Every day about 3 p.m., nurses, doctors and staff in the emergency room at UPMC Children’s Hospital of Pittsburgh brace for impact.

That hour marks the beginning of an eight-hour stretch that in recent months has been the busiest time of day for the department, which has seen a spike in activity from a combination of respiratory syncytial virus (RSV), covid-19 and flu cases.

Dr. Raymond Pitetti, pediatric emergency medicine director at Children’s, said the surge, which aligns with a national rise in cases of the three viruses, is taking its toll on the ER team.

“The sheer volume of patients we are seeing is worse than it was during covid,” he said. “We are seeing historic numbers in terms of volume coming into the emergency department, and it is really hard right now on staff.”

Of the three viruses, covid cases are the most controlled, he said. The first rise in RSV cases began in August and September and is leveling off “a bit” but still shows higher numbers than normal. Flu cases also are on the rise, he said.

“We are still seeing, every day, a couple kids with covid, but nowhere near the numbers we were seeing before,” Pitetti said. “I think that with vaccinations and public awareness, we’ll still have covid — we’ll always have covid — but it is a little more controlled right now.”

Contagious challenges

RSV and the flu often present symptoms that resemble a common cold. RSV, in particular, can be devastating to young children and infants, Pitetti said.

“What RSV does is, it causes inflammation in your lungs, but it also causes secretions to increase,” he said. “The lungs get congested, and babies get particularly nasally congested. If their nose is all clogged up, it makes it really hard for them to feed if they have a bottle in their mouth. We will often see babies who have RSV have a really tough time feeding.”

RSV cases have increased tenfold compared to 2019, he said. Influenza and RSV normally are prevalent this time of year, but the winding-down of disease-mitigating precautions such as masks, social distancing and staying home when sick has meant more ill children coming to the hospital.

In 2020, there were virtually no cases of RSV, he said.

“During the height of the pandemic, it was easier to stay home — and businesses and employment, from my perspective, would cut you a break. I think that has sort of gone away,” he said. “The mitigation efforts we put into place for covid worked really well for RSV and the flu.

“Now, as we move into this new normal, people aren’t masking and social distancing like they were.”

Fewer families are getting their kids get vaccinated against the flu, Pitetti said.

“That whole anti-vax movement has really hurt the vaccination of children, inappropriately so,” he said.

A flood of patients

On a normal day, Pitetti said, patient volume in the Children’s ER in a 24-hour period hovers around 220 children. Nowadays, the ER is seeing “easily 250, 260, 270 per day,” with some days breaching 300 patients. The ER is seeing between 25 and 50 patients with RSV per day.

At the beginning of November, Children’s put up a tent outside its Lawrenceville hospital to add resources to deal with the influx of patients sick with RSV.

The tent is still used whenever the number of patients coming in requires more room, Pitetti said.

“We use (the tent) when we need it, when all the rooms in the ER are filled and there are a large number of patients waiting to be seen,” he said. “We only staff it when we need it, and typically, that’s in the evening hours. I get why it can be sort of concerning for the public when they see this tent, but I sort of look at it as, we are responding to the need and trying to provide resources to be able to effectively see these patients.”

The larger numbers of sick children have meant longer wait times, he added.

“There’s a lot of anger and anxiety and frustration on the part of the families because they have to wait,” he said.

Busy schedules

Dr. Jennifer Bradford, pediatrician at the Irwin office of Pediatric Associates of Westmoreland, said her office has been busier in recent weeks.

“In a day, usually you would see between 20 and 25. … Recently, it’s been in the 30s because of all the illness,” Bradford said. “Probably most commonly right now it’s flu, more than anything. We still have some covid here and there and RSV definitely, but I would say by far the majority of my kids are testing positive for flu.”

Bradford has seen increased concern among parents about both illnesses. She advised that if the situation is not severe, children don’t always need to be taken to the ER.

If the child is otherwise healthy and breathing normally and is staying hydrated, she said, it is fine for a parent to watch them at home. If the child’s fever lasts longer than three or four days, or if they are in any respiratory distress, caregivers should contact a doctor or the ER, she said.

“If it’s more severe, I would definitely have them go to an ER, but more often than not, I feel it’s probably something we can do here,” she said.

Schedules are packed at Allegheny Health Network pediatricians’ offices, too, said Dr. Joe Aracri, chair of AHN Pediatrics.

“We are seeing a lot of volume and a lot of kids coming to our offices, but the acuity is not high,” he said. “We are not seeing a lot of what we would call high acuity — that’s very sick children — but we are seeing a lot of sick children.”

Aracri described scheduling for pediatricians as “completely booked,” adding that parents have been bringing their children in more frequently for concerns about RSV than they did for covid.

“Especially when home testing for covid came around, parents would test their kids and keep them home if they had covid. For this, parents want to be seen,” he said.

For most kids who are not vulnerable infants, RSV is treated like a bad cold virus, he said, with rest, increasing fluids and acetaminophen or ibuprofen.

“Every child will have RSV twice by the time they are 2. It’s a common cold,” he said. “The ones that we get really concerned about are babies that have a history of being premature or having cardiac disease that requires them to be on oxygen or are immunocompromised, or kids going through chemo, babies under the age of 1, kids with a history of bad asthma.”

Wendy Reynolds, clinical director of the Family Additions Maternity Center at Excela Health Westmoreland Hospital, said new mothers are taught common signs of illness in their babies before they go home.

“Lethargy, not wanting to eat, crying, just general malaise, anytime a baby is not looking right or acting normally, you need to bring the baby back in,” Reynolds said.

Gretchen Peske, an Excela Health Homecare Hospital liaison, said Excela sends children with more severe cases of RSV to Children’s for treatment.

Future of the surge

Aracri expects pediatricians will be busy throughout the winter.

“RSV has already peaked and is starting to come down a little bit, but we are seeing flu and other colds,” he said. “The facts that kids have been separated and masked for the past couple years, their bodies are not really good at handling viruses, so we are expecting it to be a pretty busy year all the way through March.”

Similarly, Pitetti predicted the surge could last several months.

“When kids go back to school, that’s when we start to see these viruses circulating,” he said. “Winter break, spring break, when we break for summer, we will certainly see a drop then. … I think it is going to be another three, four, five months before we see that break.”