It’s been 30 years since my grandmother’s death, but her insistence on those around her “coughing into your elbow,” “covering your sneeze,” “washing hands before meals,” and “caring for each other” resonates with me still. Her wisdom reflects her pre-antibiotic, pre-immunization generation, which survived the 1918 flu pandemic, polio, rheumatic fever, and Typhoid Mary, just to name a few. Nothing I learned in medical school ever suggested she was wrong.

To this day, especially when the weather starts to change and sniffles emerge, I catch myself reflexively following her sage advice.

Each fall, in pediatrics, we can usually predict how many patients we will see with respiratory ailments at our outpatient clinic, and how many will land in the hospital. Temperatures drop, viruses emigrate from the Southern Hemisphere, and children share their germs with classmates, with pretty predictable results. The three most common diagnoses for pediatric hospitalizations over the years were mostly respiratory. Coming in close behind were bronchiolitis — a common lung infection caused by a virus — asthma, and pneumonia, along with dehydration, usually due to a gastrointestinal bug. Cellulitis, an infection of the deeper skin, is also common, as kids scrape their knees on playgrounds or irritate a neighbor’s pet, resulting in puncture wounds that become infected.

We prepare for this increased volume by “up-staffing” our clinic, our emergency room staff, and opening areas of the hospital that were dormant over the summer.

“Heads in beds” is a century-old business model for hospital administrators, who need to generate income. Over the last few years, many hospitals have been trying to prevent some of these hospitalizations, but in pediatric centers during the cold months, heads were usually in many beds.

Then COVID-19 hit.

Social distancing and mandatory masking have joined the usual disease prevention advice, and also have made the predictable in pediatrics less so. We have already started to see the benefits in terms of fewer sick kids coming into our hospital. Those who do are coming in for different reasons.

Reports from New Zealand and Australia, where winter is just ending, have shown that only 0.4% of their populations have been suffering “flu-like” symptoms in recent weeks. The World Health Organization processed nearly 200,000 influenza tests in those countries and found just 46 positives. In a typical year, the number would be closer to 3,500. In a year of horrific stories, statistics, and inequities due to COVID-19, this decrease in the flu, along with its many respiratory cousins, could change who is coming into our pediatric exam rooms and inpatient beds.

This is, of course, a forecast. The reality in Philadelphia could take a dramatically different turn depending on social distancing and vaccination rates.

In our hospital, we are seeing more newborns with higher bilirubin levels, better known as jaundice, because often babies and moms are leaving the hospital early due to concerns over COVID-19. Usually, the babies are fine, but it is concerning to new parents.

Of much greater concern: We are seeing more babies experiencing withdrawal from maternal opioid use disorder, as drug use has risen during the pandemic. “Diseases of despair,” such as substance use and even suicide, are increasing as stress and social isolation triggers addictive behaviors. And, sadly, there are more severe cases of child abuse.

We are seeing more mental health hospitalizations and desperate calls from families, and this is not unusual these days. The U.S. Centers for Disease Control and Prevention reported that 75% of adults ages 18 to 24 have reported behavioral or mental health symptoms during the pandemic.

Rare, but most serious of all, we are seeing a new entity, multisystem inflammatory syndrome in children (MIS-C), related to COVID-19.

As a pediatrician, I have to focus on what I know I can do to help my young patients and their families.

I know making sure my patients get the flu shot is a priority — as always, for their own health, and this year, to help distinguish flu from COVID-19, which have similar symptoms. Making sure I check in more frequently and more in depth with my teen patients about their mental health, and referring them to the Philly Hopeline at 1-833-745-4673, is of vital importance.

Given the economic toll of this virus, I’m sharing social service resources from Cap4Kids with all of my patients and their families routinely, knowing that not everyone will tell me if they can afford the basics all families need.

Finally, I’m planning to spend more time on preventive medicine via well visits and vaccinations, if it does turn out that we have fewer sick children coming to the clinic.

Above all, we need to be flexible, to be compassionate, to be prepared, to care for each other.

Daniel R. Taylor is an associate professor at Drexel University College of Medicine and director of community pediatrics and child advocacy at St. Christopher’s Hospital for Children.