Here’s what parents should do about RSV, flu, and COVID, too

What to expect, at-home treatments, and when to go to the ER.

Dr. Caitlyn Berg, a pediatrician, holds her infant daughter Natalie, who contracted RSV, at their home in Mount Zion, Ill., on Oct. 30, 2022.JAMIE KELTER DAVIS/NYT

A stream of mucus has poured forth from my kindergartner’s nose since late September. His friend was out for a week with RSV. At the same time, the threat of COVID — remember COVID? — still looms. Also: Don’t forget the flu! Meanwhile, headlines about overcrowding in emergency rooms make the prospect of getting sick even scarier. And it’s not even Thanksgiving.

What next? Two experts — Dr. Kristin Moffitt, a pediatric infectious disease physician at Boston Children’s Hospital, and Dr. Robyn Riseberg, founder of Boston Community Pediatrics — patiently answered my nagging questions. Grab your tissues, pour yourself a NyQuil, and read on.

On just how bad this winter could be: After years of distancing and masking to reduce COVID transmission, germs are now having a mask-free reunion.

“This is the worst September and October that I’ve ever seen in my career. We’re seeing COVID, we’re seeing the flu [earlier than I’ve ever seen it], and we’re seeing RSV,” says Riseberg, as well as common colds.

“What we’re seeing, at least at Boston Children’s Hospital — which I think is pretty reflective of what’s happening nationally in pediatric health care — is just a ton of respiratory viral infections. Part of this is definitely because we’re seeing more RSV infections in a shorter period of time right now than we typically do in an RSV season,” Moffitt says.

Normally, the season stretches from November through March, with a peak in January or February. Moffitt says a peak is happening now. She’s also starting to see an uptick in flu. Kids under 3, who have spent most of their lives in masks and might not have been exposed to other germs, are especially vulnerable. Moffitt calls this an “immunity gap”: Their reserves just aren’t as strong.

Candid conversations for parents.GLOBE STAFF

On how to distinguish between COVID, flu, and RSV: Many pandemic-hardened parents now assume that every sniffle is COVID, but there are plenty of germs to go around! All three illnesses can present similarly: coughs, fevers, runny noses.

A pediatrician can test for these viruses, of course. But if you’re in the at-home detective stage, each illness does have potential nuances. Riseberg says she often sees the highest fevers with the flu. RSV can be characterized by lower respiratory symptoms, with faster breathing and wheezing. According to the Centers for Disease Control and Prevention, severe infections may cause bronchiolitis, an inflammation of the small airways in the lung, and pneumonia. Kids 6 months and under are the most likely to be hospitalized for breathing support and hydration.

As for COVID, “In general, kids have not had the most profound COVID symptoms,” Riseberg says. “But, though I think kids are still faring well [with COVID], we still want to prevent it. We don’t know what the long-term effects of COVID are.”

In most cases, treatment will look the same regardless of illness.

“Knowing the cause of the respiratory viral infection doesn’t typically impact care unless your child has a compromised immune system or an underlying health condition that puts them at risk of more severe infection,” Moffitt explains. “In those cases, people should be in contact with their pediatrician fairly early on in the course of symptoms so that they can have a plan in place. Otherwise, most of these infections can be managed at home.”

On what at-home management entails (besides Amazon Prime and iPads): If your child does come home sick, it can’t hurt to take a COVID antigen test on the first day of symptoms. If symptoms are the same on the second day, test again.

“Not all COVID infections are positive on home tests on the first day of symptoms. If two tests in a row have been negative, then it’s most likely that your child is experiencing a respiratory viral infection with something other than COVID-19,” Moffitt says.

In all cases, fluids are key. (Moffitt likes Pedialyte mixed with water, and popsicles, which she says are actually a popular ER hydration remedy.) If your child has trouble blowing their nose, and what child doesn’t, try a bulb aspirator. Cool mist humidifiers also help with congestion and breathing. Sanitize frequently touched surfaces, where viruses thrive. And, even though it’s hard, try to keep sick older kids away from healthy infant siblings.

On when to seek urgent medical help: “Signs of dehydration or signs of increased work of breathing” require immediate care, Moffitt says. Especially for babies, this could look like fast breathing, the use of extra muscles under the ribs or collarbone to breathe, or grunting and flared nostrils. If your child isn’t able to say the alphabet without gasping or isn’t drinking enough to urinate once every six hours, also seek immediate care. And, if your child has been coughing for more than a week (juicy or dry), if a cough gets progressively worse, or if a fever persists for more than five days, call the doctor.

Popsicles are a great way to stay hydrated.Wild Pops

On the ER conundrum: These places are packed. Doctors are stretched thin. Wait times are long. What’s going on? Riseberg theorizes that many people became accustomed to heading straight to the ER with COVID symptoms. Of course, if your child is in acute distress, get urgent help. But don’t forget about your pediatrician.

“I think people got used to going to urgent care or going to the ER, and that is not at all what I recommend. I always say, ‘If you think you’re going to the ER, you should call your pediatrician,’” she says, who could either see you in person, consult over the phone, or offer a video visit.

“We want to make sure that the people who are ending up in the ER are the people who absolutely need to be seen by the ER,” she says.

If you do head to the ER and your child has a fever, Moffitt suggests trying to bring it down with acetaminophen or ibuprofen in advance. This surprised me: Do you really want to mask a symptom?

“Children look even sicker than they really are when they have a fever,” Moffitt says. “If your child has a fever when they’re being evaluated in the ER, one of the first things they’re going to do is treat it, because a lot of symptoms improve when the fever goes down. Part of the body’s natural response to having a fever is to breathe faster or to look flushed.”

On reducing transmission: First, the obvious: There are vaccines for COVID and flu, and both doctors stress the importance of staying up to date with shots, especially before seeing extended family during the holidays.

Next, “Do not underestimate the importance of hand-washing,” Riseberg says. “I’m also a believer in getting all the germs out when kids come home from school: Change their clothes; maybe give them their bath,” she says. And it’s never too early to teach kids to cough or sneeze into their arms.

Another silver lining (or not): People are most infectious right before they become symptomatic, Riseberg says. So, if a small child does cough all over you at drop-off, take heart: They were probably contagious before, and you didn’t even know it.

“That’s not to say that they’re not infectious, but probably less so,” she says.

On masking when most people aren’t: It can’t hurt, and it really might help.

“The methodology for studying respiratory virus transmission has gotten a lot better, but those are still tough studies to do, because there are a lot of variables at play,” Moffitt says. “What I would say is, if you have a child who is old enough to comfortably wear a well-fitting mask, and to keep it on without fidgeting with it, it can be effective at reducing the likelihood of becoming infected with a respiratory virus if they’re within six feet of someone who’s infected.”

Good luck out there!