H1n1

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KidDr

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Hi all,
I'm a peds EM fellow so I spend all of my time in the ED...and as a result I've been seeing a TON of H1N1 recently.

I recognize that my experience in the field of pediatrics is somewhat limited (a little over 5 years)...but I feel like I'm seeing way more really sick kids with H1N1 compared to anything I ever saw with regular seasonal influenza in past years. At the same time, however, I also suspect that my worldview is a little warped right now because I'm seeing SO many kids with H1N1 (and thus lots of kids with more serious associated conditions)...

In the past 2 weeks, I've seen the following conditions in kids with confirmed influenza A (presumed H1N1):
Myocarditis (EF ~20-25% on her initial ECHO)
Severe croup
Complex febrile seizures (recurrent seizures)
Lots of vomiting with resultant severe dehydration
Bad pneumonia
RAD exacerbations with prominent wheezing
Bronchiolitis
Severe myalgias (to the point that I had one kid come in with a CC of "refusal to walk")
Infants who have fever and are pretty irritable (but not many other symptoms)
Multiorgan failure (on a ventilator and dialysis)
And all of the regular influenza-type stuff

None of this is too crazy...it's just that there's so much of it coming through our doors.

I'm curious...what other interesting things is everyone out there seeing in kids with H1N1? I'm especially curious to hear the most common things that are landing kids in the ICU with H1N1.

And to everyone else out there working in peds EDs and urgent care and primary care (and any other specialty seeing lots of H1N1)...I feel your pain :)
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I've been in the ER and seen about 50 kids just myself with H1N1 who had just that. They were fine--some got Tamiflu cuz they were small or had high-risk household contacts, or whatever, but most did fine.

I have also seen a lot of kids who are much worse off though--now doing Heme/Onc, so the Sickle Cell patients with H1N1 have been hit hard, as with the neutropenic (ANC=0) kids who have had it for >1wk despite appropriate treatment. Bone Marrow Transplant patients with it scare me, but I guess they can do fine with their new T-cells. Several patients in the ICU are otherwise healthy but have been put on ECMO and vents and all kinds of crazy things.

So I dunno, I'm an intern and haven't seen the seasonal flu do these kinds of things, but I guess it can. Still, it seems scary. I'm glad my daughter has managed to avoid it thus far!
 
I've been on my Peds outpatient rotation. The attendings seem to be calling everything with fever, cough, and myalgia H1N1. Of course none of it is confirmed H1N1 and everyone gets better.
 
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Adding to KidDr's list I have also seen h1n1 encephalitis (case reports out there).

We have a boat load of business this year and over the last 2 months our ED volume is up almost 40%!!! :eek:

PICU volume is also up with h1n1 resp failure (intubated or biPap) and all the usual stuff; the most common flu stuff we seem to be seeing is initially gastro type symptoms.
 
CrazyPeds527 said:
Adding to KidDr's list I have also seen h1n1 encephalitis (case reports out there).

We have a boat load of business this year and over the last 2 months our ED volume is up almost 40%!!! :eek:

PICU volume is also up with h1n1 resp failure (intubated or biPap) and all the usual stuff; the most common flu stuff we seem to be seeing is initially gastro type symptoms.
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Thanks for adding the H1N1 encephalitis---I was curious if anyone had seen that yet (I haven't). I wonder, though, if a couple kids I've seen might have a few white cells in their CSF and a mild encephalitis, because some of the younger kids I've seen have been so irritable and miserable. I didn't tap them so who knows.

If you have a minute, could you describe the case of H1N1 encephalitis that you saw (signs/symptoms/etc)? Thanks.

Our ED volumes this past weekend were almost 3x our normal levels for this time of year...yikes (we had 8 kids sign in right at 5 AM this morning, all with flu-like symptoms). I worked Friday through Sunday and it was a ZOO. Saw more patients each shift than I'd ever seen before. Lots of really sick kids. Call me crazy...but aside from the not sick kids with H1N1 who were just in the ED to get some ibuprofen...it was actually kind of fun.

EDIT--
I was just following up on a kid I admitted recently:
Afebrile teenager (with no seizure history) with URI symptoms came in acting encephalopathic for several hours, then had a generalized seizure. CSF normal. Rapid flu negative, viral culture growing influenza A. So I guess I've now seen H1N1 encephalitis (with normal CSF).
 
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Neuronix said:
I've been on my Peds outpatient rotation. The attendings seem to be calling everything with fever, cough, and myalgia H1N1. Of course none of it is confirmed H1N1 and everyone gets better.
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A lot of those kids probably do have H1N1...I'm essentially only doing the rapid test on kids I'm admitting to the hospital, and I'm getting about as many positive tests as I would expect (i.e., about a third of the kids who I think have H1N1 have a positive test...which means I'm wrong on about a third of them and another third do have H1N1 but with a negative rapid test...sorry I know my math doesn't exactly add up but you get what I mean). Basically--this just says that our clinical judgment, in a pandemic situation, is pretty good. In the end though like you said, it really doesn't matter. Whatever virus the kids have (influenza or another), most will get better with supportive care and all of them need good instructions on what symptoms to watch for and when to return if they get sicker.

The CDC definition of an influenza-like illness is really broad...and I think it's okay to diagnose ILI really broadly...as long as people are using Tamiflu appropriately. Where I'm at the ED doctors are following the CDC guidelines, which means Tamiflu for kids under 2, pregnant teenagers, or any kid with an underlying illness (and kids admitted to the hospital with an ILI). In the end most kids are getting sent home without Tamiflu.

I hope the attending you're working with in peds clinic aren't handing out Tamiflu to everyone with an ILI...
 
generic said:
I have also seen a lot of kids who are much worse off though--now doing Heme/Onc, so the Sickle Cell patients with H1N1 have been hit hard, as with the neutropenic (ANC=0) kids who have had it for >1wk despite appropriate treatment. Bone Marrow Transplant patients with it scare me, but I guess they can do fine with their new T-cells. Several patients in the ICU are otherwise healthy but have been put on ECMO and vents and all kinds of crazy things.
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I've seen a couple of heme/onc kids with H1N1...they were miserable.

For the kids with H1N1 who ended up on ECMO---was it myocarditis? Really bad ARDS? Or something else?
 
KidDr said:
If you have a minute, could you describe the case of H1N1 encephalitis that you saw (signs/symptoms/etc)? Thanks

I was just following up on a kid I admitted recently:
Afebrile teenager (with no seizure history) with URI symptoms came in acting encephalopathic for several hours, then had a generalized seizure. CSF normal. Rapid flu negative, viral culture growing influenza A. So I guess I've now seen H1N1 encephalitis (with normal CSF).
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My kid was a pre-teen with HA, URI Sx who became altered in the ED. No seizure, LP was bloody (tap on a pre-teen who was altered, not encephalopathic---much props to my co-resident who got anything). Rapid Flu negative but full DFA panel was positive for FluA. Mental status normalized in 12 hours, but kid was intermittently out of it and "not himself for 12-16 hours.

The ED volume being so high does not bode well if H1N1 continues into the usual flu/RSV season...EDs and hospitals could be disaster zones come february.

I saw the kid on the ID service the next AM and they looked much better

We had 2 kids (so far, I think) on ECMO for ARDS (one with ParaFlu III - bad paraflu season up here, another with H1n1)

And yes - you are crazy :)
 
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KidDr said:
EDIT--
I was just following up on a kid I admitted recently:
Afebrile teenager (with no seizure history) with URI symptoms came in acting encephalopathic for several hours, then had a generalized seizure. CSF normal. Rapid flu negative, viral culture growing influenza A. So I guess I've now seen H1N1 encephalitis (with normal CSF).
Click to expand...

Was this kid on Tamiflu when he became encepholopathic? Remember that one of the side effects of the drug is neurological dysfunction, confusion, things that may look like encephalitis (I always have this discussion before offering Tamiflu to a high risk kid, and it can also be used to talk people out of wanting the drug if they don't need it). Normal CSF would lead me to believe that you'd either caught it very early or that there was something else going on.
 
Stitch said:
Was this kid on Tamiflu when he became encepholopathic? Remember that one of the side effects of the drug is neurological dysfunction, confusion, things that may look like encephalitis (I always have this discussion before offering Tamiflu to a high risk kid, and it can also be used to talk people out of wanting the drug if they don't need it). Normal CSF would lead me to believe that you'd either caught it very early or that there was something else going on.
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No, good thought but he wasn't on Tamiflu. I'm waiting to see if the viral cultures from his CSF grow Influenza A. I suspect they might. He was placed on Tamiflu after he was admitted because we suspected H1N1 and the benefits were thought to outweigh the risks in him. He was also started on maintenance doses of antiepileptics.

I do warn parents about the neurological side effects of Tamiflu, specifically hallucinations and other bizarre neurological stuff. There is also a small risk of seizures--I asked one of our pharmacists and she told me it's less than 1%.

Last week I had a kid with epilepsy who I thought warranted treatment with Tamiflu. Before I put her on it I discussed it with both the pharmacist and her neurologist and told her mom about the risks...and documented everything in my note.
 
I think there are 4-5 kids in with suspected or confirmed Hinny in our unit currently. I've only been peripherally involved in one because he had a cardiac history (not really a major contributer to this illness) and he went on to ECMO.


OK, I'm going to derail for a moment into an interesting case of a bad respiratory failure. The case will only last a couple of responses I suspect so not worth a new thread...so apologies ahead of time:cool:

Infant <2mo presents to outside ED with severe respiratory sx. OSH viral labs unremarkable. Comes to PICU and placed on HFOV and is sick. Cards called in the wee hours for echo due to persistent, non-fluid responsive tachycardia and some duskiness-concern for cardiomyopathy/carditis. Echo shows structurally normal heart, dilated and poorly functioning RV, RV hypertension (systemic+ RVPs). LV is underfilled and hyperdynamic. An interesting part of the story is there was severe, rising leukocytosis (like, the oh s--t; is this leukemia? variety). Neonatal leukemia vs leukemoid rxn thought of (cytometry c/w the latter). Cards called mostly for echo vs. advice but NO suggested, troponins suggested (just thinking of neonatal MI d/t hyperviscosity; mildly elevated). All that stuff in the last sentence is mostly Blah, Blah. Rumor mill is that at one point early on an attending says "there's only one thing that does this". Lab test confirms.
Dx?
 
J-Rad said:
I think there are 4-5 kids in with suspected or confirmed Hinny in our unit currently. I've only been peripherally involved in one because he had a cardiac history (not really a major contributer to this illness) and he went on to ECMO.


OK, I'm going to derail for a moment into an interesting case of a bad respiratory failure. The case will only last a couple of responses I suspect so not worth a new thread...so apologies ahead of time:cool:

Infant <2mo presents to outside ED with severe respiratory sx. OSH viral labs unremarkable. Comes to PICU and placed on HFOV and is sick. Cards called in the wee hours for echo due to persistent, non-fluid responsive tachycardia and some duskiness-concern for cardiomyopathy/carditis. Echo shows structurally normal heart, dilated and poorly functioning RV, RV hypertension (systemic+ RVPs). LV is underfilled and hyperdynamic. An interesting part of the story is there was severe, rising leukocytosis (like, the oh s--t; is this leukemia? variety). Neonatal leukemia vs leukemoid rxn thought of (cytometry c/w the latter). Cards called mostly for echo vs. advice but NO suggested, troponins suggested (just thinking of neonatal MI d/t hyperviscosity; mildly elevated). All that stuff in the last sentence is mostly Blah, Blah. Rumor mill is that at one point early on an attending says "there's only one thing that does this". Lab test confirms.
Dx?
Click to expand...

Pertussis?
 
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J-Rad said:
I think there are 4-5 kids in with suspected or confirmed Hinny in our unit currently. I've only been peripherally involved in one because he had a cardiac history (not really a major contributer to this illness) and he went on to ECMO.


OK, I'm going to derail for a moment into an interesting case of a bad respiratory failure. The case will only last a couple of responses I suspect so not worth a new thread...so apologies ahead of time:cool:

Infant <2mo presents to outside ED with severe respiratory sx. OSH viral labs unremarkable. Comes to PICU and placed on HFOV and is sick. Cards called in the wee hours for echo due to persistent, non-fluid responsive tachycardia and some duskiness-concern for cardiomyopathy/carditis. Echo shows structurally normal heart, dilated and poorly functioning RV, RV hypertension (systemic+ RVPs). LV is underfilled and hyperdynamic. An interesting part of the story is there was severe, rising leukocytosis (like, the oh s--t; is this leukemia? variety). Neonatal leukemia vs leukemoid rxn thought of (cytometry c/w the latter). Cards called mostly for echo vs. advice but NO suggested, troponins suggested (just thinking of neonatal MI d/t hyperviscosity; mildly elevated). All that stuff in the last sentence is mostly Blah, Blah. Rumor mill is that at one point early on an attending says "there's only one thing that does this". Lab test confirms.
Dx?
Click to expand...

Congenital AVM?... well, leukocytosis doesn't really fit :(
 
CrazyPeds527 said:
My kid was a pre-teen with HA, URI Sx who became altered in the ED. No seizure, LP was bloody (tap on a pre-teen who was altered, not encephalopathic---much props to my co-resident who got anything). Rapid Flu negative but full DFA panel was positive for FluA. Mental status normalized in 12 hours, but kid was intermittently out of it and "not himself for 12-16 hours.
Click to expand...

Thanks for posting the case. It has a lot of similarities to the teen I saw. Acute encephalopathy is always an interesting symptom to work up...I will post later when the CSF viral culture result comes back from the kid I saw.

CrazyPeds527 said:
The ED volume being so high does not bode well if H1N1 continues into the usual flu/RSV season...EDs and hospitals could be disaster zones come february.
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Agree that RSV season is going to make this already crazy situation even worse...we've already added more staff (MD & RN) and expanded into various other spaces to accommodate the increased volumes we're seeing, but we're still overflowing. We can probably find more space if we need to, but it's not like we can magically multiply our staff.

CrazyPeds527 said:
I saw the kid on the ID service the next AM and they looked much better

We had 2 kids (so far, I think) on ECMO for ARDS (one with ParaFlu III - bad paraflu season up here, another with H1n1)

And yes - you are crazy :)
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Wow...ARDS & on ECMO from paraflu virus...that sucks.

And you can call me truly crazy if I'm still having fun once RSV arrives :)
 
J-Rad said:
Yup.
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Wow, great case!

I'm curious how you handled the "structurally normal heart, dilated and poorly functioning RV, RV hypertension (systemic+ RVPs). LV is underfilled and hyperdynamic." I'm assuming some sort of inotrope like milrinone, but how were diuretics and sedation approached? It seems like you'd want to relieve one ventricle but maintain adequate preload on the other. One thing I've learned is to respect the right ventricle because you can get into trouble easily when it fails...
 
Hi all,
Just an FYI--saw another case of Influenza+ croup last night. Kid had a history of "tactile" fevers at home and was afebrile in the ED (temp 37.4 I think), but I was admitting him so I had him swabbed for flu (as is our protocol if we suspect possible H1N1 on admitted kids) and he was positive, so he's getting his Tamiflu. Think about H1N1 in kids with febrile croup and who look a little sicker (though not toxic...that would be a different story) than the average crouper (this kid re-developed stridor an hour after his 1st neb) and get them started on Tamiflu.

On the other hand...I also admitted 2 kids last night with confirmed Influenza A and pneumonia. Both had been sick for 7+ days and both had been on Tamiflu (one had been on it for about 3 days, the other had already finished her 5 day course). Both were hypoxic and I expect they'll be inpatient for a few days. So who knows if Tamiflu is actually efficacious in shortening symptoms or preventing complications. Right now all I'm hearing is anecdotes about Tamiflu's efficacy or lack of efficacy. Anecdotes are fine, but at some point down the road (probably not for at least a year, unfortunately), it will be interesting to see the aggregated efficacy data on 1000s of cases of kids with H1N1 who were given Tamiflu (at least I hope someone is planning to do this study!!). In the meantime, I will keep following the CDC's guidelines.
 
KidDr said:
Anecdotes are fine, but at some point down the road (probably not for at least a year, unfortunately), it will be interesting to see the aggregated efficacy data on 1000s of cases of kids with H1N1 who were given Tamiflu (at least I hope someone is planning to do this study!!).
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As we know now NON h1N1 flu from prior years have shown increasing tamiflu resistance; i can't imagine this year's piggy flu being super different, especially after seeing a couple of kids need 2 runs of tamiflu (one was an organ transplant patient)
 
KidDr said:
So who knows if Tamiflu is actually efficacious in shortening symptoms or preventing complications. Right now all I'm hearing is anecdotes about Tamiflu's efficacy or lack of efficacy. Anecdotes are fine, but at some point down the road (probably not for at least a year, unfortunately), it will be interesting to see the aggregated efficacy data on 1000s of cases of kids with H1N1 who were given Tamiflu (at least I hope someone is planning to do this study!!). In the meantime, I will keep following the CDC's guidelines.
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I wonder the same thing, and generally feel that Tamiflu isn't that great of a drug. A quick lit search did turn up some interesting things though...

Tamiflu as prophylaxis in children. They say it's cost effective and seems to have reduced the incidence of new cases, but it's not the best study.

Reduction of symptoms in adults of only about half a day. I say big deal.

Still I can't find any data that treating reduces complications of flu, even in high risk populations. It's also important to keep in mind that it can have significan side effects, most notably neurological. Overall I'll continue to prescribe it as recommended (high risk groups in first 48 hours of symptoms, high risk groups who have definite contact), but I'm not convinced it's doing much good other than create resistance. And I always discuss possible side effects with patients/parents just in case.
 
Stitch said:
I wonder the same thing, and generally feel that Tamiflu isn't that great of a drug. A quick lit search did turn up some interesting things though...

Tamiflu as prophylaxis in children. They say it's cost effective and seems to have reduced the incidence of new cases, but it's not the best study.

Reduction of symptoms in adults of only about half a day. I say big deal.

Still I can't find any data that treating reduces complications of flu, even in high risk populations. It's also important to keep in mind that it can have significan side effects, most notably neurological. Overall I'll continue to prescribe it as recommended (high risk groups in first 48 hours of symptoms, high risk groups who have definite contact), but I'm not convinced it's doing much good other than create resistance. And I always discuss possible side effects with patients/parents just in case.
Click to expand...


This is just from personal experience (yes I used Tamiflu for confirmed Flu A, presumed H1N1)...but I think Tamiflu is a wonder drug. My symptoms did a 180 within 24 hours after starting (started within 48 hours of symptoms). I actually read that it reduces symptoms by 30% overall...not just duration of symptoms. I was sick as a dog when I started it...sicker than I've ever been with the flu in the past. My wife had it first and her symptoms lasted for 7 days total (without Tamiflu). My symptoms lasted 4 with Tamiflu.

Don't knock it till ya try it! :)
 
Stitch said:
Still I can't find any data that treating reduces complications of flu, even in high risk populations. It's also important to keep in mind that it can have significan side effects, most notably neurological. Overall I'll continue to prescribe it as recommended (high risk groups in first 48 hours of symptoms, high risk groups who have definite contact), but I'm not convinced it's doing much good other than create resistance. And I always discuss possible side effects with patients/parents just in case.
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This is what I'm most interested in, because this is ultimately what matters the most to me (though rotatores---I'm certainly not dissing your experience---I can imagine that shortening H1N1 symptoms by a few days is nice!).

If Tamiflu ultimately is proven to actually reduce rates of hospitalization and reduce the incidence of more severe/invasive disease, then awesome--I'll be way more excited to be handing it out like water, and the risk of potential side effects will be more worth it (IMHO) if the benefit (beyond symptom duration reduction) is real. But prescribing Tamiflu to all of these babies and toddlers makes me a little nervous--some of of them (maybe 1%?) are going to have a seizure or severe neuro symptoms and are going to get a huge expensive, painful workup because of it (CT, LP, EEG, etc, etc). If we're not preventing hospitalization and severe complications, are the potential side effects worth it?
 
Got a robocall from my older kid's school about a ~40% absentee rate this weekend due to illnesses.

Our PICU has almost half the open beds with kids with H1N1. Most with underlying conditions but not all. One recent demise and locally there was one who didn't make it past the ED. We've lost a couple of our adult congenitals as well. It seems to be hitting pretty hard here.
 
Well, yesterday I developed URI symptoms, myalgias and fever to 101.9.

I got my H1N1 Flumist 3 days before symptoms so I probably got it from one of those little mongrels before I got vaccinated. I've started Tamiflu. I'll let you know what my anecdotal evidence shows.
 
BigNavyPedsGuy said:
Well, yesterday I developed URI symptoms, myalgias and fever to 101.9.

I got my H1N1 Flumist 3 days before symptoms so I probably got it from one of those little mongrels before I got vaccinated. I've started Tamiflu. I'll let you know what my anecdotal evidence shows.
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That stinks! Get well soon.
 
You mean the vaccine didn't make you sick? :)

I got my pig flu shot last week, and as we were having a laugh on the elevator, i said to a group of residents "If this new vaccine gives me autism I'm going to be pissed!" :laugh:
 
CrazyPeds527 said:
You mean the vaccine didn't make you sick? :)

I got my pig flu shot last week, and as we were having a laugh on the elevator, i said to a group of residents "If this new vaccine gives me autism I'm going to be pissed!" :laugh:
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We debated if it would make us autistic and/or zombies like the vaccine in I am Legend
 
CrazyPeds527 said:
You mean the vaccine didn't make you sick? :)

I got my pig flu shot last week, and as we were having a laugh on the elevator, i said to a group of residents "If this new vaccine gives me autism I'm going to be pissed!" :laugh:
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I got mine today. We can combine our data for a definitive case series of n=2.
 
TexasRose said:
ooh, ooh, I got mine, too! But I got the intranasal version. A comparison data point? ;)
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I got the intranasal one about a month ago, no autism yet! ;)
 
Tamiflu (oseltamivir) is now approved to treat children as young as 2 WEEKS. Recommend 3 mg/kg BID for 5 days for infants...and dispense an appropriate oral syringe for doses less than 5 mL.
 
Way to resurrect an old thread! :)
At my hospital, we've been giving Tamiflu to infants when needed, with input from our pharmacists. Most of them get admitted.

I was just reading through this thread and remembering the glory days of late 2009. Interestingly, our seasonal flu numbers this year (2012-2013 flu season, including influenza B, H3N2, and H1N1) have bypassed our numbers during the 2009 H1N1 pandemic flu season (I'm at the same hospital now as I was at back then). It's definitely stretched our ED beyond capacity on repeated occasions. Fun times.
 
We're seeing some very bad flu as well. Most that have ended up in the unit have had staph superinfections. I've put three on ECMO in the past few months. Not pretty.
 
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