Viral infections are the bread and butter of pediatric practice. For those that care for children, learning the art of deciphering which child is really sick and which one isn’t, which one has a possible bacterial infection and which one is viral has been the crux of practice. But a simple respiratory infection is no longer so simple. Layered now with such issues like altered appearances of previous seasonally based viral infections and constant-COVID-concerns has varied the clinical considerations in practice. How do these infections present in the clinical setting?

Here is the peds prototype: A two-year-old child comes into the office with a goopy nose, slight cough, low-grade fever, perhaps a sore throat and a decreased appetite. This child can present with variations in age, degree of fever, cough particulars and may exhibit some aspect of a gastrointestinal complaint, filling the schedule slots daily. However, the first questions one might have initially posed have morphed. Is it COVID? Do they need a PCR swab? Does the rest of the family need to be tested/quarantined? When can they return to childcare/preschool? Ready to bring out a guitar and my scratched Peter, Paul and Mary 45 (a nod to all the old vinyl record collectors), “Where have all the common colds gone…,” I sing along with a sigh and the acknowledgment that children, disease states, and our practices are evolving.

A Viral Overview

There are some organisms that have patterns and findings specific to that organism, while others vary depending on the age and the immune status of the child. Due to aggressive vaccine campaigns in many US states, some common viral infections of childhood may be absent, or present at later ages and varied virulence patterns when vaccine-induced immunity wanes.

The typical child can have anywhere from four-to-eight respiratory infections per year, varying with factors such as age, numbers of siblings, school exposures, second-hand smoke and co-morbidities (i.e., eczema).¹ Due to the changing immune function of children based largely on diets filled with industrial and processed food and pesticides, immunocompetence has also changed with varying presentations of immunodeficiency, either primary or secondary as well as states of chronic inflammation.² However, there are still common features of the most prescient viral infections with some of the more usual viruses discussed below.

Respiratory Syncytial Virus (RSV)

Previously mostly occurring in the winter, RSV is now circulating year round. It typically presents as a cold-like illness, but this is the nasty virus that can descend into the chest and cause bronchiolitis or pneumonia. This is a particularly problematic infection for young infants especially premature, those younger than three months, and those with chronic heart and/or lung disease. Apnea may be the only finding in very young infants.³ When young infants are affected with RSV, they may go on to develop recurrent wheezing.

These RSV-infected children usually present with rhinorrhea and a decreased appetite. This is a Pediatric Pearls reminder of the value of the follow-up call/email since the cough may develop two-to-three days later after the onset of the goopy nose, with or without wheezing (which may affect 20-30% of infected infants). Fever may or may not be present. Most children acquire the primary infection within the first year of life and later reinfection is possible. The advent of the rapid office antigen-based testing for RSV has tremendously improved clinical practice, especially since it has allowed us to gear away from complex lab techniques previously utilized such as immunofluorescence assays, cell cultures, and nucleic acid amplification.⁴

There is now a drug therapy recommended by the American Academy of Pediatrics for prophylaxis to prevent hospitalization for high-risk infants using monoclonal antibody (Palivizumab).⁵ However, for routine infections in normal children there are many homeopathics available that are symptom-based depending on the specifics of the features of individual cases. Most of the parents I’ve worked with were advised to get a copy of Dana Ullman’s Homeopathic Medicine for Children and Infants so that they may develop the skills necessary to care for their children with minor illnesses.⁶

Adenovirus (ADV)

Adenovirus has become a popular topic since their recent release in viruses-as-vaccine-vectors to shuttle a gene from CoV-2 into cells to produce spike proteins. There are many types of adenoviruses, but from the clinical/lab perspective, they are grouped together. They are not only responsible for respiratory illnesses (common cold), but can also cause conjunctivitis, infection along the bronchial tree (croup/bronchiolitis/pneumonia), and gastrointestinal infection (GI). While common in the winter, they now seem to have emerged throughout the year.

Any age group can be infected with adenovirus, but it is more likely to occur between six months to two years, especially in children in childcare. The GI effects are more prevalent in younger children, particularly under five years old. They can have a long incubation period from 2-14 days after an exposure, and it should be remembered that viruses can take a long time to replicate and cause disease. Similar to the above symptoms noted for RSV, adenovirus infections also may produce swollen lymph nodes, headaches, conjunctivitis, coughs with varying severity, abdominal pain, vomiting, and diarrhea. Presently, there isn’t a rapid test for ADV, and infections were previously difficult to identify. However, there is now a direct fluorescent assay for the rapid diagnosis which is often ordered as part of a respiratory panel.⁷ Additionally, children with GI symptoms may have ADV antigen detected in their stool. A rapid diagnosis test can be helpful in a sick child and avoid unnecessary antibiotic therapy.

Another Pediatric Pearl reminder is that ADV can present with high and prolonged fevers, an elevated WBC and ESR similar to what you would expect in bacterial infections. Viruses, in general, tend to decrease the WBC.⁸ High WBC (and granulocyte) counts are clear evidence of bacterial infections, and even though low or normal counts are more typical in viral infections, this is not always an exact rule especially in regard to ADV.⁹

Influenza

Moving further up the illness intensity scale are the flu viruses. There are four types of viruses; A, B, C and D. Human influenza A and B viruses causes seasonal epidemics (“flu season”). Influenza A has been broken down into subtypes based on two surface proteins; 18 hemagluttinin subtypes and 11 different neuraminidase subtypes. This has become important due to the creation of yearly flu vaccines made on predictions of the next season’s variant. Commonly, viruses circulating include A(H1N1) and A(H3N2). The B viruses are classified into two lineages and broken down further and tends to circulate via geographic locations.¹⁰ The combination of the two A viruses with one or two B viruses are included in each season’s influenza vaccines.

Influenza illness in children presents with the sudden onset of fever, usually accompanied by a racking cough, chills, diffuse myalgia, headache, and malaise. Subsequently, the child may develop HEENT symptoms, including sore throat, nasal congestion, and otitis media. GI symptoms may occur but are less common. Pediatric Pearls recommends to look for calf tenderness in an appropriately aged child, which can aid in diagnosis of influenza (and also with parainfluenza, Epstein-Barr virus and mycoplasma).¹¹ There are serious sequelae that can occur in children from influenza illness including encephalitis, myocarditis, and myositis. Younger children, particularly under six months, and children with underlying chronic health conditions are at greater risk.

Another great office-based lab test is the rapid influenza diagnostic immunoassay, which can identify A and B nucleoprotein antigens from a nasal swab.¹² However, there is a risk of false negatives compared to reverse transcription-polymerase chain reaction (RT-PCR) testing or viral cultures. Faced with a sick child with respiratory illness, several swabs can be taken which can quickly aid in the diagnosis of RSV, influenza, and CoV-2 (to be discussed below).

If diagnosed within two days of illness, there are four antiviral drugs approved in the US for children, including oseltamivir (>2 weeks old), zanamivir (>7 years), peramivir (>2 years old, IV), and baloxavir (single dose by mouth >12 years old). I personally have had success prescribing weekly doses of homeopathics starting in the late fall using oscillococcinum and increasing the frequency to daily dosing if the child becomes ill. There are also homeopathics created specifically with the new seasonal variants that can be administered weekly. I also find Thymuline 9c weekly can boost immunity along with all the other immune-support therapies in our toolboxes. For the classic flu symptoms described above, there are many homeopathic remedies to help ease the symptoms, including Belladonna for high fevers, Antimonium tartaricum for a wet cough, Eupatorium for bone pain, and Gelsemium for the heavy/droopy state. However, even though similar remedies will come up for similar illnesses, it is still recommended to repertorize each individual when prescribing for flu (and any other) viral illness. The more the similimum is matched (‘like cures like’), the better the clinical result.

SARS-CoV-2

What is written now may evolve over time as we learn about this newest addition to the corona family of viruses. The incubation of CoV-2 appears to be about 2-14 days, averaging six days. The signs and symptoms are very similar to the other respiratory infections described above and include fever, fatigue, headache, myalgia, cough, goopy nose, sore throat, GI complaints, and a decrease in appetite. The novel symptom that is particular to this virus is a loss of taste and smell, with recovery times being very variable. This may be very hard or impossible to diagnose in children. In clinical practice, the majority of kids we’ve seen had few respiratory symptoms, often barely noticeable and if symptomatic, had more GI complaints as compared to adults. A recent study suggested that as many as half of children may be asymptomatic, which has been our experience anecdotally.¹³

There are currently two rapid diagnostic tests for SARS-CoV-2, including molecular and antigen tests. The molecular test detects the presence of viral genetic material using the RT-PCR test. The antigen test looks for specific surface viral proteins. Both take approximately 15 minutes. The accuracy of these tests can vary. Industry reports that the molecular tests are able to identify 93% of positive samples and 98% of negative tests. Antigen tests are reporting a higher possibility of false negatives. Whether this is accurate is unclear at this time. Certain pharmacies are offering rapid tests.¹⁴

There are a very small number of children that have developed multi system inflammatory syndrome (MIS-C), consisting of global inflammation (heart, lung, kidneys, brain, GI, etc.).¹⁵ Overall, children have seemed to do extremely well with this virus due to their high levels of antioxidants, such as glutathione, as well as increased levels of NK cells that have a protective effect against CoV-2. There are now ongoing clinical trials evaluating the effect of NK cells at the University of California, Irvine.¹⁶ Treatment for children has been supportive, focusing on antioxidants (vitamin C), immune boosters (such as vitamin D), selected symptom-based homeopathic remedies, and a healthy, organic plant-based diet.

Time for a pause. The purpose of this review is a reminder of some of the clinical features and differences in these common viral illnesses of childhood. As any experienced clinician knows, there can be a lot of overlap and uncertainty when assessing children, particularly nonverbal kids. The child may have a different idea about their illness than what the book describes!

References

Gruber C, et al. History of respiratory infections in the first 12 yr among children from a birth cohort. Pediatric Allergy Immunol. 2008;19:505-12.

Perro M, et al. What’s Making our Children Sick? Chelsea Green Publisher, 2017, chap 1.

https://www.cdc.gov/rsv/clinical/index.html.

Predergast C, et al. Rapid antigen-based testing for respiratory syncytial virus: moving diagnostics from bench to bedside? Future Microbio. 2013. Apr;8(4):435-44. doi: 10.2217/fmb.13.9.

https://pediatrics.aappublications.org/content/134/2/415.full.

https://pediatrics.aappublications.org/content/113/1/e51

Ruuskanen O, et al. Adenoviral diseases in children: a study of 105 hospital cases. Pediatrics. 1985 Jul;76(1):79-83.

Korppi M, et al. White blood cell and differential counts in acute respiratory viral and bacterial infections in children. Scand J Infect Dis. 1993;25(4):435-40.

https://www.cdc.gov/flu/about/viruses/types.htm

Capoferri G. Et al. Sporadic acute benign calf myositis: Systematic literature review. Neuromuscular disorders; Vol 28, Issue 5; May 2018, Pages 443-449

https://www.cdc.gov/flu/professionals/diagnosis/clinician_guidance_ridt.htm

Police J, et al. Systematic Severe Acute Respiratory Syndrome Coronavirus 2 Screening at Hospital Admission in Children: A French Prospective Multicenter Study. Clin Infect Dis. 2020; ciaa1044.

https://www.goodrx.com/blog/covid-19-rapid-test

https://www.cdc.gov/mis/about.html

https://clinicaltrials.icts.uci.edu/trial/NCT04365101