Swine flu: the risks for children

The H1N1 virus is back, and the young are most vulnerable. Just how worried should we be – and how can we keep our children safe? Jeremy Laurance gets the answers from Britain's leading paediatrician

In the swirl of speculation about swine flu, one man has been fielding more calls than most. Professor Terence Stephenson, president of the Royal College of Paediatrics and Child Health, is the sort of expert most parents would choose to have beside them when – if – their child falls ill with the winter lurgy. They have not been slow to seek his advice.

"I spent so much time answering questions from friends, relatives and the media about swine flu, that I decided to write the answers in a book. I approached the publishers who were fantastic in turning the concept around quickly. I wrote it in August at a friend's house in France and delivered it on 26 August. I hope it will save me from taking so many calls and emails."

The result is Swine Flu – What Parents need to Know, 150 pages of sage advice published this month. It is an impressive feat for a man who is the father of teenage children, Lucy and Patrick, head of a medical royal college and, on 1 October, took up a new post as Nuffield Professor of Child Health at University College London, and honorary consultant paediatrician at Great Ormond Street Hospital. If you want something done, ask a busy person.



How dangerous is swine flu?

"No more dangerous than seasonal flu – that is what all the evidence suggests. But there is an important caveat. Swine flu is caused by a novel H1N1 virus to which most people, especially the young, have no immunity. Up to 30 per cent of the world's population could be infected by it.

"If you get a lot more people infected , more will become seriously ill and more will die. Swine flu does not affect children more severely than adults – the percentage being admitted to intensive care and dying is no greater than for other age groups although the death of any child is a tragedy for their family. But more children are getting infected.

"This is like the 1977 "red" flu outbreak, which started in Russia. It almost exclusively affected people under 25. Why are young people more prone to infection? One theory is that we are not all complete bio-virgins so far as this virus is concerned. When you get to 40 or 50 there seems to be some immunity from exposure to other strains.

"The elderly tend to be most vulnerable in seasonal flu outbreaks, which is owing to poorer nutrition, general frailty and chronic conditions. With swine flu they appear less likely to get infected."



Which children are at greatest risk?

"The Government says that all those who have had drug treatment in the past three years for asthma are at increased risk. This is contentious. One in five young children will have had a wheezy episode at some point. I doubt all these are at serious risk from swine flu.

"There is also no evidence for the recommendation that all children who attend hospital with a flu-like illness but are not ill enough to warrant admission should be sent home with a supply of antibiotics. Only children with a suspected bacterial complication of swine flu should be prescribed antibiotics.

"However, those children with chronic conditions, such as lung, heart, kidney, liver or neurological disease or diabetes may be at increased risk."

Should I have my children vaccinated against swine flu?

"I will be having it [as a front line health worker] and I will recommend my children have it. This is not an illness I want to get. I could be quite ill with it, I could be off work with a high, swinging fever for four or five days, diarrhoea and vomiting. I want to avoid that.

"A survey by the magazine Nursing Times found a third of nurses would refuse the vaccine. That presumably reflects their perception that it is not a very serious illness. "This raises a fundamental issue about vaccination. For an individual parent the risk of swine flu to their child is low, so the benefit from vaccination is low. But if you have a virus that affects 30 per cent of the population then a lot of people will fall ill and a lot will die and the best way to prevent that is to have all the population vaccinated.

"The benefit for any one individual is low but the benefit for the population is great. The benefit will be greatest for very young children and those with chronic conditions and the elderly because they are most vulnerable. By accepting vaccination we help to protect them."



Should I give my children Tamiflu?

"At the onset of symptoms no one can say if this will be an average attack of flu and the child will get better in four or five days, or if will it lead to complications like pneumonia. My children have asked me if they should take Tamiflu and I have said 'yes' and I would take it myself. The side effects are minimal and if it prevents complications and shortens the illness by one day that is worth doing. The numbers affected by the virus could be big and any drug that shortens the severity, longevity and spread of the illness is worth having. Some other countries do not have the liberal prescribing policies that we have but that is because we have built up a large stockpile of Tamiflu. We are lucky enough to have it, we have paid our taxes, so let's use it."

How do I get my child to take Tamiflu?

"If a child cannot swallow the capsule it can be opened and the powder sprinkled on food. However, the powder is very bitter and experience has shown that unless it is disguised young children will refuse further doses. The manufacturer of Tamiflu [Roche] recommends a variety of foods to disguise the taste but experience has shown that undiluted blackcurrant drink concentrate such as Ribena or chocolate syrup (the runny kind that is poured or squirted, not chocolate spread) work best. They are universally popular tastes. Even though Ribena labels carry a warning that they are unsuitable for children under three, if the small amount means children accept their doses then it can be used."



Do face masks offer protection against swine flu?

"I am against [ordinary surgical] face masks for the public, such as we saw on the streets of Hong Kong during the Sars outbreak and on some tourists here in July. If you wear one all day it gets soggy and stops working, if you touch it you transmit the virus on your hands and it may spread complacency. There is no evidence that for the public they are of any benefit. However, for doctors or health staff examining a patient they are useful because they offer protection if the patient coughs or sneezes all over you. And health workers are more likely to change them regularly."



Will the NHS be able to cope with swine flu?

"It depends critically on intensive care. That will be the pinch point. Even though swine flu may be no more lethal than seasonal flu, and the vast majority of people suffer only mild illness, it could still overwhelm the NHS. There are 3,636 intensive care beds and a third of those are for specialist treatment such as burns and spinal injuries. Even the Cabinet Office admits the intensive care system might struggle to cope.

"We can cancel routine operations, and open up more beds, provided there are the staff to run them. But in a real pandemic with 30 per cent of the population affected it is hard to imagine any health service in the world could cope. You would need thousands of intensive care beds that for the rest of the year would do nothing. The NHS is as prepared as any health service anywhere."



How bad will swine flu turn out to be?

"No one knows for sure. We will only find out when it comes. It is unlikely to be a complete damp squib and case numbers are rising again each week. We don't know if it will mirror experience in the southern hemisphere where it has not been particularly bad or whether the higher population density in the northern hemisphere could lead to a very serious pandemic. There is a higher population living in temperate zones in the northern hemisphere where people live indoors. In Australia and South Africa people spend more time outdoors even in winter. That could make a difference."



'Swine Flu – What Parents Need To Know', by Professor Terence Stephenson, Jessica Kingsley, £7.99

Is it swine flu? The telltale signs

* Typical symptoms of swine flu are fever, cough and runny nose. These are the same for seasonal flu. But it can be difficult to distinguish from the common cold and other winter viral illnesses. Anti-viral drugs such as Tamiflu are only effective if given early so there are bound to be cases where it is given unnecessarily. But while Tamiflu is not a treatment for a cold, neither will it make it worse.

* Potentially more serious is the child diagnosed with swine flu at home and given Tamiflu who actually has a more serious disease. I have heard of a new case of diabetes (the patient had a headache and abdominal pain) and of meningitis being treated initially with Tamiflu. This is almost inevitable when there are large numbers of cases. The only advice I can give is to ask parents to remain vigilant. If their child deteriorates markedly they should seek further advice.



* If your child has any of the following they should go straight to A&E or call 999:

Severe breathing distress – indrawing of lower ribcage or breast bone, noisy breathing when calm.

Increased breathing rate – more than 40 breaths a minute (50 breaths for the under ones).

Lips and skin appear grey or blue.

Breathing stops intermittently – pauses of over 20 seconds.

Severe dehydration or shock – not drinking and sunken eyes or fontanelle (the soft spot on the head of a baby).

Altered conscious level – strikingly agitated, irritable, having seizures, or generally floppy.

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