Why are all the kids sick right now? And can the system handle it?

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Jordan Heath-Rawlings If you’ve ever cared for a sick young child, you know the sinking feeling in your stomach hoping they’ll get better, doing everything you can to make them feel good. But you’re watching, wondering to determine when or if you need the experts, if you need to take your kid to the hospital. It is a truly awful feeling at the best of times. And this is not the best of times. Usually at this time of year, about 800 kids show up daily at Ontario’s Ers for respiratory illnesses. This past week it’s been nearly triple that. An Ottawa facility announced the opening of a second pediatric ICU. Sick Kids is also postponing surgeries. Children have been waiting months, even years, for the twelve hour wait to be seen at BC Children. The Alberta Children’s Hospital is overwhelmed with demand. There are waits of more than 4 hours just to clear triage. 17 hours to see a doctor with lineups out the door. Right now, most children’s hospitals in Canada are packed. Wait times are hours long, and at least until the supplies the government has procured make their way to store shelves, there isn’t much effective medication to be found to care for sick kids at home. So how did we get here? What is happening in children’s hospitals and why? What do parents need to know about the crisis in pediatric care? And how should they care for a sick kid given the current climate? I’m Jordan Heath-Rawlings. This is The Big Story. Dr. Catherine Smart is a practicing paediatrician in Canada’s North. She is also the past president of the Canadian Medical Association. Hello, Dr. Smart.

Katherine Smart Hello.

Jordan I want to start with the hat you are wearing right now. One of the reasons we called you. What is it like to be a pediatrician in Canada at this moment in time?

Katherine Smart Well, you know, I think for all of us, it’s a pretty intense time to be doing clinical medicine. You know, we’re seeing just a lot more volume of sick children than we typically would. And there’s pressures really across the system. In my setting, I work in Whitehorse in the Yukon, where we’re in a rural and remote setting. So when there’s only one of us on call a week at a time and I was just up there recently working, and I admitted more kids to the hospital in those seven days than I ever have in the last five years I’ve been working there. So there’s a lot of pressures, I think, from communities. Of course, everyone’s hearing in the news about our children’s hospitals and the overwhelming emergency departments. And I think that’s right now, just the story across the country, there’s a lot of kids sick with a lot of viral illness. I know you can’t probably cite stats from individual children’s hospitals, but to put that in context a bit around what people are hearing, what is going on at these children’s hospitals, I mean, particularly in Ontario where I think we’ve heard the most about the crisis. But now I understand we’re seeing high volumes in Alberta and BC and every province is getting hit. Absolutely. I think it is really the same thing across the country. And what’s happening is we’re just seeing a lot of very significant viruses that are common for children to get all happening at the same time. So you’re hearing people start to say the Tridentemic, the big three that are out there right now are RSV influenza, and influenza is really spiking right now and still COVID. And in the background there’s other common viruses that are still circulating. Things like enterovirus para, influenza, Abnovirus. These things are also in our communities, so they’re happening kind of all at the same time. So what that’s creating is a lot of kids getting sick simultaneously and it’s leading to just really unusual volumes of people presenting for medical care. And this is of course in a backdrop of more challenge access in carrying the community, fewer family doctors, less primary care, so more reliance on emergency departments, and that’s been very stressful. And we’re seeing volumes double or triple what would be typical. And because the other aspect of what’s going on here is we have kind of three cohorts of kids who are getting exposed to these common respiratory viruses all at the same time. So that denominator of the number of children who are sick and needing admission and at times needing critical care is also larger than normal. And that’s why we’re hearing things like ICU’s being overwhelmed and children’s hospitals having to stand up, additional intensive care capacity to meet the needs of this surge. That would be atypical in a moment I want to get into the reasons for that and then I’ll get you to give some practical advice to parents who might be struggling right now. But first, I think by now, everyone listening to this show is very familiar with COVID and what it does. We all understand the flu.

Jordan Can you just explain what RSV is and why and how it can be so dangerous to young kids?

Katherine Smart Absolutely. So RSV is a virus that pediatricians have never liked. It’s respiratory virus. That’s particularly concerning in young children, especially kids under twelve months of age. And the reason for that is in younger kids it can get down into their lungs and cause lower airway inflammation or inflammation of the lungs. And what that looks like clinically is a child who is full of snot, lots of runny nose and congestion, but also weaving and struggling to breathe and work of breathing. And that clinical name we use for that is bronchiolitis. And that happens mostly in young kids. And it can be a really common reason, in fact, it’s the most common reason for hospitalization in kids under twelve months of age. So this is not a new phenomenon we’ve dealt with this forever. I think what’s different right now is it’s just people are talking about it a lot more. And because it’s happening with these other viral surges all at the same time, it is contributing to those pressures that we’re seeing. What’s a bit different right now is, you know, RSV, it’s so common that almost all children will have had an RSV infection by the time they’re too at least 90% of kids. And each time you get RSV, it’s more mild. So usually the first time you get it, you’re the sickest, and then your immunity builds over time and gradually it just becomes a common cold. And in older kids or adults that get RSV, you would just have a runny nose and maybe a bit of cough and you wouldn’t think much of it. But what’s happening right now is we have three cohorts of kids who have not had that same exposure to RSV as it was typical. So we’re seeing that bronchitis or that lower airways inflammation, clinical picture needing oxygen, more distress, sometimes hospitalization sort of happening in three years of kids all at once. And that’s another reason why we’re seeing those pressures on our hospitals.

Jordan So I have heard this theory discussed. There are other ones that I want to get to in a second, but since you just discussed it, the common theory circulating is that this is the result of a, quote, unquote, immunity debt. Can you explain what that is and what evidence do we have that that’s what’s causing this search?

Katherine Smart Yeah, important question, because that language is sort of out there, particularly on Twitter, I think, right now. And I think it’s challenging language because people are using it to mean a variety of things. So it’s a challenging term and I think it’s important that we talk about it. So people are meaning two different things when they’re using that language. Some people are referring to individual children, other people are referring to immunity at a population level. So really, I think what’s important for people listening to understand is there’s kind of two things. One is children’s immune systems are working just fine and children are not harmed by not having infections, but they don’t build up immunity when they’re not exposed to common viruses. So it’s not that we’re saying it’s good to get sick, but we do live in an ecosystem with viruses. And over time, as you get exposed to these common viruses in your day to day life as children, you become immune and over time, those infections get less severe. And that’s a normal process because of the pandemic protections, which were good and appropriate and necessary. We had two years of much less viral circulation in the community. Things like influenza all but disappeared the first year. RSV, we saw none of it. It did come back after that, but not at the same level that we would normally see. So kids have not had those common exposures. That’s not bad. I mean, that’s good. We don’t want young children getting these infections because they can be significant. But it also does mean at a population level, we don’t have the same level of immunity that we would typically have. We’re also seeing these viruses circulated atypical times. So when RSV came back last year, it was more in the summer. It’s been early this year. It started in the summer, it’s now gone into fall. So the patterns are different than what’s typical as well. And of course, the challenge this time of year, colder weather, more people indoors. Now we’re really back to a much higher level of social interaction with each other. People are not masking anymore. These things are spreading much more aggressively. And that’s what we’re seeing in the pediatric population right now. Now, what’s I think important to understand, the other thing that people are sort of talking about is this some sort of mass immunosuppression from children having COVID.

Jordan That was my next question. That is a theory that’s everywhere right now. And I wanted to know if we do have any evidence, what do we know about that?

Katherine Smart Yeah, so it’s really a theory. There’s really no evidence that that’s the case. And what I can tell you is no one that I’ve spoken to who’s a pediatric clinician or an expert in child health thinks that that’s very plausible. What we’re seeing right now is not different than what we would normally see. The difference is the denominator. It’s not the actual clinical presentation. So these viruses have always caused severe disease in some children, and let’s say 1% of kids need hospitalization or in some cases intensive care. That’s not new. But what’s different right now is that denominator is so much bigger. So all of a sudden, if it’s 1% of 300, that’s a lot different than if it’s 1% of 100, as an example. And that’s the challenge that we’re seeing. When you look at other countries that were coveted, spread differently than here, places like New Zealand, they’re seeing the exact same thing that we’re seeing, and they did not have the same timing of things. So there’s really, you know, when you look around the globe, there’s really nothing suggesting that this is likely a COVID immune effect. Now, of course, COVID is a novel virus. I think it’s always good to stay curious and monitor what’s going on. But right now, I think people really don’t feel that that’s a very plausible concern.

Jordan If we’re talking about just the surge in young kids in hospitals, are there any other factors that are contributing to that? And just to mention a couple, you know, we could talk about COVID precautions, as you mentioned, kind of mostly gone by the wayside at this point. But also the government is pushing hard, they say, to get fever, reducers children’s pain medication, Tylenol, Advil, etc. On store shelves. What role has that shortage played, if any, in this search.

Katherine Smart Yeah, those are great questions. So I think there’s a few things going on. No question that the lack of access to things like tylenol and Advil that people use at home, of course, to self manage these conditions in kids has been a factor. So fever itself is not dangerous in children, but it does make kids feel awful. So if you’re a parent with a highly febrile child and you’re not able to bring that fever down, your child is going to look worse to you, you’re going to be worried and you’re going to feel like, I need to do something about this. And if you’re not able to access that medication, you’re going to go to the hospital looking for it. And I’m hearing that from many colleagues that work in paediatric emergency departments. They’re seeing a lot of families that are really there looking for medication. So that’s absolutely a factor in that overwhelm. So that’s really concerning. Another factor right now is just incredible spike we’re seeing in influenza and the overall low rates of vaccination uptake. So I think it’s really important for people to know influenza is vaccine preventable. It’s a high risk disease in young children. It can make anybody sick, but particularly in kids under two kids, six months and up can be vaccinated, as can older children and adults. But we’re not seeing great uptake of the flu vaccine, so that’s a contributor as well. So I’d really urge people to get your flu vaccine this year. It’s a very good match for the circulating strain of flu, so that’s something that we could be doing. But again, I think there’s that bit of fatigue around vaccination after all the push around COVID, we also have very poor uptake of the COVID vaccine, young kids, so that’s also putting young children more at risk of COVID which is highly circulating, so we’re not necessarily taking advantage of those protective tools that are available to us. And then, of course, the masking, even though we’re being told and encouraged to mask in indoor places, I think any of us who are out in public, you’ll look around and you’re often the only person wearing a mask, or maybe there’s one or two other people. But clearly as a society, we have not latched on to this idea of masking in indoor crowded spaces. So that’s another thing that’s just allowing these viruses to circulate more, especially right now when we’re indoors more together. Also encouraged to wear masks means a very different thing to young children than older adults who just are better able to be the only one wearing them, perhaps if they want to. Yeah, absolutely. And of course, really young children can’t wear masks effectively. You know, full aged kids absolutely can. But a two year old or a one year old, I mean, you could put a mask on them, but it’s not going to be worn in a way that’s likely to be very effective. But certainly older kids and adults can be helping by masking right now, for sure.

Jordan With regards to vaccines, And I’m just curious about this. Are we seeing lower uptake than usual of the flu shot this year? And is that because of the misinformation around the COVID vaccine, like, let’s say, two or three years ago? Was the uptake better?

Katherine Smart That’s a good question. I haven’t seen the exact statistics, so I couldn’t tell you for sure. But what I’m hearing is we’re not seeing resounding demand for the flu shot. So I think it is challenging. I do think there’s a few things that play. The misinformation piece has been really challenging around vaccination, and I think it’s brought that vaccine hesitancy up again, where people are kind of going, oh, should I get vaccinated or not? I don’t know. There’s a lot of really negative messaging out there on social media around it. And what I really noticed in my work as a pediatrician is for a lot of families, it’s not necessarily that they’re anti-vaxxers. We all know there’s this hardcore group of people that are really aggressively spreading misinformation and are really anti vaccine. I don’t think that’s the majority of people, but sometimes that messaging is just enough to plant that seed of doubt that leads to Hesitancy, and Hesitancy leads to not making a decision. And that’s what I find for a lot of families I talk to. It’s not that they’re not going to get vaccinated, they’re just not sure. And because they’re not sure, they haven’t actually done it. And it’s moving people, I think, to answer their questions so they can move from uncertainty to feeling confident to choose the vaccination. And right now, especially for influenza, I think that’s really, really important because the numbers that we’re seeing are really concerning and it can make children very, very sick and those outcomes can be prevented with a very safe vaccine.

Jordan So vaccines first for flu, then for COVID. Priority one, let’s be practical a bit for parents. What else should parents of young kids under the age of ten, under the age of eight, what should they be doing right now while we’re in this tridemic?

Katherine Smart Yeah, great question. So I think what’s really important is a few things. One, keep your child home when they’re not well. That’s really critical because when kids are coughing and runny noses and around each other, that’s how these things spread. So it’s really important to stay home when you’re not feeling well. But that being said, I think this is another source of stress, right? People haven’t had to miss a lot of work. It’s challenging when your kids aren’t able to go to school or daycare. So I think that’s a stress for parents and I think that’s something we need to think about. And at this time of year, yes, kids are almost always snotty or coughing in some capacity. Absolutely. And I think that is what’s so tricky. Right? And then what are we doing, sort of as a society to support parents in that way? Like, with paid sick time support to have your kids at home, right? Like, it’s one thing to ask people to do something, it’s another thing to have practical support so that they’re able to do it. And I think that’s really challenging. You know, you want to keep your kids away from other kids that are sick. That’s obviously important. Good hand washing is important. Having your child masking if they’re old enough when you’re in crowded indoor spaces, those things are helpful. And then, of course, making sure all their routine vaccinations, as well as flu and COVID are up to date, those are really the things as a parent, that you’re able to do. I know from experience, and I know probably anybody listening to this who is a parent will have the same experience. As much as we hear horror stories about what it’s like to wait in Er at children’s hospitals right now, having a sick kid at home that’s not getting better can be really scary.

Jordan What would you tell parents about when they should consider a trip to the ER, given the current climate? What should they try first? And when do you just pack up and go anyway?

Katherine Smart I think there’s really three main danger signs in kids in the context of infectious illness. When you want to seek emergency care, let’s say maybe four, so one is a young infant. So kids three months and under with fever really do need to be seen urgently to have that assessed, because the risk of a bacterial infection is much higher in young infants. So that’s a special group of children that really do need a medical attention if they’re febrile at all. In older children, there’s really sort of three broad areas, what I like to call the danger signs, or when, as a parent, you should be concerned and seek medical care. So one is starting with their overall appearance. One thing we talk a lot about in pediatrics is kids really show us with how they look and how they’re interacting with their environment, if they’re sick or not sick. So a really sick child will have a really abnormal appearance. And what I mean by that is they’re going to look really lethargic and not really normally responsive to you as the parent. They’re going to be potentially difficult to console, they’re not going to be interacting normally with the environment, and you’re going to look at them and be like, Whoa. Like, this is not my kids. Something is really off here. Now, of course, often when kids have a fever, they can look a bit like that, but the difference is, as the fever comes down, or as you move through a few hours of the day, you’ll notice there’s kind of peaks and valleys, right? Times they don’t look great, but then times they perk up. So as long as you’re seeing that up and down, you know you’re okay. But if you’re in that valley and your child’s really not improving, that’s a real concerning sign, and you need to seek care. The second thing is hydration status. So one of the big risks that children aren’t drinking well, especially if they have vomiting or diarrhea, which are common viral symptoms, is dehydration. So the signs there would be, again, that abnormal appearance, but also maybe no tears when they’re crying, dry inside the mouth, not peeing normally. Those are signs that you need to get medical care as well. And the third one is really the breathing side of things because, of course, with a lot of viruses, what we’re worried about is them getting down in the lungs and causing difficulties breathing. And what you’re going to see there is what we call work of breathing normally. When you look at a child, it’s imperceptible that they’re breathing. A child who’s got a problem in their lung, whether it’s viral inflammation or bacterial pneumonia, they’re going to be struggling to breathe, so they’re going to be breathing fast. You’re going to see effort with those muscles, meaning they’re sucking in under the ribs, in between the ribs, their nose may be flaring or they may start going off colour. So if you’re seeing those signs of respiratory distress, that’s another reason to be seen. So those are really the big three things appearance, hydration status, work of breathing. When those things are off, you really do need to seek medical care immediately based on what you’re seeing in your practice and what your colleagues are telling you.

Jordan If it does get to that point, and parents need to go, I mean, they’ve heard a lot of awful stuff, what should they expect? And do you have any tips for you’ve got ahead to the emergency room?

Katherine Smart Yeah, I think there’s a few things. One, if you have access to somewhere else to touch base, that can be a good place to start. Unless, you know, your child’s really struggling to breathe, some of these other things can be assessed in your community. So if you have access to a family doctor, virtual service or paediatrician, that can be a good starting point. If you’re really worried about your child, like those three things we were talking about, and you really think your child is very sick, absolutely. Go to the emergency department. It’s important for people to know that emergency departments aren’t first come, first serve. You’re going to be triaged by an experienced nurse who’s going to check your child’s vital signs, look at all those things, and decide how urgently they need to be seen by a physician. They’re also able to start supportive care if needed. So, you know, say your child did need oxygen or need some fluids. Those things can be started at the triage process. So it’s important, I think, for parents not to be dissuaded by wait times. Those wait times that we hear that are long, those are not for children that are critically ill. Those are for kids that often have less severe problems now, not to minimize that. Of course, when you’re worried about your child, you want to be seen. And it’s horrible to be waiting no matter why you’re there. But there is a process in place to make sure that the sickest people are seen first. And the last thing we would want is ever for parents to be staying home with a really sick child because they’re worried about that weight. So that’s why we have those triage processes in place.

Jordan What are you hearing from parents right now about the crisis in paediatric, Karen, and what are you telling them when they ask you about how bad it is?

Katherine Smart I’m hearing a lot of concern from parents because I think the other thing we need to realize is it’s not only that people are concerned with their sick children and how to get medical attention for them, there’s also a lot of other impacts on other families who are having their surgeries canceled. Other things diagnostic imaging, other procedures that require that specialized care of a children’s hospital, a lot of those things are being deferred again, as those resources are being pivoted to help with this viral surge. So people are really being impacted in a variety of ways, both people with acutely sick kids, but also families who are waiting and waiting and waiting, and the wait times for paediatric surgery and some paediatric diagnostic imaging and in a lot of places, including Ontario, are actually longer than adults. And of course, in paediatrics, there’s no such thing as elective surgery. If your child needs an operation, it’s because they need an operation. And right now, we’ve got kids that have been waiting for years in some cases for certain procedures. So that’s really stressful for parents. The other thing I’m hearing is people are concerned even about having procedures like will I be able to get Tylenol or advocate for pain control and should I be deferring my child’s operation if I’m lucky enough to get one? Because I’m not sure I’m able to manage their pain at home. So that’s worrying people. You know, people, of course, are worried about their child getting sick and having to go to an emergency and wait a long time. People are worried about losing access to primary care providers in their communities, which, again, forces more people to go to the Ed if they’re not able to find a touch point with a community based provider. So that’s worrying people. And I think parents, they’re struggling, right? Like, just what you said before, kids can have a cough or runny nose for days or weeks, like, at what point can I send them back to school? When is that reasonable? How am I balancing that with my job? You know, there’s a lot of stresses right now for families. A lot of pressure people are under and I think when you’re seeing all these headlines it just adds to that cumulative stress. And of course this is we’re almost three years into this now. It’s on the background of a really stressful time that people have been going through. So that cumulative trauma, unfortunately it’s ongoing, I think at this point for everyone, including providers and families and patients.

Jordan One last question, how long can this keep up for? You mentioned everything seems to be peaking. At the same time, everybody’s now familiar with the prospect of waves from the pandemic. Are we going to burn through the kid population quickly enough to get things back under control? Well, that’s the million dollar question really, isn’t it?

Katherine Smart I think we are seeing some signs that RSV may be plateauing a little bit, so we’ll see. But again, that virus is usually around for several months so I don’t necessarily think it’s going to go away completely, but we may not be quite seen. The dramatic surge, influenza is really on vertical rise right now. So what happens there I think is going to depend on what people do. Do people get their vaccines? Are people going to start masking again more in public, staying home when they’re sick? These are all things that could blunt that impact. So I think exactly how long it goes on and how dramatic it is is going to depend a lot on the choices that people make here over the next few weeks. Those other respiratory viruses, they’re around in the winter, they’re not going anywhere either. So I think we’re probably going to see a bit of a peak and then a slow burn. I don’t think we’re necessarily through it yet. I think the next few months are still going to be challenging and it’s something that we’re going to really have to continue to monitor very closely and make sure that we’re trying to get those supports to people in our pediatric hospitals to be able to continue to deal with these pressures.

Jordan Dr. Smart, thank you so much for this. As always, very informative. Thanks for having me. Dr. Smart is a pediatrician and a former president of the Canadian Medical Association. That was the big story. I will say only one thing here to reassure you. If you are a parent of young children and you are a little freaked out about the possibility of needing the Er, I have been in the exact situation Dr. Smart described with a child with RSV headed to a crowded emergency room. The nurses at Triage take care of you and children’s hospitals, I swear to God, are the worst places to have to go once you’re there. They are the best place in the world to be. So if your child is struggling to breathe, is really sick, don’t worry about the wait times go. They’ll look after you. You can find the big. Story at thebigstorypodcast CA. You can talk to us on Twitter at thebigstory FPN for as long as it works. You can email us hello at thebigstorypodcast CA, and of course, call us 416-935-5935 the Big Story is available in every podcast player you possibly want, and it’s available on your smart speaker. Just ask it to play the big story podcast. Thanks for listening. I’m Jordan Heath-Rawlings. We’ll talk tomorrow.