ED visits are up dramatically, community practices are getting flooded, families are anxious over confirmed cases in their local schools, and vaccines are just beginning to arrive. Those were some of the not-so-positive bullets on the current circumstances surrounding the swine flu, or H1N1 virus, reported by hospital, city and state health department officials at a press conference at Hopkins Children’s October 7. As Hopkins Children’s infectious disease specialist Aaron Milstone concluded, “Pediatricians are getting slammed by both the sick and the worried well.”

So, what are community pediatricians to do?

Counsel their patients’ parents to take a deep breath and call before bringing their child into the office or hospital emergency department, answered Milstone. And set up a telephone triage system and information line to keep those visits limited to those who need them.

“They need to have a plan and a way to triage patients so they can do more over the phone and less bringing in patients to the clinic,” Milstone said. “Then they’ll have less of a surge in their clinic.”

The good news, Milstone and others explained, is that the virus is behaving much like typical seasonal flu strains, leaving patients with the usual high fever, headache, sore throat, body aches and, for some, stomach upset. And fortunately the vast majority of afflicted patients experience a speedy recovery simply by doing a few simple things – getting lots of rest, drinking lots of fluids, and taking Tylenol or Motrin to reduce fever.

“The vast majority of cases in the community are doing quite well with mild to moderate flu,” said Anne Bailowitz, Acting Chief Medical Officer for the Baltimore City Health Department. “The exception to the rule is someone being hospitalized.”

Nonetheless, pediatric EDs and pediatric practices have indeed been inundated with not only sick patients but patients who may have some flu-like symptoms but not the flu – or mild-to-moderate flu that doesn’t require a visit. Sitting in a pediatrician’s or ER waiting room, Millstone said, may put children at risk of infecting other patients or catching something they don’t have. Patients who should see the pediatrician are those with underlying chronic conditions like asthma or diabetes, which may be exascerbated by the flu and place them at greater risk of bacterial infections. 

This presents another issue for pediatricians – the need to consider early anti-viral therapy for patients with this particular strain of flu, especially those with underlying chronic conditions. “In general,” Milstone said, “pediatricians aren’t very accustomed to using anti-virals for influenza.”

Parents need to be proactive, too, and partner with their pediatrician, said Lucy Wilson, Chief of the Center for Surveillance and Infection Prevention and Outbreak Response with the Maryland Department of Health & Mental Hygiene: “It is not unreasonable to contact your pediatrician and discuss a plan. ‘If my child has these symptoms, what should I do? Get medicine? Come in for an office visit?’ Go to the ED?’ Pediatricians know your child and his or her medical condition, and can give the best advice on how to guide you.”

Hopkins Children’s emergency medicine physician Mitchell Goldstein said that pediatricians in the community have established triage protocols to manage the influx of cases – protocols that are key for hospitals like Hopkins Children’s to effectively treat the more serious cases of H1N1: “If patients are being triaged and funneled through primary care and not ending up in our ED, then we’ll have more capacity to take care of the kids that are falling into the extremes.”

The Baltimore City Health Department, the Maryland Department of Health and Mental Hygiene, the Centers for Disease Control and Prevention, and the American Academy of Pediatrics provide information for pediatricians on triage algorithms, diagnostic testing, H1N1 vaccination, and guidance on antiviral treatment of patients with H1NI. Johns Hopkins Medicine also provides information on H1N1 and seasonal flu, preventive measures like hand hygiene and cough etiquette, and updates on vaccine availability.