What Doctors Want You To Know About Treating Colds (but are afraid to say)

This is a change from my usual blogging style because I want to share a Facebook post. I follow a few private Facebook Groups and in one for physicians the following post was shared. I tracked down the original author for permission to share publicly. He was not intending for this to reach a wide audience, but authorized me to share without his real name. He asked that I refer to him as Dr. Nate. 

I did not write anything in the post or the comments I posted below, but I see value in it. It highlights the fears and desperation of many parents and the frustration that even doctors have in treating coughs and colds. 

It might offend some because of its snarkiness, but it might help parents who are frustrated that their child is sick... again. 

As you can see, Dr. Nate answers questions about treating a child's cold and cough rather bluntly, but from the many, many positive responses, rather accurately. It's a behind-the-scenes look at what doctors really want to say but can't.

I'll first post screenshots of the post and some of the replies (there were also GIFs and more comments of essentially the same "love it" responses) and then I copied the wording below for ease of reading.

Saw this posted over on ********* and figured this group would appreciate it the most given the snarkiness! 😏 #ParentingIsHard#TrueStory

"Shamelessly and unapologetically plagiarized from ***********:

And now, for a pediatric URI Q & A session with your friendly neighborhood doctor.

Q: My kid has had a cold for four days now, and he isn’t getting any better! What should I do?
A: most colds spent 4-5 days getting worse and 4-5 days getting better. Call me if it’s been consistently worsening for a week, and we’ll talk. Otherwise, regular supportive care is all we do for a cold.

Q: He’s coughing up green and yellow junk! My friend Becky says that mean he needs antibiotics.
A: normal viral colds involve a full rainbow of sputum colors. Green, yellow, and white junk tells you nothing about whether it’s viral or bacterial, especially in babies.

Q: My baby has had a cold for 3 weeks. What now?
A: probably not really. Your kid can have a cough that lingers for up to 4-6 WEEKS after recovering from a viral infection like RSV. If there’s no fever, and no other symptoms of infection, a cough alone is expected.

Q: But he’s been coughing for 3 weeks!!!
A: You will notice that 3 is less than 4-6. This does not surprise me.

Q: But that’s a long time!
A: tough. #ParentingIsHard

Q: But it’s really interfering with his sleep!
A: Oh, well in that case, let me go get the cure for the common cold and post viral cough that we doctors have been keeping secret. Lol, J/K - #PIH

Q: My friend Becky told me to come to the hospital because my baby had a fever of 99 degrees.
A: First off, in babies, a fever is 100.4 degrees. A temperature of 99 is not legally a fever. Second off, stop listening to Becky.

Q: does my child have a sinus infection?
A: since kids don’t really have sinuses, probably not. They may have small ethmoid sinuses that don’t often get infected, but they don’t have fully formed adult sinuses until they’re middle school aged. Those are the ones that get sinus infections.

Q: does my baby have bronchitis?
A: no. Just, no. Babies can get bronchIOLItis, but almost never get true bronchitis. And if they did, the treatment for bronchitis is not usually antibiotics.

Q: it’s been 30 days and he’s STILL coughing!
A: Wow, parenting really does suck. Nothing to do about it though.

Q: I want antibiotics
A: does your kid have strep, pneumonia, an ear infection, or a UTI? If not, tough.

Q: My kid has a runny nose, a sore throat, and a cough. Becky says it’s strep.
A: WTF did I say about listening to Becky?! Strep doesn’t cause runny nose and cough (except in babies under a year, which is a different entity than strep throat).

Q: My toddler has been sick for the last two months.
A: your kid, at this age, can get a dozen viral respiratory infections a year. Each one can last up to two weeks. You do the math - toddlers are sick almost just as often as they’re well.

Q: what about vitamin C and zinc?
A: MAYBE vitamin C prevents colds in certain subsets of the population, but not for everyone, and once you have a cold they won’t stop it. And don’t give your kid zinc.

Q: (something something essential oils or coconut)
A: the only natural treatment for a cough with good data is honey, and never give honey to a baby under 12 months.

Q: what over the counter medicine is best for a kid with a cold?
A: none of them. They all suck for kids. Tylenol and Motrin are good for fevers in general, but stay away from “cold and flu” medicines.

Q: Well, _I_ had a different experience than one of the above scenarios. I actually DID need antibiotics/ have a kid with a sinus infection/ found a worrisome reason for a lingering cough / got better with essential oils.
A: 1) that was likely a coincidence if it happened at all. 2) this is called an “outlier” and does not nullify the general rule 3) is this Becky? Go away Becky.

Q: All 6 of my kids are sick. What can I do?
A: Mirena, Nexplanon, and Depo-Provera are all good options for you.

Q: You’re a mean pediatrician
A: that’s not a question. But yes, yes I am."

New High Risk Child RSV Prevention Guidelines

Today the American Academy of Pediatrics published a new policy statement, Updated Guidance for Palivizumab Prophylaxis Among Infants and Young Children at Increased Risk of Hospitalization for Respiratory Syncytial Virus Infection.

photo source: Shutterstock

This very long title is basically the roadmap that physicians should follow when deciding which infants and young children would benefit from a vaccine to prevent the virus commonly known as RSV (Respiratory Syncytial Virus). RSV is a very common virus, affecting nearly all children by 2 years of age. Reinfection seasonally (late fall to early spring) is also common. It typically causes common cold symptoms and ear infections, but in infants it can lead to bronchiolitis, a condition where there is wheezing and difficulty breathing. Most people who are infected can be treated with home therapies, but some infants require hospitalization for oxygen or iv fluids. The majority of hospitalizations occur during an infant's first year of life and are among otherwise healthy, term babies, not premature or otherwise at risk babies. This is likely due to the fact that parents of at risk infants tend to be much more cautious and aware of infection prevention and tend to avoid situations that could increase risks, such as daycare. It would be impractical for most working parents to stay home with their children the first winter, and the overall risk of hospitalization of a healthy baby is still very low despite the use of daycare. The virus is spread through close contact with others who have the virus and it can live on contaminated surfaces for several hours. Unfortunately since it only produces mild symptoms in older children and adults and can be spread before symptoms develop, caution must be taken throughout the cold and flu season to avoid spreading germs.

The palivizumab vaccine is commonly called Synagis. It has been used since 1998 to prevent RSV infection in at risk children ~ those whose lungs are underdeveloped due to prematurity, those with significant heart defects, and other risk factors. Due to cost and needs analysis, it has never been recommended for routine use in otherwise healthy children. When deciding which children will benefit from the vaccine, experts review its effectiveness, drug resistance, and cost analysis.

We are fortunate to live in a country that has high quality medical care for premature and sick infants. Preterm babies tend to be much healthier than they were in years past due to advances in medical care. The rate of hospitalization for RSV illness has declined over the years in both those who did and did not get the palivizumab vaccine.

Research now shows not only that palivizumab prophylaxis has a limited effect on hospitalizations for RSV, but also no measurable effect on mortality and only a minimal effect on wheezing. Due to these new findings, the new recommendations limit the use of palivizumab compared to years past. I am sure there are infants that were born last season whose parents anticipated they would get the vaccine again this season, but with the new guidelines they will not be eligible. While this might cause anxiety among parents, it is based on good data that they wouldn't benefit from it. And remember that RSV is only one of the many viruses that cause significant illness in at risk babies, so the primary preventions of infection control are important regardless of whether or not an infant gets this vaccine.

New guidelines recommend the use of palivizumab in

• infants born before 29 weeks gestation and in the first year of life (previously 32 weeks)
• infants with significant congenital heart disease in the first year of life (previously 2 years)
• infants with a compromised immune system under 24 months of age (similar to previous recommendations)
• infants with chronic lung disease or who require at least 28 days of oxygen after birth and in the first year of life. If they continue to have need for oxygen, diuretics, or corticosteroids, they may qualify the second year of life.
• infants with neuromuscular diseases that affect the ability to clear the airway in the first year of life (previously 2 years)
• Alaskan Native and Native American populations may have expanded uses 

For those infants who qualify, they can receive up to 5 monthly doses during the RSV season. If they are born later in the season, they may require fewer doses. If a child has a hospitalization for RSV despite the vaccine, they stop future doses of palivizumab. 

It is still important for all infants, especially those born preterm, to use infection prevention strategies, such as 

• use breast milk whenever possible
• frequent hand washing
• clean toys regularly
• immunize household members against influenza, pertussis, measles, and other recommended vaccines
• limit contact with ill people 
• avoid smoke exposure
• avoid large crowds during the first winter season
• limit use of large daycare centers during the first winter season

Remember that even infants who are getting palivizumab vaccine prevention are still at risk for other illnesses, so it is important to use the above precautions in them as well. For treatments of cough and cold symptoms, please visit Cough and Colds.

My Child's Cough and Breathing Sounds Like...

Parents often bring in kids with a cough but can't describe what it sounds like. I sometimes get to hear it if they cough, but Murphy's Law also says that a child who coughs often throughout the night and frequently during the day will have a 15 minute period of no cough at the exact time the doctor is in the exam room.

photo source: Shutterstock

In all seriousness -- coughs, regardless of the source -- are usually worse at night, which means your  doctor won't usually get to hear the worst of it.

I often wish there was one place I could refer parents to so they could see what various coughs sound like, so I decided to put a list together. The internet is ripe with videos now, but I have spent many hours watching videos that weren't very helpful in order to find these. I'm sure I missed some of the best ones, so if you have one that you really like, please post in the comments below.

My next blog will be on how to treat cough and colds.

Regardless of how the cough sounds, if you are worried about your child's breathing or the sound of the cough, bring your child in to be seen.

Disclaimer: I have no ties to any of the videos below and am not responsible for any of the opinions or errors within them. Some are professionally done and others are videos parents uploaded. Some have advertisements which I do not necessarily endorse.

Croup

The initial seconds of this baby with croup stridor video show the typical croupy cough. At about 0:55 it shows the stridor that many kids with croup have. Stridor is a whistling sound as the baby breathes in (often confused with wheezing, which happens when you breathe out). It is common in croup and is caused by the swelling near the voice box. (Older kids and adults who get the same viruses that cause croup in younger kids often get laryngitis from the swelling near the voice box in a larger neck.)

This ER physician of TheEDExitVideo spends the first couple of minutes discussing what causes croup. At 2:27 sounds of stridor in an otherwise happy looking baby are shown. At 3:44 is a picture showing intercostal retractions (also seen with wheezing or other types of respiratory distress).

Dry Cough

Dry cough can be from an irritation in the throat, asthma, acid reflux, or any common cold. It can also come from a habit cough (often seen after an illness and goes away with sleep only to return when awake).

Laryngomalacia

Laryngomalacia wasn't on my original list because it isn't from a virus or bacteria causing illness, but it is a cause of noisy breathing in infants. It is caused by floppy tissues near the voice box (i.e. larynx). Linden's Laryngomalacia - 3 Months shows this breathing. It is often worst when baby is excited or fussy.

For more information on this (even a video of a scope into the airway), check out Children's Hospital of Philidelphia's Laryngomalacia page. 

Pneumonia

The cough with pneumonia can sound like a wet cough or dry cough, so no specific videos are for this cause of cough. The clues to pneumonia include a fever with cough, difficulty breathing between coughs, shallow breathing, shortness of breath with brief exertion, pain in the chest, rapid breathing, or vomiting after cough. Pneumonia can be caused from viruses and bacteria and can range in severity. Walking pneumonia generally means that the person is not sick enough to require hospitalization. Some pneumonias lead to severe difficulty breathing and require oxygen support.

Wet Cough

Wet cough can be from pneumonia or bronchitis, but also from postnasal drip with a common cold or allergies.

When kids "cough stuff up" it is usually the postnasal drip being coughed up, not mucus from the lungs coming up. The same is true if they "cough up blood". This blood is usually from a bloody nose draining into the throat, not from lung tissue. (Note: bloody mucus can be from more serious causes and if your child has no signs of blood in the nose or is otherwise ill, he should be properly assessed by a physician.) 

Wheezing

Wheezing is typical in asthma (and bronchiolitis). Many parents mistake the upper airway congestion sound that many kids make with postnasal drip as wheezing. Wheezing can sound like a whistle as a child breathes out. Ethan's wheezing shows a baby with noisy breathing without distress. This Wheezing - Lung Sounds Collection video has the sounds one would hear with a stethoscope, but if you put your ear against your child's back (without a shirt) you might be able to hear them. If you don't hear wheezing, but your child is struggling to breathe, it does not mean there is no wheezing! Treat like you would if you hear the wheeze.

Asthma

Asthma Attack in a child starts with information on asthma, then at 1:50 video of what retractions look like. 

Asthma attack shows the typical short breathing in phase with long exhale seen with an asthma attack. Also you can see the airway pulling in at the neck (retractions).

Bronchiolitis, often simply called RSV, but caused by many viruses

Bronchiolitis Cough, 3.5 months old shows a baby with a wet sounding cough, typical of bronchiolitis. 

Bronchiolitis is a video from the ER physician Dr Oller. He reviews causes of bronchiolitis, how it's spread, and how it affects the body. At 1:40 he discusses the natural progression of the simple cold into bronchiolitis. At 3:04 there is a picture of how we collect a nasal swab to help with diagnose of any viral illness.

Sick with Bronchilitis shows an infant with suprasternal retractions (sucking in at the base of the neck) and the typical cough associated with bronchiolitis. The man erroneously says "croupy", see below for croup.

RSV and Infant Treatment shows the best treatment for babies with RSV (or any bronchitis): suctioning. Some babies need this deep suctioning in the doctor's office or hospital. Others can get by with nasal aspirating at home. (Note, the next blog will be about treatments, but I have to say here that the bulb syringe is fairly useless for this.)

Whooping Cough

Pertussis - Whooping Cough: A Family's Story is an informational video on pertussis with the classic whooping cough in a child and pictures of a newborn with pertussis.


Silence the Sounds of Pertussis - Whooping Cough is a commercial for vaccinating, but it starts with the typical whooping cough sound.


Pertussis (whooping cough) shows a young infant with a cough from pertussis. Young infants do not always whoop, they stop breathing.

8 Year Old With Pertussis (Whooping Cough) shows a typical cough for an older child. Her positioning in front of the toilet shows that these kids often vomit from the force of the cough. The 2nd video from this same girl shows how normal and healthy kids can appear between episodes.