Erin Haddad-Null's 4-year-old son had a cold with a persistent cough for several days leading up to his birthday last year.

A day after his birthday party, Oct. 23, he woke up significantly sicker, wheezing with labored breathing, and his parents took him to the Comer Children's Hospital emergency room.

"He was never actually diagnosed with RSV, but they said pretty much, 'You can pretty much just assume he has it,'" she said. "One of the other children at the daycare he attends had been diagnosed with it and attended before they knew what it was."

The emergency department was busy with families of young children in similar situations to Haddad-Null's son. They were among the many, many children in Hyde Park and beyond who got incredibly sick late last year, one infection after another, taxing both their parents and the pediatric health care system.

The infections young children get have gone out of sorts in recent years due to the COVID-19 pandemic, and it is unclear when things will return to normal.

Haddad-Null's text message group with other daycare parents buzzed when her son was sick.

"It was a tough time for everyone. We were talking about how worried we were and exhausted. I remember at one point on the text exchange saying that I had burned through all my sick time," she said.

The family had gotten COVID-19 in September after an outbreak at the daycare, which shut the facility down for about a week.

"We were fortunate medically that they were mild cases; mild for my son meant that he seemed pretty unaffected by it," Haddad-Null said. "I was miserable. I felt really, really sick. But all things considered, I didn't have that high of a fever, didn't need to be hospitalized. I just was very knocked-out for a few days, and then the symptoms lingered for a while."

The opposite happened when he got so sick with RSV a month later; Haddad-Null had a runny nose around the same time but could still operate. But in all, the fall "was just one thing after another: COVID-19, cold, RSV. My step-son had the flu really bad and was out of school for a week. It felt like for a couple of months I was either sick or caring for someone who was sick."

Dr. Allison H. Bartlett, medical director of the Comer Infection Control Program, said studies indicate that little kids got eight to 12 colds a year before COVID-19.

"Fifty percent of the time, kids under 5 have a respiratory virus detected," she said. "They have symptoms like 28% of the time. So they are snotty all the time. And it sucks, because their parents get it, and the kids are bouncing around, and the parents feel like crap.

COVID-19 has changed the landscape in terms of the necessity of testing and set periods of time during which infected people need to stay home from school or work. Bartlett noted that kids have always run the risk of getting very sick from influenza, hence medical practitioners' emphasis on flu shots for everyone 6 months old and older. RSV can be severe for young and premature infants, which is why a select group of infected kids can get monoclonal antibodies.

"What happened this fall — around mid-September to mid-November was the worst of it — was all of this happening at the same time," said Bartlett, adding that every child gets RSV by age 3 and that the first infection is worse than the ones that follow.

Post-COVID-19, there were two or three years of kids who had never gotten infected having their first bout with RSV. Luckily, Bartlett said, they have bigger airways than babies and could tolerate respiratory inflammation better than them, but the unexpectedly early RSV season with more kids than usual getting very sick, overlapping a bit with influenza season and the circulation of however-many other respiratory viruses.

By the end of October, Comer was "overwhelmed" by an "early and aggressive respiratory virus season" and turning away "hundreds" of patients or transferring them out of state for care, Bartlett said. She also said the pandemic worsened pre-existing issues with insufficient pediatric health care resources, given decreased staffing levels in children's clinics and hospitals.

Comer adjusted by taking over ambulatory clinic space to expand emergency room fast-track capacity for less-acutely ill children, which provided more space for more-critically ill children. Comer also sought to bring in more providers to care for the number of patients, eased policies around neonatal intensive care unit admissions to limit capacity crunches elsewhere, worked on increasing inpatient capacity by putting older adolescents in adult care and directed more patients to outpatient clinics to reduce strain on the hospital.

It appears that the pediatric RSV and flu peaks have passed. COVID-19 is increasing across the board, but that disease tends to be less severe in children than RSV and the flu.

Fortunately, pediatric fatalities did not significantly spike during the waves. Some kids needed supportive care, oxygen and/or fluids, and then recovered.

But there is an outstanding question about the flu. There are two different types of influenza, A and B; A tends to peak in January and B in the spring. Bartlett expects a Type B problem.

"Whether that's in February or May, I don't know," she said. "The good news is flu vaccines cover A and B."

Meanwhile, COVID-19 vaccines and omicron-oriented boosters are "incredibly, disappointingly low among children and adults," Bartlett said, supposing that people think, with reason, that kids won't get incredibly sick from COVID-19.

"But from a societal standpoint, having protection for everybody is really important,” she said. “And we're starting to learn more and more about the dangers of repeated COVID infections, and, from a practical standpoint, just how disruptive missed days of school for children, or missed days of daycare and therefore missed days of parental work, are having in terms of education and productivity."

Although breakthrough infections happen, COVID-19 vaccines do prevent a number of coronavirus infections at a societal level. They remain significantly effective against hospitalization.

Things are expected to remain abnormal in the post-pandemic landscape of children's respiratory viruses. Children's hospitals saw an even earlier surge of RSV cases in the late summer of 2021; Bartlett doesn't know if that means RSV will peak this coming September or next January, but she thinks there will be another RSV season. She also thinks epidemiologists will be able to detect when an RSV surge is imminent and treat more highest-risk kids with monoclonal antibodies. RSV treatments are improving.

Haddad-Null is happy her job provides paid sick leave and flexible working hours for times of sick kids and closed daycares. That said, she thinks about how much more difficult it would be if she worked hourly or under contract.

"Even with the fact that I'm fortunate in that regard, it does make me angry at how badly our society supports childcare and care work in general, and how little of a safety net there is," she said. "At this point I know people have heard this before, but there's not enough childcare options. There's not affordable childcare. There's not enough paid sick leave. There's just not enough done to support when there are pandemics and illnesses going around."

Bartlett noted that health care systems do not make a lot of money from pediatric care. There have always been times when children's hospitals are at capacity; they almost never are for extended periods of time, as they were last year.

"Even though it's not a moneymaker, the right thing to do is to have the capacity to take care of pediatric patients when they need it," she said. "How can we be ready to scale up the pediatric health care system in times of surge like we saw and we'll probably see again?"

And she hopes, even though there is no indication that city officials will institute another mask mandate, that people will keep wearing them when sick and that schools will consider having students wear them while the pediatric health care system is operating at crisis levels.

"None of this prevents all the infections, but at some point, every little bit can really impact our care," Bartlett said.

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