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咳嗽和流鼻涕的问题:什么时候让孩子待在家里?

(2009-02-10 18:19:19)
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杂谈

There are moments when I feel I have spent large parts of my professional life dropping off my own marginally ill children at school (or at day care) and then hurrying to work to examine children who are notably less sick but have been kept home by their parents and brought to see the doctor.

I’m talking about the common cold, the winter crud, the lingering nasal drips and irritated coughs that mark our children’s passage through the varied mix of respiratory viruses — or perhaps mark the viruses’ passage through our children.


What I’m not talking about is childhood fever. I vigorously deny those vile rumors that I occasionally, in the distant deniable past, gave my warm-to-the-touch toddler a big dose of ibuprofen at day-care drop-off time — though we’re admittedly entering into the Deepest Secrets of the Working Parent Zone here. The child with fever clearly needs to stay home, as does the child who is vomiting or is just plain miserable.

On the other hand, I do remember getting several calls from day-care directors or school nurses to inform me that although my child seemed happy and active, there was in fact a lurking fever — and I remember biting back the question, what kind of zealot takes the temperature of a happy, active child?

But of course, they were worrying about the other children. And that is a fair question with any child who is borderline sick: who is infectious, what’s the risk, and is there anything we can do to reduce it?

Doctors, as a group, are big believers in sending children to school. Every doctor I’ve talked to is more concerned about children unnecessarily missing school than about their posing an infection risk to their classmates.

What do we know about the common cold, and about how it is transmitted? Just how infectious is that child whose cough hangs on for weeks? And how about the one with the drippy nose?

One problem is that there are many different viruses.

Dr. Caroline Breese Hall, a professor of pediatrics and medicine at the University of Rochester, has a particular interest in the transmission of viruses. She recalled a study years ago on respiratory syncytial virus, or R.S.V.

This virus can cause serious infections in infants, but in school-age children and adults, it generally causes a plain old common cold. Dr. Hall’s study looked at how hospitalized babies did or did not transmit the virus to “sitters, touchers and cuddlers.” The sitters were adults who sat in the room, more than three feet away from the infected baby. The touchers came into the room when the baby wasn’t there and touched the area around the crib. And you can guess what the cuddlers did.

The sitters didn’t catch the virus at all. The cuddlers did, and so did the touchers, pointing up the importance of direct contact with secretions, but especially of fomites — objects and surfaces with infectious viral particles still on them. It was more dangerous to touch the empty crib than to sit in the room with the sick baby.

Children with viral infections can be infectious before they show symptoms, as well as after their symptoms clear up. On the other hand, some children with R.S.V. can cough for weeks, not because there are still viral particles but because the virus has affected the lining of their lungs.

So you can have an asymptomatic child who is shedding virus, a coughing child who is no longer shedding virus, and infection by viral particles that lurk on surfaces and objects. “It’s not practical to keep everybody out who’s shedding virus — that’s everybody all winter long,” said Dr. Robert Tolan, chief of the division of allergy, immunology and infectious diseases at the Children’s Hospital at St. Peter’s University Hospital in New Brunswick, N.J.

How, then, do you reduce infections?

“The only thing we can really show well in infection control is hand washing,” Dr. Hall said. “Even for those viruses that are spread by aerosol” — through the air.

The bottom line, then, is this: Keep your child home from school if there’s fever, or if the child feels too crummy to participate — but don’t worry so much about the runny nose in the row behind.

And you can certainly take precautions to make sure that a runny nose is not the harbinger of a more serious disease. Children should be fully immunized against pertussis (whooping cough) and measles, for example, and the American Academy of Pediatrics recommends an annual flu shot for all children from 6 months to 18 years old.

Probably less helpful is giving cold and cough preparations to try to ease a child’s symptoms. Dr. Michael Shannon, a pediatrician and toxicologist at Children’s Hospital Boston and Harvard Medical School, was one of the public health experts who successfully petitioned the Food and Drug Administration to stop the marketing of cold remedies to parents of young children.

In 2008, the F.D.A. advised that such medications not be used in children under 2, to whom they can be dangerous. “At best these medications are about 6 percent effective, at making adults or school-age children have relief from symptoms,” Dr. Shannon told me.

And what really excites the experts is the possibility of instituting infection-control measures in the schools: hand washing, hand washing, hand washing, but maybe also dispensers for hand sanitizer, faucets that turn on automatically, bathroom doors that open when you approach them — all the strategies to reduce the chance that viral particles will make it onto a child’s hand, and from there to the receptive epithelium of the nose or the eyes.

It is precisely those kinds of infection-control measures on which we clinic personnel rely to keep ourselves healthy and do our jobs — and which, in the long run, will do a lot to keep schoolchildren from getting sick.

Or as Dr. Hall put it: “Taking one child out of the school who sits next to your child is going to do little when your child goes into the lunchroom and there are secretions all over the table. You cannot focus on one sick child because there’s a world of much cleverer microbes.”

 

我感觉在我的工作时间中丢下我自己在学校或日托生病的孩子忙着去检查其实病得很轻但被家长留在家里并去看医生的孩子这种情况常常发生。

我谈论的是普通的感冒,冬天的污物,不停的鼻涕和令人烦恼的咳嗽声标示着我们的孩子染上了各类混合的感冒病毒,或者可能是病毒经过了我们的孩子。

我谈论的不是发烧。我强烈反对加诸于我的污蔑,说我偶尔给需要温暖的孩子在日托中吃抗生素——虽然我们公认地加入了双职工家庭深层秘密中心。发烧的孩子明显需要待在家里,就像呕吐或是很痛苦的孩子一样。

另一方面,我还记得从日托管理者和学校护士那里收到好几个电话告知我虽然我的孩子看起来开心又活泼,实际上发着低烧——我还记得我抑制不住问了这个问题,什么样的烧能使小孩又开心又活泼?

当然,他们对其他小孩也很担忧。对任何可能生病的小孩来说那是一个正常的问题:谁会传染,谁有危险,我们又能做什么来预防它?

医生,作为一个群体,是相信将孩子送到学校的。和我谈论过的医生更关心孩子不必要地逃学超过他们可能传染给同学的风险。

关于通常的感冒和它如何传染我们知道什么呢?咳嗽了几周的孩子传染性有多高呢?流鼻涕的孩子又如何呢?

有许多不同的病毒是一个问题。

罗切斯特大学的儿科和药学教授Caroline Breese Hall博士,对病毒的传播特别感兴趣。她一年前恢复了一个关于呼吸道病毒的研究。

病毒能对婴儿产生严重的感染,但对学龄儿童和成年人,它通常只能引起普通感冒。Hall博士的研究是关于婴儿是否会传染病毒给看护、接触、拥抱者。看护者是坐在病房里的成年人,离生病的婴儿还有3英尺远。接触者是当孩子不在的时候进来接触童床周边的。你可以猜猜拥抱者是干嘛的。

看护者并不会染上病毒。拥抱者和接触者会染上,这里强调了直接和分泌物接触的重要性,但特别是污染物——内外都还有传染性的微粒。接触空的童床比坐在有生病的婴儿房间里更危险。

染上传染病的孩子们在表现病征前也有传染性,病征消除后也有。另一方面,染上传染病的孩子可能咳嗽几个星期,不是因为传染病毒还在,而是因为病毒影响了他们的肺部。

所以你可能有一个摆脱病毒无症状的孩子,或者一个没摆脱病毒咳嗽的孩子,传染性病菌会潜伏在内外的。“将正在摆脱病毒的人隔离在所有人之外是不实用的——每个人都会觉得像冬天那么长,”新泽西州新布伦威克市St.Peter医科大学的儿童医院的过敏症,免疫学,传染病主要领导Rober Tolan医生说。

那么,怎么来减少传染呢?

“我们在传播控制方面能很好做到的只有洗手,”Hall博士说。“即使病毒是通过气体——空气传播的。”

底线是:如果孩子发烧或是很不舒服不能上学就让他留在家里,但是不要过于担心在最后一排流鼻涕。

而且你必定可以采取预防措施来确认流鼻涕不是更严重的病的预兆。比如说,应当使孩子们完全免疫百日咳和麻疹,而且美国儿科协会给6岁到18岁所有孩子每年的流感防疫针。

可能对于感冒咳嗽的准备来试图减轻孩子症状是很少有所帮助的。波士顿哈佛医学院儿科医院的儿科医生和病毒学家Michael Shannon,是成功呼吁食品药物部门停止给予小孩子父母感冒药市场的公众专家之一。

2008年,美国食品及药物检验局通告称这样的药物由于危险性不能对2岁以下的小孩使用。“这些药物对学龄儿童和成年人减弱症状最多有6%的功效,”Shannon医生告诉我。

真正使专家兴奋的是可能开始研究学校的预防措施工作:洗手,可能分发杀菌剂,自动水龙头,靠近就打开的浴室门——所有降低传染病毒到小孩手上,从那又到敏锐的鼻子和眼睛上皮细胞可能性的策略。

我们诊所个人依靠这些刻板的病毒控制措施来保持健康,持续工作。从长远看来,能为学校生病的孩子做更多。

就像Hall医生说得一样:“将一个坐在你孩子邻座的孩子带出学校并不能为你进入桌上到处都是分泌物的食堂的孩子做些什么。你不能只关注一个生病的孩子因为更聪明的细菌充满了世界。”

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