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Pediatric - Swine Flu (H1N1)

Swine flu (H1N1 flu)

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Does this describe your child's symptoms?

  • Swine Flu (H1N1) is a viral infection of the nose, throat, trachea, and bronchi
  • You think your child has Swine Flu because other family members have it
  • You think your child has Swine Flu and it's prevalent in the community

Symptoms of Swine Flu:

  • The symptoms of Swine Flu are the same as those seen with regular, seasonal influenza
  • The main symptoms are fever, cough, sore throat and runny nose
  • FEVER must be present to make this diagnosis (CDC)
  • Other common symptoms are muscle pain, headache and fatigue
  • Some people also have vomiting and diarrhea, but never as the only symptom

Diagnosis: How to Know Your Child Has Swine Flu (H1N1 Flu)

If Swine Flu (H1N1 Flu) is widespread in your community and your child has Swine Flu symptoms with a fever, then he or she probably has Swine Flu. You don't need to get any special tests. You should call your doctor if your child is HIGH-RISK for complications of the flu (see the following list). For LOW-RISK children, you don't need to call or see your child's doctor, unless your child develops a possible complication of the flu. (see the "When to Call Your Doctor" section).

HIGH-RISK Children for Complications From Swine Flu (CDC)

Children are considered HIGH-RISK for complications if they have any of the following conditions:

  • Lung disease (such as asthma)
  • Heart disease (such as a congenital heart disease)
  • Cancer or weak immune system conditions
  • Diabetes, sickle cell disease, OR kidney disease
  • Diseases requiring long-term aspirin therapy
  • Pregnancy
  • Healthy children under 2 years old are also considered HIGH-RISK (CDC: September 2009)
  • Note: All other children are referred to as LOW-RISK

Swine Flu (H1N1 Flu): General Information

  • Cause: The H1N1 virus is a combination virus that contains genes from swine flu, avian flu and human flu. Cases of swine flu in humans were first detected in Mexico during March 2009. An outbreak of swine flu in humans occurred in the U.S. and Canada in April 2009. By June 2009, the WHO declared it a global pandemic.
  • Severity of Symptoms: Symptoms of swine flu can be mild to severe, just as with regular human flu. Thus far in the US and Canada, the symptoms have generally been mild to moderate.
  • Transmission: The swine flu virus is spread via airborne droplets, from sneezing and coughing, just like other influenza viruses. It also can be transmitted by hands contaminated with secretions. It no longer has anything to do with pigs; it is only spread person-to-person. Swine flu is NOT transmitted by eating pork.
  • Expected Course: Like regular flu, the fever lasts 2-3 days, the runny/congested nose 1-2 weeks and the cough 2-3 weeks. With some flu viruses, the fever lasts 4 or 5 days.
  • Contagious Period: A person is contagious for 1 day prior to and for 7 days after the onset of symptoms (e.g., the fever and cough)
  • Incubation Period: After exposure, a person will come down with swine flu symptoms in 4 to 6 days (5 days on the average). An outer limit rarely could be 7 days. This virus has a longer incubation period than seasonal flu (1 to 3 days).
  • Attack Rate: The chance of getting swine flu depends on the degree of exposure and is always higher for household contacts. While the attack rate is unknown for this virus, it should be high (20-30%) because there is no natural immunity to swine flu viruses.
  • Diagnostic Test: At this time, testing is mainly indicated for patients with severe disease (CDC, May 2009). Accurate testing takes 2 or 3 days.
  • Treatment: See below.
  • Prevention: Prevention measures include avoiding sick people and crowds (social distancing). Hand washing is very important. A complete list of preventive tips is available on the CDC website.
  • Vaccine: No vaccine is currently available to prevent Swine Flu. The vaccine should become available in late fall 2009. The yearly seasonal flu vaccine offers no protection against Swine Flu.

Complications of Swine Flu

Children who develop the following complications need to be seen by their doctor:

  • Ear infections and sinus infections occur in 10% of children
  • Pneumonia: both viral and secondary bacterial (mainly in HIGH-RISK children)
  • Influenza-induced flare-ups in those with asthma
  • Dehydration, often due to a severe sore throat that limits fluid intake
  • Muscle pains (viral myositis) in the legs can be severe and cause limping or refusal to walk

Prescription Antiviral Drugs for Swine Flu

  • For optimal results, antiviral drugs (such as Tamiflu) should be started within 48 hours of the start of flu symptoms. They can be started later in some cases.
  • The CDC recommends they be used for: 1) any patient with severe symptoms AND 2) for all HIGH-RISK children (see that list) with any flu symptoms.
  • The CDC doesn't recommend antiviral drugs for LOW-RISK children with mild or moderate Swine Flu illness.
  • Their benefits are limited: they usually reduce the time your child is sick by 1 to 1.5 days. They reduce the symptoms, but do not cure the disease.
  • Side effects: Vomiting in 10% of children.

Return to School

  • If you or your child get sick with Swine Flu, the CDC recommends that you stay home from work, school or child care until at least 24 hours after the fever is gone (CDC: August 2009).

Internet Resources For U.S.

  • Centers for Disease Control and Prevention, United States (CDC)
  • For most up to date information, visit CDC's Swine Flu web site at:

If not, see these topics
  • Seasonal Influenza suspected, See INFLUENZA
  • Swine Flu exposure (Close Contact), but NO symptoms, See SWINE FLU (H1N1 FLU) EXPOSURE
  • Cough and NO exposure (Close Contact) OR cough begins over 7 days after Swine Flu exposure, See COUGH
  • Cold symptoms and NO exposure (Close Contact) OR cold begins over 7 days after Swine Flu exposure, See COLDS
  • Sore throat and NO exposure (Close Contact) OR sore throat begins over 7 days after Swine Flu exposure, See SORE THROAT
  • Influenza vaccine reaction suspected, See IMMUNIZATION REACTIONS

When to Call Your Doctor

Call 911 Now (your child may need an ambulance) If
  • Severe difficulty breathing (struggling for each breath, making grunting noises with each breath, unable to speak or cry because of difficulty breathing)
  • Lips or face are bluish when not coughing
Call Your Doctor Now (night or day) If
  • Your child looks or acts very sick
  • Difficulty breathing (under 1 year old) not relieved by cleaning the nose
  • Difficulty breathing (over 1 year old) present when not coughing
  • Breathing becomes very rapid
  • Lips or face have turned bluish during coughing
  • Wheezing (tight, purring sound with breathing out)
  • Stridor (harsh sound with breathing in)
  • Ribs are pulling in with each breath (retractions)
  • Dehydration suspected (no urine for more 8 hours AND very dry mouth, no tears, ill-appearing, etc.)
  • Age under 12 weeks with fever above 100.4° F (38.0° C) rectally (Caution: Do NOT give your baby any fever medicine before being seen)
  • Fever over 104° F (40° C) and not improved 2 hours after fever medicine
  • Your child is HIGH-RISK for complications of Swine Flu (such as age under 2 years OR underlying heart disease or lung disease, OR weak immune system, etc) (See that list)
Call Your Doctor Within 24 Hours (between 9 am and 4 pm) If
  • You think your child needs to be seen
  • Continuous (nonstop) coughing
  • Age under 1 month old with any cough
  • Age 1 to 3 months with a cough for more than 3 days
  • Earache or ear discharge also present
  • Sinus pain (not just congestion) is also present
  • Fever present for more than 3 days
  • Fever returns after going away for more than 24 hours
Call Your Doctor During Weekday Office Hours If
  • You have other questions or concerns
  • Age over 6 months and needs flu shot
  • Coughing has kept home from school for 3 or more days
  • Nasal discharge lasts over 2 weeks
  • Cough lasts more than 3 weeks
  • Swine Flu symptoms last over 3 weeks
Parent Care at Home If
  • Probable Swine Flu with no complications, your child is LOW-RISK, and you don't think your child needs to be seen
  • Tamiflu Questions
  • Prevention of Swine Flu

Treatment for Swine Flu Symptoms
  1. Reassurance:
    • Since Swine Flu is widespread in your community and your child has flu symptoms (cough, sore throat, runny nose) with fever, your child probably has Swine Flu.
    • Special tests are not needed.
    • You don't need to call or see your child's doctor unless your child develops a possible complication of the flu (such as an earache or difficulty breathing).
    • For healthy people, the symptoms of Swine Flu are similar to those of the common cold.
    • With flu, however, the onset is more abrupt and the symptoms are more severe. Feeling very sick for the first 3 days is common.
    • The treatment of Swine Flu depends on your child's main symptoms and is usually no different from that used for other viral respiratory infections.
    • Bed rest is unnecessary.
  2. Runny Nose with Profuse Discharge - Blow or Suction the Nose:
    • The nasal mucus and discharge is washing viruses and bacteria out of the nose and sinuses.
    • Blowing the nose is all that's needed. For younger children, use nasal suction.
    • Apply petroleum jelly to the nasal openings to protect them from irritation. ( Cleanse the skin first.)
  3. Nasal Washes To Open a Blocked Nose:
    • Use saline nose drops or spray to loosen up the dried mucus. If not available, can use warm tap water.
    • STEP 1: Instill 3 drops per nostril. (Age < 1 year, use 1 drop and do one side at a time)
    • STEP 2: Blow (or suction) each nostril separately, while closing off the other nostril. Then do other side.
    • STEP 3: Repeat nose drops and blowing (or suctioning) until the discharge is clear.
    • Frequency: Do nasal washes whenever your child can't breathe through the nose.
    • Saline nasal sprays can be purchased OTC
    • Saline nose drops can also be made: add 1/2 tsp of table salt to 1 cup (8 oz) of warm water
    • Reason for nose drops: suction or nose blowing alone can't remove dried or sticky mucus.
    • Another option: use a warm shower to loosen mucus. Breathe in the moist air, then blow each nostril.
    • For young children, can also use a wet cotton swab to remove sticky mucus.
    • Importance for a young infant: can't nurse or drink from a bottle unless the nose is open.
  4. Cold Medicines:
    • Cold medicines are not recommended at any age. (Reason: they are not helpful. They can't remove dried mucus from the nose. Nasal washes can.)
    • ANTIHISTAMINES are not helpful, unless your child also has nasal allergies.
    • DECONGESTANTS: OTC oral decongestants (Pseudoephedrine or Phenylephrine) are not recommended. Although they may reduce nasal congestion in some children, they also can have side effects.
    • AGE LIMIT: Before 4 years, never use any cough or cold medicines. (Reason: unsafe and not approved by FDA) (Avoid multi-ingredient products at any age.)
    • NO ANTIBIOTICS: Antibiotics are not helpful, unless your child develops an ear or sinus infection.
  5. Homemade Cough Medicine:
    • Before 1 year of age, only use warm clear fluids (e.g., water or apple juice) to treat the cough. Dosage: 1-3 teaspoons (5-15 ml) four times per day when coughing. Avoid honey.
    • After 1 year of age, use Honey 1/2 to 1 tsp (2 to 5 ml) as needed as a homemade cough medicine. It can thin the secretions and loosen the cough. (If not available, can use corn syrup.) Drugstore cough medicines are not as helpful as honey.
    • After 6 years of age, use Cough Drops to coat the irritated throat. (If not available, can use hard candy.)
  6. Sore Throat Relief: For mild sore throat, use warm chicken broth over 1 year old and hard candy over 6 years old. For throat pain more than mild, Ibuprofen is very effective (see Dosage table).
  7. Fluids: Encourage adequate fluids to prevent dehydration.
  8. Fever Medicine:
    • For fever above 102° F (39° C) or discomfort, use acetaminophen or ibuprofen (See Dosage table)
    • AVOID ASPIRIN because of the strong link with Reye's syndrome.
    • FOR ALL FEVERS: Give cold fluids in unlimited amounts. Avoid excessive clothing or blankets (bundling).
  9. Pain Medicine: For pain relief (e.g., muscle aches or headaches), give acetaminophen every 4 hours OR ibuprofen every 6 hours as needed. (See Dosage Table)
  10. Humidifier: If the air in your home is dry, use a humidifier. Moist air keeps the nasal mucus from drying up.
  11. Prescription Antiviral Drugs for Influenza:
    • For optimal results, antiviral drugs (such as Tamiflu) should be started within 48 hours of the onset of flu symptoms. They can be started later in some cases.
    • The CDC recommends they be used for any patient with severe symptoms AND for all HIGH-RISK CHILDREN (see that list).
    • The CDC doesn't recommend antiviral drugs for LOW-RISK children with mild or moderate Swine Flu illness.
    • Their benefits are limited: they usually reduce the time your child is sick by 1 to 1.5 days. They reduce the symptoms, but do not eliminate them.
    • Side effects: Vomiting in 10% of children.
  12. Contagiousness and Return to School:
    • Symptoms usually start within 4-6 days of exposure to a person with Swine Flu (7 days is an outer limit).
    • Your child can return to child care or school after the fever is gone for 24 hours and your child feels well enough to participate in normal activities. (CDC, August 2009).
  13. Call Your Doctor If:
    • Breathing becomes difficult or rapid
    • Retractions (pulling in between the ribs) occur
    • Dehydration occurs
    • Earache or sinus pain occurs
    • Fever lasts over 3 days
    • Nasal discharge lasts over 14 days
    • Cough lasts over 3 weeks
    • Your child becomes worse
  14. Expected Course: The fever lasts 2-3 days, the runny nose 7-14 days and the cough 2-3 weeks.
Tamiflu Questions
  1. Treating Swine Flu - Tamiflu:
    • Tamiflu can reduce symptoms of Swine Flu illness.
    • Indications: Severe symptoms OR underlying health problems (HIGH-RISK group)
    • For HIGH RISK children, call your doctor at the start of flu symptoms.
    • Most patients have mild to moderate symptoms and Tamiflu treatment is not necessary.
    • Unnecessary overuse of Tamiflu causes resistant strains of the virus. (8/2009 some resistance has occurred)
    • Tamiflu also has side effects: Vomiting in 10% of children.
  2. Preventing Swine Flu - Tamiflu:
    • The drug Tamiflu may help prevent Swine Flu (prophylaxis).
    • Indications: Recent close contact with person with confirmed Swine Flu AND the exposed person is in HIGH-RISK group (see that list)
    • It is effective only while your child is taking it and ceases once your child stops taking it.
    • Your child should only take Tamiflu if your child's physician recommends it.
  3. Personal Stockpiling of Tamiflu - Not Recommended:
    • Definition: Some people request a prescription for Tamiflu for all family members just in case they come down with flu symptoms. They currently are well and have not been exposed to Swine Flu.
    • Doctors are opposed to this practice, as is the CDC and your State's Public Health Department.
    • The supply of Tamiflu is limited and needs to be kept available for patients who have severe symptoms OR have underlying health problems.
Prevention of Swine Flu
  1. How to Protect Yourself From Getting Sick:
    • Wash hands often with soap and water.
    • Alcohol-based hand cleaners are also effective.
    • Avoid touching the eyes, nose or mouth. Germs on the hands can spread this way.
    • Try to avoid close contact with sick people.
    • Try to avoid unnecessary visits to the ER and urgent care centers because those are the places where you are more likely to be exposed to Swine Flu, if you don't have it.
  2. How To Protect Others - Stay Home When Sick:
    • Cover the nose and mouth with a tissue when coughing or sneezing.
    • Wash hands often with soap and water, especially after coughing or sneezing.
    • Limit contact with others to keep from infecting them.
    • Stay home from school or work for at least 24 hours after the fever is gone (CDC, August 2009).
  3. Face Masks:
    • Face masks refer to disposable masks labeled as surgical or dental masks.
    • For healthy people, face masks may help reduce the risk of getting swine flu in crowded settings, if swine flu becomes prevalent (CDC).
    • Avoiding sick people and frequent handwashing are more effective preventive measures.
    • At the present time, face masks are not needed in the U.S. for healthy people. (Possible exception: households where a family member has Swine Flu).
    • Sick people should wear a face mask if they must leave their home to seek medical care.
  4. Swine Flu Vaccine:
    • The Swine Flu vaccine is in development.
    • It should be available by late fall 2009.
    • The CDC will provide guidelines about who should receive the vaccine.
    • This is the best way to prevent Swine Flu.
  5. Anti-Viral Medication:
    • Tamiflu can be used for prevention following close contact with a person who has Swine Flu.
    • It is only recommended for HIGH-RISK patients (CDC).

And remember, contact your doctor if your child develops any of the "Call Your Doctor" symptoms.

Disclaimer: This information is not intended be a substitute for professional medical advice. It is provided for educational purposes only. You assume full responsibility for how you choose to use this information.

Author and Senior Reviewer: Barton D. Schmitt, M.D. Clinical content review provided by Senior Reviewer and Healthpoint Medical Network

Last Review Date: 8/9/2009

Last Revised: 10/12/2009

Content Set: Pediatric HouseCalls Online

Copyright 1994-2009 Barton D. Schmitt, M.D.

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