done mostly for surveillance purposes and to help determine whether to isolate a child who is in the hospital to keep the virus from spreading. “At the hospital, we sometimes need to have patients who come from different households in double rooms,” she says. “At home, if you have a sibling who is high risk—meaning they have a chronic medical condition or are a very young baby—you should separate them as much as possible. But often, they’ve already been exposed to the virus from living together.”
There are many different tests available now for COVID-19, and there are tests that require just one sample to determine whether a child has COVID-19, flu, and RSV; they are expected to become available closer to flu season.
2. The flu vaccine is important for kids
The CDC recommends every child who is 6 months or older get a flu vaccine appropriate for their age by the end of October, although it may be available earlier.
Flu can be serious and even deadly in children; it was remarkable that in the 2020-21 flu season, there was only one report of a child who died of the flu, according to preliminary reports from the CDC. The agency attributed the low flu activity to all the COVID-19 mitigation strategies we had in place last year: staying home, hand washing, school closures, reduced travel, increased ventilation of indoor spaces, and physical distancing. The tally for pre-pandemic seasons was quite different: Since 2004-2005, flu-related deaths in children reported to CDC during regular flu seasons have ranged from 37 to 199, depending on the year.
Before the pandemic, it was reasonable to send a child back to school once symptoms subsided. You can't do that anymore. Magna Dias, MD, a Yale Medicine pediatrician
The CDC notes that in most cases of child flu deaths (about 80%), the children had not been fully vaccinated against the flu, meaning they either had not received the shot or the illness arose before immunity kicked in. While it is true that the flu shot changes year to year—based on what experts believe will be the predominate strains—it’s not always a perfect match. But Dr. Oliveira emphasizes that even so, the vaccine remains a strong tool for preventing the flu, and it can mean the difference between mild and severe illness in a child who does get sick.
This year, the flu vaccine also could help reduce confusion, Dr. Dias says. “When a child gets sick, you wonder, ‘Is this flu? Is this COVID? Can I send my kid to school? Can I go to work?’ It’s a disruptor. Vaccination is safe and keeps disruption to a minimum. I think it is one way to allow our kids to remain in school safely,” she says.
3. Make sure your kids understand how to take precautions
Parents should talk to their children about precautions and make sure they have a clear understanding of them. Children should know about:
- Washing hands: This means washing hands properly for at least 20 seconds with soap and water or cleaning them with hand sanitizer containing least 60% alcohol. The CDC has recommended this for COVID-19, although it says touching surfaces is not the main way the virus spreads, but it is a key precaution against colds and flu. It’s also important to disinfect surfaces as much as possible, says Dr. Dias, noting that RSV is a virus that lives on surfaces for a long time. “You could touch a surface that a child with RSV has touched, and you could catch RSV from that,” Dr. Dias says.
- Wearing a face mask. Not only can mask-wearing prevent transmission of COVID-19, but it protects against other respiratory viruses as well. Last winter, when rates of mask use were high, the number of children in the hospital with flu and other non-COVID-19 respiratory diseases was historically low, Dr. Dias says. “We didn't see flu. We saw very, very little RSV. Then the masks came off, and we saw these things all over again. So, the science is clear on this,” she says.
They should also know to avoid people who are sick and to stay home if they feel unwell, not only to take care of themselves, but also to prevent spreading illness to others, the doctors say. The CDC’s advice for parents also recommends asking the child’s school how they separate sick students and staff from others, finding out who cares for sick children in the school until they can go home, and inquiring about the absentee policy for sick students and staff.
Parents should be especially vigilant if they have a child who is at high risk for getting sick from a respiratory illness and developing complications, which can range from sinus problems and ear infections to pneumonia and brain dysfunction. At-risk groups include children younger than 5 years old and especially those younger than 2, as well as those with chronic medical conditions such as asthma, diabetes, or heart disease.
“This is a special group, and it's definitely going to be challenging, as a parent, to know what the right thing is to do,” Dr. Dias says. “It's hard to give a generic answer to this, except to say, ‘Discuss it with your pediatrician. Take a look at the specific circumstances and try to make a plan to keep that child safe,’ because that is a kid who's going to be at higher risk for complications, as well as for catching it.”
4. You can reduce family anxiety by keeping calm
Many parents are anxious about what the fall will bring—and understandably so. Many are worried about the “unknowns,” Dr. Dias says. They don’t know if there will be vaccination and mask-wearing mandates, and if other families will comply. Nor do they know whether they are facing another year where social isolation will take a toll on their children’s mental health.
The first step in relieving any anxiety kids have is to be open to conversation, she adds. Parents can start a discussion with open-ended questions and by asking their children how they're feeling. “We think we know what's in their heads and what they're worried about, but sometimes they’re thinking about things that are not on our radar at all,” Dr. Dias says.
Parents can also model positive ways to think about taking steps to stay healthy in the pandemic. “Kids are pretty flexible and adaptable, and they take their cues from us, so we can reassure them—while remaining realistic, because we know it's not all rainbows and unicorns right now,” Dr. Dias says. “Parents can say, ‘Just understand that we're working to keep you safe.’”