As the school year approaches in the United States, so does respiratory virus season.

Last year, the United States saw a rebound of several seasonal viruses after a pandemic lull. Surges of respiratory syncytial virus, or RSV, among babies and young children last fall led to an explosion in hospitalizations, overwhelming children’s hospitals around the country, TODAY.com previously reported. Along with a COVID-19 wave and an early and severe influenza season, the “tripledemic” persisted well into winter.

For this fall and winter, health officials are already preparing for another possible tripledemic of COVID-19, RSV and flu in the U.S., Dr. Mandy Cohen, the new director of the Centers for Disease Control and Prevention, told NBC News.

Now that many respiratory viral diseases are settled back into their pre-pandemic seasonal patterns and people have returned to pre-pandemic behaviors, what can we expect to see this fall?

Which illnesses will affect children this fall?

It’s still too early to tell exactly how this fall and winter will play out compared to last year and how another tripledemic could impact children, experts note.

“I think there are two wildcards that are going to be very important to watch,” Dr. Thomas Murray, associate medical director for infection prevention at Yale New Haven Children’s Hospital in Connecticut, tells TODAY.

The first is whether or not there will be a fall resurgence of COVID — “When that comes back, it tends to affect the other respiratory viruses,” Murray adds. The second is how the RSV vaccine for older adults and the newly approved monoclonal antibody injection for children under 2 will affect RSV transmission, says Murray.

Regardless, there are a number of illnesses that we can count on circulating among children once school is back in session, experts note. Parents should not panic, but be aware of these common classroom contagions and how to keep kids healthy.

Strep throat

“No matter which region you are in, the first thing we tend to see as pediatricians is strep throat,” Dr. Victoria Regan, a pediatric specialist at Memorial Hermann in Houston, tells TODAY.com.

Strep throat is a highly contagious bacterial infection of the throat and tonsils caused by Group A streptococcus bacteria, and it’s most common among children and teens, per the CDC. Strep is spread between people through respiratory droplets and flourishes in classrooms when children are in close contact, Regan adds.

Strep can occur at any time of year, but cases tend to ramp up in the fall, and peak season is usually from December to April, says Regan. During the spring of 2023, there was an “explosion” in strep among children. Many pediatricians around the country have continued to see a high number of strep cases this summer, the experts note.

“It’s definitely something parents should be on the lookout for, especially with the increased numbers that we’ve seen this spring and summer,” Dr. Shannon Godsil, pediatrician at Omaha Children’s Hospital & Medical Center, tells TODAY.com.

Symptoms include a sore or scratchy throat; red, swollen tonsils; fever; pain with swallowing; and headaches or body aches, per the Mayo Clinic. This spring, there were reports of children presenting with unusual strep symptoms, including congestion and cough, TODAY.com previously reported.

Testing is key, because strep can be treated with antibiotics and symptoms tend to improve within two days of starting medication, Regan notes. If left untreated, strep can lead to complications like abscesses, ear or sinus infections, or rheumatic fever.

COVID-19

Although the U.S. federal COVID-19 emergency ended this May, SARS-CoV-2, the virus that causes COVID-19, is still circulating and will infect kids this fall, the experts note. “As frustrating as it is that we might be seeing COVID every year, I think that’s probably our new normal,” says Godsil.

The omicron XBB sub-lineages remain the dominant strains in the U.S., according to CDC data. “However, the SARS-CoV-2 virus has the potential to mutate, so there is a chance that there will be a strain of COVID that we haven’t seen before,” says Godsil.

One caveat is that testing has decreased, and it’s difficult to know the true number of cases, Murray notes. Additionally, fewer cases are being sequenced, which makes it harder to track new variants, TODAY.com previously reported.

COVID-19 hospitalizations have dropped since 2022, likely due to increased immunity from vaccination or prior infection, as well as better treatments, Murray adds. However, the U.S. has seen a slight uptick in the last few weeks, according to an NBC News tracker.

While it’s unclear what COVID-19 will look like this fall and winter, especially among kids, vaccination is key, the experts note.

Data show the vaccine is safe, effective and has fewer side effects than if a child gets COVID-19, says Regan, adding, “No children have died from the COVID vaccine, but we do have children that die from COVID.”

The U.S. Food and Drug Administration has advised drugmakers to update booster shots to target the dominant XBB strains, and they could be ready as soon as this fall, NBC News reported.

Speculating, Regan says she predicts the recommendation going forward will be to get the COVID-19 vaccine every year.

Respiratory syncytial virus or RSV

“Even before COVID, RSV was always a really worrisome thing for pediatricians in the fall,” says Godsil.

RSV is a common respiratory virus among children that usually causes mild, cold-like symptoms, per the CDC. It can also cause wheezing and breathing difficulties, especially in children with underlying lung diseases, Regan notes, and in severe cases, RSV can lead to complications like pneumonia.

There is no specific treatment for RSV, but supportive care is recommended while the virus runs its course, which is usually takes about one week, the experts note.

“The usual pattern of RSV was that it began in October, and the season went through March,” says Regan. Last fall, RSV hit many parts of the U.S. much earlier than expected. “It was intense, and kids were very sick,” says Murray.

The experts note that this was likely due to a combination of dropping precautions and increased social mixing. Additionally, many babies and young children were more vulnerable because their immune systems weren’t exposed to these seasonal viruses during the pandemic, TODAY.com previously reported.

“It’s still too early to say how this season is going to look for RSV, but we haven’t seen any big early spikes so far,” Regan adds.

The new monoclonal antibody injection could be a game-changer. “If there’s high uptake of that (injection) and if it works as well as it did in the clinical trials, that could have a significant impact on the number of babies coming through our emergency room with RSV,” says Murray.

The injection is still new, so it’s unclear when it will become widely available or whether insurance will cover the cost, says Godsil, so parents should talk to their child’s doctor.

Influenza

Every year, parents can count on influenza keeping kids out of school. The flu is a highly contagious viral infection that causes mild to severe illness, per the CDC, and symptoms include a fever, cough, sore throat, stuffy nose, body aches, fatigue and chills.

Most kids will recover on their own without needing medical care, but flu antivirals like Tamiflu can limit disease severity.

The 2022 to 2023 flu season was one of the earliest and most severe seasons the U.S. has seen in a long time, TODAY.com previously reported. It’s too early to tell what this year’s season will look like, the experts note, but there are some worrisome signs.

Australia’s flu season, which runs from April to September, is often a harbinger of what to expect in the U.S. in the fall. “Australia is having a heavy flu season again, so we’re kind of anticipating ours to be a little rough again this year,” says Regan. 

“Influenza has always been cyclical, and there are good years and bad years depending on the kind of strain that is circulating and how well it matches what’s in the influenza vaccine,” says Murray. Regardless, it’s crucial to get kids vaccinated, he adds — even during a less severe flu season, children can get very sick.

“Unfortunately, there are children who die from influenza every year, including healthy kids with no underlying diseases,” says Godsil.

The seasonal influenza vaccine is safe and effective for everyone ages 6 months and older. The experts recommend children get the shot in September or October. “Get it by Halloween,” says Godsil.

Colds and other viruses

Every fall and winter, parents can expect to see the usual gamut of viruses that cause cold symptoms like congestion, sneezing, runny nose, headache and cough, the experts note. These include but are not limited to rhinovirus, adenovirus, parainfluenza and hMPV.

Rhinovirus is the most common cause of colds among children and has continued to circulate in high numbers in recent years, says Murray — less commonly, it can lead to hospitalizations.

Another common cause of respiratory illness among kids are human parainfluenva viruses, Murray adds. In addition to cold symptoms, parainfluenza can present in babies as croup, which causes the airways to swell and create a “barking” cough, Murray says.

Non-polio enteroviruses can also cause mild respiratory illness, Murray adds, and cases tend to ramp up in the late summer and fall.

The vast majority of children who get the common cold will recover on their own within a week and do not need treatment, the experts note. “For a lot of these respiratory viruses, it’s just supportive care, providing fluids, and close monitoring to make sure breathing is not getting worse,” says Murray.

Pinkeye

We can also expect to see pinkeye ramp up this fall, says Godsil, which can be caused by viruses or bacteria. Symptoms typically include redness, watering, itching or discharge in one or both eyes.

Pinkeye infections are highly contagious, Godsil notes. Young children often have trouble keeping their hands to themselves and out of their faces, which makes it easy for pinkeye to run rampant through daycares and schools.

Viral pinkeye is often preceded by a cold or respiratory illness and will clear up along with cold symptoms on its own, says Godsil, whereas bacterial pinkeye is treated with antibiotic eyedrops or ointment. “There’s lots of factors that help us decide whether it is probably bacterial or viral,” Godsil adds, which is why it’s important for parents to consult their child’s pediatrician.

Stomach viruses

Another common — and very unpleasant — illness that keeps kids out of school every year is gastroenteritis, or an inflammation of the lining of the gastrointestinal tract, which causes vomiting, diarrhea, and stomach cramps, the experts note.

Often called “stomach flu” or “stomach bug,” the viruses that cause gastrointestinal illness are highly contagious and can spread like wildfire through classrooms and among families at home.

Norovirus, the most common viral cause of gastroenteritis, surged this past winter and spring in the U.S.

Most children will recover on their own at home, but supportive care like hydration and rest are key, the experts note. “Stomach-related viruses tend to last three to five days, and children tend to do quite well,” says Regan.

How to keep children healthy

Children should get vaccinated when possible, the experts emphasize. This includes the required vaccines to enter school, such as polio, chickenpox, and mumps, measles and rubella, as well as recommended vaccines, like the flu shot and COVID-19 booster.

Beyond vaccination, the experts recommend teaching children to practice routine hand-washing (for at least 30 seconds with soap and water), to avoid touching their faces and to cover coughs or sneezes.

Cleaning contaminated surfaces and improving ventilation indoors can also stem the spread of bugs in the classroom. “Masking remains an option for those who are worried about their own health or want to prevent the spread to others,” says Murray.

“If your child is sick, keep them home, whether that be from school, a party or a sports game,” says Godsil, adding that children can return to school once their symptoms have resolved.

Sending children to school sick can delay their recovery and infect classmates, says Regan. “It really does pay to keep your child home a couple days and get them fully recovered before they return to school,” she adds.

The experts encourage parents to consult their child’s pediatrician with any concerns or questions.

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