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(2009-02-10 18:19:19)



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.”










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。




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。





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。






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