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Saturday, August 1, 2020

Post #51 Our Family’s School Decision Making Process

My boys do not want to wear pants.


A small factor, but part of the reason they campaigned for remote learning. My daughter, who generally prefers clothing, remained on the fence.


The remote vs. in-person learning decision has so many different factors it is very difficult as a pediatrician to give families a single clear answer.


As new data emerges, it further confounds a family’s decision that seemed crystal clear just 2 internet articles ago.


Several people have asked point blank, “What are you doing for your own kids?”

If I have left your text unanswered or have not replied to your email or Facebook comment, I apologize! A binary, “remote” or “in-person” response seemed too hasty and irresponsible.


While every family will have their own personal best answer, I hope sharing how my wife and I arrived at our decision will benefit the process for other parents.


To start off, some demographics are in order:


Our children are 12, 14, and 16 years of age – boy (7th grade), boy (9th grade), girl (11th grade) respectively. I am a pediatrician and my wife is a former elementary school teacher and now stay-at-home mom.


We are zoned to Cy-Fair Independent School District and the schools our children attend are Title 1 schools, with an eclectic mix of socio-economic backgrounds.


Children’s Health


The first and most important factor in making our decision was the health of our children. As of the writing of this blog, the overall risk to healthy children from COVID-19 is very small.


The CDC keeps a provisional death count by age, and as of August 1, 2020, there have been a total of 42 deaths in children younger that 15 years for the entire country. To put things in perspective there have been 185 deaths due to influenza in children younger than 18 for the 2019-20 season. Overall, children have fared extremely well with the pandemic in terms of deaths and medical complications.


If I were only factoring in the health risk to our children, I would feel safe sending them to school, given a few caveats that I will get to later in this blog.


Family’s Health


Our home is solely occupied by our nuclear family (no grandparents) and everyone is in relatively good health with no underlying health conditions.


If we had people over 60 living at home (the older the more concerning) or if someone at home had a serious underlying medical problem, I would be much more concerned about in-person learning.


The newest data from Chicago shows that, contrary to earlier studies, young children do get infected and do have high levels of virus.


Further, in a study from a Georgia sleep-away camp of all ages, of 344 campers and staff for whom tests were available, 260 tested positive after just a few days at camp.


The vast majority of kids may not get seriously ill, but it appears they can bring it home, and as such, an important part of the decision making process has to include the risk to family members.


Community Spread


The initial data from Europe, Asia, and Australia was quite comforting in terms of community spread risk from reopening schools. It is important to note that local COVID-19 caseload numbers were low and under control in the countries that reopened schools.


The recent data from Israel, South Korea, Georgia, and Chicago has rained on the parade.

Epidemiologists all agree that schools will contribute to spread in some fashion, but to what extent is still up for debate. The pendulum appears to be swinging towards children being as infectious as adults.


Ultimately, regardless of children’s infectiousness, the more important factor affecting community spread will be a school’s ability to follow certain protocols: masking, social distancing, and sanitizing. If these measures are rigorously followed, community spread should be minimal.


Additionally, it will be prudent to pay attention to local COVID-19 statistics. If caseloads are rising and hospital are overwhelmed, school closures may be necessitated.


Another important factor in community spread will be the population density at each school. As more families opt out of in-person learning, it will commensurately improve the risk for those who do attend, including the risk to our educators, many of whom will not have a choice but to be physically present.


For those who have the ability to do so, I encourage you to strongly consider remote learning to lessen the risk for those who cannot.


Educational Value


A child’s aptitude for learning remotely has to be a major factor. For some children, the value of in-person school is enormous.


Can they learn independently?


Can they focus for extended periods of time?


Will the lack of peer stimulation hamper their education?


Continuity


Attending in-person school may get interrupted from time-to-time should quarantine and isolation protocols be triggered by someone in the classroom testing positive for COVID-19.


This may force remote learning for periods of time, disrupting the continuity and flow of school.


For those kids who do not do well with change, remote learning may be the better option.


Family Decision


These were some of the variables that my wife and I contemplated as we arrived at our decision. We let our children voice their opinions as well, which we factored in.


So what did we decide?


I thought my wife said it perfectly, so with her permission, I have copied her words from her recent Facebook post.


“We are going online for the first grading period for the following reasons:


· Online instruction will be live and interactive (as opposed to the video lessons we did last spring).


· My kids are able to focus fairly well with the online learning.


· They actually are not going insane with the lack of peer interaction (they see some friends occasionally, with safety measures in place). I know this is a big deal for a lot of kids, and I totally get it.


· Our school community is around 70% low income. A lot of those families would benefit from in-person instruction, so we will be 3 less kids on campus to try to help with the numbers.


· If school has to shut down, we won’t have to transition from in-person to online instruction (I still can’t wrap my head around what this will look like).


· Masking for long periods of time is hard. So is wearing pants.


So this is our decision. We will do this for the first grading period and see how it goes. Stuff is constantly changing, so it’s hard to plan ahead this far in advance. We still have a lot of questions about how things will work, but we just have to wait and see.”


As my wife mentioned, this is a decision in flux that may change as new data or family issues emerge.


But at least for the first six weeks, my boys will be pants-less.

 

Thursday, July 23, 2020

Post #50 School Reopening during the COVID-19 Pandemic

There is probably not a more emotionally charged topic of discussion currently than that of school reopening this fall. And for good reason - nearly everyone has a stake in it.

Society is concerned because of the real risk of increased community spread.

Teachers are concerned because of the COVID-19 risk to themselves and how the logistics of school will directly affect their livelihood and stress level as they have to constantly adjust to the barrage of changes and duties. 

Families are concerned because of the COVID-19 risk to their children and to those living at home. Not to mention, many depend on school to allow for both parents to work. And what about the educational risks if everything is remote learning? And if kids stay home, will mom and dad working from home stay sane?

The number of different factors weighing in on the discussion is overwhelming. The implications affect the economy, family lives, the future of our country, and society as a whole. Superintendents, teachers, and those directly affecting school policy have their work cut out for them - thank you in advance for everything you are doing.

A good place to start the discussion is assessing the real risk to the different groups as listed above.

Students

A recent study of nearly 65,000 people in South Korea made an important distinction in children younger than 10 and those between the ages of 10 and 19, in that the younger group transmits the virus much less often than adults do. 

Ten years is not some magical demarcation as almost everything in medicine is a continuum with COVID-19 risk increasing commensurately as a child ages. For those seeking a technical explanation of this, it is likely related to the lower number of ACE2 receptors in the respiratory tract of children. 

Other possible factors that may contribute to children posing lower risk could stem from their smaller volume of breaths and the fact that they are short and thus their inhalation and exhalation is closer to the ground and not in the same plane as adults. Obviously, if they are in school and with their peers, the latter advantage becomes less relevant.

The take home message here is that younger children pose a substantially lower risk for COVID-19 spread than older children and adults. Elementary school is likely safe. Middle school and high school remain suspect. 

As for deaths in children, the CDC keeps a provisional death count by age, and as of July 22, 2020, there have been a total of 36 deaths in children younger that 15 years for the entire country. To put things in perspective there have been 185 deaths due to influenza in children younger than 18 for the 2019-20 season. Overall, children have fared extremely well with the pandemic in terms of deaths and medical complications.

Families

There is a real risk that students attending school will bring the virus home to their families. For those living with their grandparents or an immunocompromised individual or family members with underlying health issues, this poses a difficult conundrum. 

A recent systematic review of 700 scientific papers found that children are rarely the index case in outbreaks and were unlikely to impact the COVID-19 mortality in older people. While this data gives a great deal of reassurance, children still contribute to some level of spread, and as the South Korean data demonstrated, older kids are likely on par with adults in terms of risk.

Teachers

The best data on school spread comes from other continents where school reopenings have already taken place.

An excellent case study in Australia looked at 18 infected individuals (9 students and 9 staff) from 15 schools from March to mid-April of this year. 735 students and 128 staff were close contacts of these initial 18 cases. No teacher or staff member contracted COVID-19 from any of the initial school cases. However, one child from a primary school and one child from a high school may have contracted COVID-19 from the initial cases of their schools.

Another paper from the Journal of Pediatrics reviewed outbreaks in Switzerland, China, France, and Australia (cited above) and found that children are rarely drivers of COVID-19 transmission.

This is not to say that there is zero risk to teachers from students, but the data suggests it is minimal. And while children are unlikely to infect teachers, other staff and teachers pose a real risk to each other; adult to adult transmission is real and South Korea suggests students 10 and older are on par with adults.

Guidelines are Needed

If school reopening is to happen, detailed guidelines must be in place. The American Academy of Pediatrics (AAP) recently published excellent guidance for reopening schools.

A key phrase they used was that "policy makers should acknowledge that COVID-19 policies are intended to mitigate, not eliminate, risk." This is important to bear in mind. If we are attempting a zero risk solution, it will not happen.

AAP outlines key principles in consideration of reopening schools:
  1. School policies must be flexible and nimble.
  2. Strategies may need to be revised and adapted depending on the level of virus transmission in the school and community.
  3. Policies should be practical, feasible, and appropriate for the child's developmental stage.
  4. Special considerations should be made for the medically fragile, impoverished, and those with developmental challenges or special health care needs.
  5. Minimize exclusion.
  6. Policies should be guided by supporting the overall health and well-being of all involved.

Strategies recommended by the AAP include to cohort classrooms to minimize crossover, utilizing outdoor spaces when possible, limiting visitors, mandating face coverings, spacing desks 3 to 6 feet apart, eliminating lockers, having teachers rotate instead of students, and creating one-way hallways.

As states consider the different options before them, some are appropriately using local COVID-19 caseload numbers and hospitalization rates as a qualification to reopen schools. Especially for middle school and high school this seems prudent. The data from Australia, Europe, and Asia school reopenings came from countries where the pandemic was under far better control than it currently is within the United States. 

Moving forward, should COVID-19 numbers improve within the community at large and thresholds are met, school reopenings should merit serious consideration. But in states where the intensive care units are at capacity and caseloads are rising, prudence makes sense.

Of course, this poses a dilemma for working parents. This is where a novel idea such as Safe Centers for Online Learning (SCOLs) could come into play. Essentially, for those who cannot watch their children at home, students could do online learning and be cared for in large venues, such as convention centers, stadiums, performing art centers, and parks that are currently going unused. 

Whether it be SCOLs or some other concept, relief must be provided in some form to allow for parents to return back to work. This will be an essential component of moving our economy forward. 

Without question, for the upcoming school year, there will be a new normal. Each school district and family will be faced with a plethora of decisions as they weigh risks and benefits. Luckily, many countries have wrestled with these same questions ahead of us and provided helpful data. Ultimately, each family understands their needs and risk appetite best. 

Ideally, schools will have the ability and resources to offer multiple options to accommodate each family. Hopefully, the information provided here will empower parents as they navigate school reopenings during the pandemic.

One thing is and has always been true: children are the future - let's keep them safe and make sure we provide them the best education possible.









Saturday, June 13, 2020

Post #49 Church Small Group Meeting Guidance during COVID-19 Pandemic

Updated June 13, 2020

Disclaimer: COVID-19 is a pandemic in flux. As the number of active cases and hospital ICU occupancy changes and new research comes out, recommendations will change. Please check with your church, doctor, local health departments, and www.CDC.gov for the most up-to-date information and guidance on meeting in person.

As most people know by now, COVID-19 is mainly targeting the old, immunocompromised, and individuals with underlying health issues. But it bears reminding that normal, healthy young adults are also getting severely ill

Importantly, children of all ages have been afflicted by a condition now termed Multisystem Inflammatory Syndrome in Children (MIS-C), which has led to some deaths in normal, healthy kids with no underlying health issues. MIS-C and healthy young adults getting severely ill is a small risk, but it is a real risk. Please bear this in mind.

However, at some point we all take risk. Driving down the freeway could lead to a fatal accident but we do it everyday. Children attending school even when there is no pandemic could lead to meningitis, but we do it everyday.

The key is calculating risk and minimizing it without going overboard - which is a very tricky thing to do with a new virus such as COVID-19.

If you are older than 60 years, have serious health issues, or are immunocompromised - you should not join an in-person meeting of a small group until further notice from public health officials.

If you are living with anyone meeting any of these criteria, you should strongly consider not joining an in-person meeting of a small group as you are putting that individual at real risk.

If you do not meet either of the above two criteria, meeting in a small group may be reasonable with the following parameters:

1. Masks should be worn as much as possible and for the entirety of the meeting.

2. If cases of COVID-19 in your city are rising, it is probably better not to meet in person. A great resource for this in Houston is www.TMC.edu.

3. If you do meet, SINGING is one of the biggest risks. It is highly advisable not to sing indoors at all. Either do praise time outside (with masks ideally) or skip praise time altogether. Even with masks on, singing in a confined space is a serious risk for spread – many people do not wear snug fitting masks and mask quality is highly variable.

4. It is advisable for mealtime to be done outdoors as it necessitates removing your masks. If you do eat indoors, you should be 6 feet apart ideally. Talking to one another for 10-15 minutes in close proximity without masks is an easy way for COVID-19 to spread.

5. Whoever is handling food prep must be masked when serving food. Everyone should thoroughly wash hands prior to eating.

6. Word time, sharing time, and prayer time can be done indoors, but outdoors is still preferable when reasonable. Either way, try to remain 6 feet apart. If sitting indoors, good air circulation is very important: turn on the AC and ceiling fan and open windows when possible.

7. Do not hug or shake hands. Elbow bumps are ok.

8. Try to keep any indoor portion of the small group as short as possible. Consider moving rooms when feasible for each segment of the small group meeting to keep the surrounding air fresh and new. Open, airy rooms with good air circulation are the safest.

9. Should you meet in-person, especially if the meeting is indoors, the smaller the group the safer.At this time, 10 people (including children) would be a reasonable cap to your group size.

10. Anyone who is possibly sick should ABSOLUTELY NOT come.

11.Anyone who cannot afford a two week quarantine period should they later find out someone in the group tested positive, should NOT come.

12. Anyone who is or is living with someone who is awaiting a COVID-19 test* or has recently been diagnosed with COVID-19 or is displaying COVID-19 symptoms should NOT come. See scenarios below to help with timeframe on returning.

*For the purposes of this guidance and the information below, a COVID-19 test refers to the nasopharyngeal nucleic acid swab test and not the antibody test – there is a major difference between the two tests that is beyond the scope of this guidance.

· Close contact with COVID but No Test Pending

o Safe to return after 14 day quarantine at home AND no symptoms develop during that time.

· Asymptomatic and COVID Test Pending

o It is definitely safest to wait until the COVID test is back. However if the individual is completely symptom free AND wearing a mask the ENTIRE time, it is reasonable to partake but would not advise.

· Symptomatic and COVID Test Pending

o Do not join until the test result returns AND the individual meets the criteria in one of the following scenarios.

· Asymptomatic and Positive COVID Test

o Safe to return when either of below criteria met:

§ 10 days after the first test was performed and remains asymptomatic.

OR

§ 2 negative nasopharyngeal swab specimens collected at least 24 hours apart. Tests for clearance should be done a minimum of 5 days after the initial POSITIVE test was performed.

· Symptomatic and Positive COVID Test

o Safe to return when either of below criteria met:

§ It has been 10 days since the onset of symptoms AND no fever for 3 days AND significant improvement of symptoms (cough, runny nose, etc.).

OR

§ 2 negative nasopharyngeal swab specimens collected at least 24 hours apart. Tests for clearance should be done a minimum of 5 days after the initial POSITIVE test was performed.

· Symptomatic but Negative COVID Test

§ Safe to return when 24 hours without fever without the use of fever-reducing medication AND significant improvement of symptoms.

Some of these recommendations may seem over-the-top, but COVID-19 warrants a high level of vigilance. It is a very serious illness and there is a long way to go before the pandemic is over. 

The safest thing of course is to meet through video-conferencing. At the present moment, it is this author’s preference until the risk further decreases.

Remember when you get together, you are not only potentially sharing germs with the people in your small group, but you are also sharing germs with everyone they live with and everyone they live with may be sharing germs with you. The larger the group, the greater the risk to everyone at the meeting.

Hope this guidance helps as you do the Lord's work!

Saturday, March 7, 2020

Post #48 Coronavirus COVID-19 Pandemic Update

Well before news of COVID-19 wreaked havoc on our borders, travels, news cycle, and hand sanitizer supplies, influenza was quietly going about its yearly routine business with minimal hubbub from the media.

To put things in perspective, consider that for the 2019-20 flu season, there have been an estimated 20,000 - 52,000 deaths thus far per the Center for Disease Control in the United States alone. That is just one country.

In contrast, there have been approximately 3,600 deaths from COVID-19 worldwide. More deaths are sure to follow, and quite possibly, the final tally may far outstrip that of the seasonal flu.

An unknown enemy is always more frightening than one that is known. With the flu, we know what to expect, we have medications to combat it, and most importantly there is an effective vaccine readily available each winter.

Unfortunately, with COVID-19 there are still a LOT of unknowns. 

But we know substantially more now than we did when this all started and we are learning more each day.


The Case Fatality Rate (CFR) is likely overestimated and will hopefully trend down.

One of the best handles as to the seriousness of a pandemic is to look at the Case Fatality Rate and compare it to other previous pandemics. 

The Case Fatality Rate is simply the ratio of deaths from a certain disease to the total number of people diagnosed with this disease for a certain time period.

As a frame of reference, the 1918 Spanish Flu, one of the worst pandemics of all time, had a CFR of approximately 2.5% to 10% - meaning that about 2.5 to 10 percent of all people who caught the Spanish Flu died. Anything greater than 2.5% would certainly be devastating worldwide.

Conversely, the seasonal flu typically has a CFR of approximately 0.1%, which is still concerning, but as mentioned in the introduction of the blog, the world has learned to take this in stride.

The more data is collected, the more accurate the CFR estimates become. The initial CFR estimates for COVID-19 were in the 2-3% range and recently the World Health Organization released a 3.4% estimate.

Certainly, these estimates are enough to give even the staunchest epidemiologist pause.

But in order to make the best guesstimates of CFR early in the course of a pandemic there must be widespread testing. Lesser testing detects fewer cases, which skews the CFR higher. This was seen with the 2009 H1N1 Influenza Pandemic

Currently, there are two microcosms of the pandemic that can give us the best estimates of the CFR for COVID-19. In both instances, widespread testing of the particular cohort has provided better data and thus a truer estimate of the real CFR.

1. The Diamond Princess cruise ship

The Diamond Princess cruise ship which had approximately 700 lab confirmed cases of COVID-19, has reported 7 deaths to date. This translates to a CFR of 1%. Importantly, it should be noted that all of the deaths occurred in passengers 70 years and older.

2. South Korea

South Korea is currently testing thousands of people a day and thus far 6,088 cases have been detected of which 37 have died. This translates to a CFR of 0.6% for South Korea. This is probably more accurate than the cruise ship figure, as the Korea numbers are more age-demographically balanced, whereas the cruise was populated by predominantly older people.

While a 0.6% CFR is much better than a 3.4% CFR, it is still significantly higher than the seasonal flu's 0.1% CFR. That figure would translate to 6x the number of people dying, if the same number of people who catch the flu annually were to catch COVID-19. 

The hope is that even in South Korea, there are many who have been infected that have NOT been tested, and are thus unaccounted for in the statistics. Accurately capturing their data would certainly bring the CFR percentage even lower. 

The bottom line is that while it is unlikely that the final CFR tally will come in at 3.4%, there is a strong chance that this pandemic is more deadly than the seasonal flu. More testing, better data, and clarity are sure to come.


Thus far, children are not being seriously affected.

A huge encouraging statistic as a pediatrician is that no children under 10 years of age have died from the COVID-19 to date and, for unclear reasons few children are developing severe symptomsThis pattern is similar to what was seen during the outbreaks of SARS and MERS. 

Children are at similar risk as the rest of the population in terms of becoming infected; so it is imperative to consider them as vectors of the virus, especially since they are less symptomatic and thus more ambulatory, and less prone to prudent hygiene habits.


Healthy people 60 years and younger are at much lower risk.

Although there are some fatalities in nearly every age demographic, the vast majority of deaths are occurring in individuals 60 years and older. Further, people who have a severe chronic medical condition affecting their heart, lungs or kidneys are also at greater risk. This follows a similar pattern to influenza and most severe respiratory viruses.


So, if there is a silver lining in any of this, those who are under 60 years of age without significant health problems have an excellent prognosis should they become infected with COVID-19.


But the fact remains that as of the writing of this blog, the CFR is likely higher than the seasonal flu and possibly significantly higher. Intensive Care Units and hospitals in China and in South Korea, particularly near the epicenters of the outbreaks are overwhelmed.

If these two countries are a peek into the future for the rest of the world, this is going to be a long and difficult battle and it will have to start with grassroots efforts. We as a society will need to be vigilant in following the directives of our public health officials and practicing a high level of personal hygiene habits.

The CDC has an excellent list:
  1. Avoid close contact with people who are sick.
  2. Avoid touching your eyes, nose, and mouth.
  3. Stay home when you are sick.
  4. Cover your cough or sneeze with a tissue, then throw the tissue in the trash.
  5. Clean and disinfect frequently touched objects and surfaces using a regular household cleaning spray or wipe.
  6. Facemasks: CDC does NOT recommend that people who are well wear a facemask. Those who are showing symptoms should wear them to prevent the spread of disease. Health care workers and caregivers should also wear them when taking care of those who are infected.
  7. Wash your hands often with soap and water for at least 20 seconds. If soap and water are not available use an alcohol-based hand sanitizer with at least 60% alcohol.

For the sake of those who are most vulnerable, we must band together to slow the spread of this disease. By slowing transmission, hopefully hospitals will not be overwhelmed with a tsunami of cases leading to a likely depletion of important resources such as ICU beds, ventilators, and healthcare workers. 

Additionally, there is hope that by this time next year a vaccine will be available. As more research is published and experience gained, the medical community will develop a better understanding of which combination of antiviral medications and treatments work best.

And if COVID-19 mimics other respiratory viruses, the upcoming warmer weather may provide a temporary reprieve, giving the world a chance to catch its collective breath before the battle begins anew in the upcoming fall and winter. 

Based on current epidemiological data, it is likely that the COVID-19 virus is not going away anytime soon. But the human race is strong and resourceful and we have more weapons at our fingertips than ever before. 

Now, more than ever, for the sake of the elderly and those with fragile health, it is imperative that we do the small things like washing our hands and staying at home when sick. 

When we stand together, there is nothing too strong or too deadly that the human spirit cannot overcome.

Saturday, February 22, 2020

Post #47 How to Optimally Utilize Tamiflu

The take home message is that because of side effects and costs, using Tamiflu during the flu season should not be a knee-jerk reaction.

Every year in the United States, the CDC estimates that influenza results in between 9 million – 45 million illnesses, between 140,000 – 810,000 hospitalizations, and between 12,000 – 61,000 deaths (approximately 100 – 200 being pediatric fatalities; typically 80% not vaccinated). 

In the United States, the immense burden of the flu is unparalleled by any other pathogen, but fortunately there is a vaccine and antiviral medications which help to mitigate the yearly morbidity and mortality wrought by influenza.

Because the flu changes its shape every year by a process called antigenic shift and drift, it is necessary for individuals to receive annual flu vaccines to maintain optimal protection against the virus. Protection from illness proffered by the immunization typically wavers between 40 – 60% in any given year; it is by far the best, no-brainer weapon that modern medicine has to offer against influenza. This author races to have it completed for his entire family every flu season as soon as the vaccine is available.

Beyond the vaccine, there are several antiviral medications that are also helpful in combatting the flu. To be clear, the antiviral medications are second line treatment as they are less effective, more expensive, and carry more side effects. 

The most common antiviral medication we use in pediatrics is Tamiflu (Oseltamivir), which is the only medication approved in children under 7 years of age. It works by inhibiting one of the key enzymes of the flu virus called neuraminidase. Tamiflu does not kill the flu virus, rather it slows down its ability to replicate, allowing the body's immune system to eventually (hopefully) overcome the virus. 

When given within the first 48 hours of the illness, it has been shown to reduce the overall duration of symptoms by approximately one day. In patients who are sick enough to warrant hospitalization, there are benefits to utilizing Tamiflu even outside of the initial 48 hour window as it can decrease the risk of complications from the flu.  

Overall, Tamiflu is well tolerated; but there are side effects, the most common being:
  • Gastrointestinal complaints (such as vomiting) in 14% of Tamiflu recipients
  • Neurological complaints (such as hallucinations) in 5% of Tamiflu recipients

Although Tamiflu can be an effective anti-flu medication - because of its side effects, timing constraints, and cost, like every other tool in medicine it must be utilized with judicious discretion. It is important to note that unlike the flu vaccine, where the protection lasts throughout the flu season, the benefits of Tamiflu are short-lived and are limited to when it is being ingested.

During the flu season parents often request Tamiflu as either treatment for an ill child or for prophylaxis to protect their healthy children. 

Some quick (but not all encompassing) criteria for when to consider Tamiflu, given that a flu test is positive, is as follows:

Child has had symptoms less than 48 hours AND is less than 2 years of age OR has an underlying health condition such as asthma, diabetes, or some other type of chronic illness.

In most children, who meet this criteria, Tamiflu should be strongly considered; however, if the child appears well and has good follow-up available, Tamiflu can be deferred.

Conversely, some quick (but not all encompassing) criteria for when to consider NOT utilizing Tamiflu, even when a flu test is positive, is as follows:

Child has had symptoms for longer than 48 hours OR appears well and is responding appropriately to fever reducers. Especially, if they are vaccinated, the necessity of Tamiflu decreases.

The three most common scenarios we are confronted with in our pediatric practice are as follows:

1. Child is sick and has a documented positive test confirming the flu.

Generally, if the child has been sick for less than 48 hours AND is less than 2 years of age or has any underlying heath conditions such as asthma, it is prudent to start a five day course of Tamiflu ASAP. If the child is acting well and responds favorably to fever reducers 
there is less onus to giving Tamiflu, especially if they are appropriately vaccinated against the flu.

2. Child is sick but does not have a documented positive test confirming the flu.

Because of the side effects and cost of Tamiflu, whenever possible, it is prudent to have a confirmatory test of flu completed before committing to treatment. One caveat to this is if a recent family member has tested positive for flu AND it has been less than 48 hours since exposure AND the child clearly has flu-like symptoms, there may be value in starting Tamiflu ASAP. However, similar to scenario one above, unless they are under 2 years of age or there is a chronic medical condition, Tamiflu may not be needed - especially if they have been properly vaccinated.

3. Child is well but has been exposed to the flu.

Per Uptodate.com:

"Postexposure prophylaxis is not routinely recommended for otherwise healthy children but may be warranted within 48 hours of exposure for children who have had close contact with a confirmed or suspected case of influenza during the infectious period (ie, one day before the onset of symptoms until 24 hours after the fever ends) AND who are at high risk for complications of influenza. Postexposure prophylaxis should be used only when antivirals can be started within 48 hours of the most recent exposure."

It should be noted that postexposure prophylaxis has modest benefits which end as soon as Tamiflu is no longer being taken.

The bottom line is, whenever possible, a confirmatory flu test can help best guide treatment. And of course, consulting your pediatrician can help you make the best decision as to if and when to initiate treatment. 

It is always a bit confounding, each flu season, to observe several families who openly embrace Tamiflu, while shunning the flu vaccine because they are concerned about putting "synthetic" material into their child's body. 

Our pediatric offices deal with far more side effects from Tamiflu yearly - including vomiting and hallucinations - compared to the relatively nominal side effects of the flu vaccine, which are redness, swelling, and pain at the site of injection.

When used properly, Tamiflu is an effective weapon against the flu, but the best protection for your child is to immunize them against influenza each and every winter. The flu can be a dangerous disease, but with proper preparation and care, you can significantly mitigate the risk to your family.