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."

How To Keep Your Family Healthy This Winter

This blog is short and sweet about avoiding illness this sick season, but has links to dig deeper as desired.

It's not a big secret. We know the best ways to stay healthy, but it takes everyone to participate to make it work.

Practice the following routinely and help stop the spread of illness!

1. Wash hands or use hand sanitizer (sanitizer is not helpful at eliminating all germs - see the link for more information on how and when it is appropriate) 
2. Eat healthy and drink water (infants under 6 months should drink breast milk or formula)
3. Sleep
4. Get vaccinated
5. Don't touch your face - this is where germs enter our bodies!
6. Probiotics might help (recent meta analysis)
7. Wipe down objects regularly: learn the difference between cleaning, disinfecting, and sanitizing.
8. Safely prepare and serve food 
9. Cover your cough and sneeze with your elbow.
10. Avoid sick people
11. Stay home when sick

Things that haven't been shown to help:

1. Mega doses of vitamins
2. Cough and cold medicines have limited benefits, if any at all
3. Homeopathic medications
4. Essential oils
5. Antibiotics for viral illnesses (most cold and coughs)
6. Using an improper medication dosing device

Related blogs:

How Long Will a Cough or Cold Last?

Cough Medicine: Which one's best?

My Child's Cough Sounds Like...

But the snot is green...

Sick, sick, and more sick

Holidays and family spoiled by illness... It's that time of year!

To Tamiflu or Not to Tamiflu?

Tamiflu: Guest Blogger Dr. Mark Helm

Adenovirus Infections

Evolution of Illness

Fever Is...

New High Risk Child RSV Prevention Guidelines

How long will a cough or cold last?

How long will a cough or cold last?

I get this question all the time. Most people want it gone now. Unfortunately despite our medical advancements over the years, we still have no cure for colds and coughs. Viruses do not get killed by antibiotics, and most colds and coughs are caused by viruses.

Unfortunately our area has been hit with Enterovirus D68, which seems to cause prolonged symptoms compared to many respiratory viruses.

I don't hold back on advice when I see kids with disturbing colds and coughs. I sympathize with the child and parents. I've been there: both as a person with a bad cold and as a parent watching my kids struggle with colds. But I still can't make them better faster.

We have our standard instructions:

• Fluids (water)
• Rest
• Saline washes to the nose
• Blow the mucus out. If a child's too young to blow his nose well, parents can suck the snot right out.
• Honey for children over 12 months of age
• Prop the head up during sleep
• Prevent spread

But then we still have the original question: How long will a cough or cold last?

One of my favorite graphs depicting the timeline of a typical upper respiratory infection is from research done in the 1960's, but since we don't have any better treatment now than we did back then, I find it to hold true to what I experience when I get a cold and what I see in the office.

Notice how the symptoms are most severe during the first 1-5 days, but still persist for at least 14 days. And at 14 days 20% of people still have a cough, 10% still have a runny nose. And the lines aren't going down fast at that point, they both seem to linger. 

A more recent review of medical studies showed that the many symptoms of illness linger for much longer than parents want to accept. From this study:

* Earache range 7-8 days, Sore throat 2-7 days

Bear in mind that children tend to get about 8 colds per year, often in the fall/winter months, so a second virus might start developing symptoms right as the first cold is finally going away. That is an important distinction between back to back illnesses versus a sinus infection requiring antibiotics. This is why doctors and nurses ask (and re-ask) about symptoms. The history and timeline of symptoms are very important in a proper diagnosis. It isn't the color of the mucus (really!) We don't want people to unnecessarily take antibiotics. That leads to bacterial resistance, side effects of medicine, and increased cost to families.

So if you're struggling with cough and cold symptoms in your house, follow these instructions. To help determine when your child needs to be seen:

Urgently or emergently: If your child is breathing more than 60 times in a minute, ribs are going in and out with breaths, or the belly is sucking in and out with each breath, your child needs to be seen in the office, at urgent care or an ER (preferably one that specializes in children), depending on time of day and your location. Another complication that kids must be seen for is dehydration. Dehydration may be present when the child is unable to take in enough fluids to make urine at least 4 times a day for infants, twice a day for older children. 

Routine office visits: If your child has ear pain, trouble sleeping, or general fussiness but is otherwise breathing comfortably and well hydrated, he should be seen during regular office hours. If the cold is worsening after 10-14 days, bring your child in during regular office hours.

More reading:

Clinical Practice Guideline for the Diagnosis and Management of Acute Bacterial Sinusitis in Children Aged 1 to 18 Years

How Long Does a Cough Last? Comparing Patients’ Expectations With Data From a Systematic Review of the Literature

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"But the snot is green…" Or "How can we treat cough and colds?"

This time of year it seems everyone is at least sniffling. Many have annoying coughs. Coughs are annoying to others who wonder why that cougher isn't staying at home keeping his germs to himself. They are annoying to the cougher who is up all night coughing (and his parent who also hears it all night long.)

And then there's all the mucus. We normally make about a liter of mucus a day. Yes, a liter of the stuff. On a good day. It helps moisturize our airway and collects the dust and germs that enter our body. It has antibodies that help fight off the germs it catches. We swallow most of what is made, but when we're sick we make even more. When we're sick it plugs up our noses and makes our head hurt. It drains down the back of our throat, causing us to cough. In kids it drips down the face. It changes color from clear to yellow to green. Sometimes it even gets bloody. It can be thin or thick and sticky. Don't be fooled that the color or thickness means it is for sure "just allergies" because it's clear, or a sinus infection because it's green. These change based on how long it's been in the sinuses, how dry the air is, and other factors. Yellow or green color does not come from bacteria or guarantee that antibiotics will help get rid of the mucus.

Colds and coughs seem to continue forever. Especially since kids get recurrent viral infections this time of year, and they each run into the next illness. I often joke that it doesn't matter if kids get sick in October or January, it will go away by April. Bad joke, but it often seems that once kids start getting sick for the season, they stay sick most days until April.

Here's a graph from way back in 1967 that shows the timeline of a typical upper respiratory illness in an adult:

Remember that kids tend to stay sick longer (and are contagious longer) than adults, so if 20% of adults are still coughing on day 14, you can bet at least that many kids still are coughing with a cold or the flu.

So what can you do to help make kids feel better? As I always say: water, water water.

Water in the air helps thin the mucus, so increase the humidity in the bedroom during the dry winter months. Use a humidifier or vaporizer in the bedroom during illnesses even if your home has a humidifier attached to the heater. Humidifiers with a cool mist are safest with young children. Be sure to follow package directions for cleaning and changing the filter. Vaporizers are generally less work to use, but the steam comes out very hot and can burn young children. Again, follow package directions for proper cleaning and use. Allow it to dry out a bit during the day to avoid build up of mold. 

Water in the nose in the form of saline can really help. The salt in the saline draws the fluid out of the swollen nasal passageways, decreasing the swelling and opening the airway to allow more mucus to be blown (or sucked) out.

Increase fluids that kids drink. Really push water. And unless a child is allergic to milk, it is an old wive's tale that milk will make the mucus worse. If that's what they want, they can have milk with a cold. 

I think what really needs to happen is to get the mucus out. Using saline along with a strong blowing (or suctioning) of the nose is important.

For infants and younger children it can be hard to blow forcefully to get the mucus out. I have been disappointed in the use of a bulb suction because it is very difficult to make a seal and to have enough air to really get a good suction. They tend to cause trauma to the nose because you need to stick it up so high to make a seal. I like nasal aspirators that seal outside the nose and have a continuous flow of air. Check out How to use the Nosefrida. A similar nasal cleaner is available from Nasopure. (Note: I am not tied to either of these companies and do not get any payment from either company.)

For kids over 2 years old, washing the nose is one of the best ways to treat (and prevent) nasal congestion. Check out this video from Nasopure for an easy how to use. (Note: I do not get payment from this company, I simply love the Nasopure company. Not only does the product work well, it is also an all American company. Bottles are made in Kansas City and assembled by disabled adults in Columbia, Missouri.)

What medicines work?

If you choose to use medicines, pick one that has a single active ingredient. Many cold and flu medicines include several active ingredients to treat different symptoms. This increases the likelihood you will use a medicine that isn't needed (because you don't have that symptom) as well as increases the risks of side effects. Also if there is an allergic reaction, you won't know which component was the culprit.

I don't recommend decongestants most of the time. They can make the mucus more thick, which plugs the nose more. If a child is old enough to say if it helps or not (generally over 6 years) and it helps, then it is okay to use a decongestant for a short term. Side effects are trouble sleeping, shakiness, nervousness, increased blood pressure and increased heart rate.

Antihistamines block the histamine that is triggered from allergies. It helps decrease the amount of mucus made when allergies flare, but don't help with the typical cold. Side effects are drowsiness, impaired coordination, excitability in children, and dry mouth.

Guaifenesin is supposed to help thin out mucus to help cough it up. Some studies say it works, others disagree. Again, if a child is old enough to say it helps and it does, use it. Otherwise don't. Side effects can include dizziness, drowsiness, confusion, blurry vision, or lightheadedness.

Studies do not show that any cough suppressant works very well. Honey has actually been shown to help better. Use honey only in kids over 1 year of age due to risks of botulism.

For influenza many people request Tamiflu. Here's my blog on Tamiflu describing why I will be forced to use a medicine I don't like. (It's too long to explain here.)

Another blog going in depth on cough medicines is Cough Medicine: Which one's best?

Cough Medicine: Which one's best?

This is the time of year I get a lot of requests for an over the counter cough suppressant suggestion or a prescription cough medicine for kids so they can sleep. Despite my attempts at educating the family about why I don't recommend any cough medicines, many parents are upset leaving without a medicine. I have collected numerous articles that show why I treat cough the way I do. Links are included throughout this blog. Click away to learn more!

First, a little background...

Most cough medicines were studied in adults and the dosing for kids was calculated from the adult dosage. Kids are not small adults. Their bodies handle illness and metabolize drugs differently. But few studies have been done to show if medicines work at all, and if they do, what the best dose is for kids of various ages and sizes.

In 2008 the FDA stated that toddlers and babies should not use cold and cough medicines. Drug makers voluntarily changed the labeling of over the counter (OTC) cough and cold products, recommending them only for children aged 4 and older. The American Academy of Pediatrics says there is no reason that parents should use them in children under age 6 because of the risks without benefit. Despite this, studies show that 60% of parents of children under 2 years have given a cough and cold medicine. Why? In my opinion, they are desperate to help their child and don't think it is enough risk to not at least try.

I know it is frustrating when your child is up all night coughing. It is frustrating when my kids and I are up all night coughing. But you know what we do in my house?

• Humidify the air of the bedroom (unless it's a spring or summer cough)
• Extra water to drink all day
• Honey before bedtime in an herbal tea (No honey before 1 year of age!)
• Encourage cough during the day to help clear the airways
• Nasal rinse with saline (I love this, but my family is not so keen on it)
• Sleep with water next to the bed to sip on all night long (even when I still had bedwetters)
• Back rubs, hugs, kisses, reminders that it will get better, etc
• Nap during the day as needed to catch up on lost sleep
• Watch for signs of wheezing or distress

That's about it for the cough. If something hurts, we use a pain reliever like ibuprofen or acetaminophen. We use those only if something hurts, not just because and not for fever without discomfort.

Why don't I give my family cough medicines?

Because they don't work.

The OTC options:

A Cochrane Review in 2007 was done to look at over the counter cough medicine effectiveness in both children and adults. These reviews look at many studies and analyze the data. Unfortunately there are very few studies, and many were of poor quality because they relied on patient report. In studies that included children, they found:

• Antitussives were no more effective than placebo for kids. (one study) In adults codeine was no more effective than placebo. Two studies showed a benefit to dextromethorphan, but another study did not, so mixed results.
• Expectorants had NO studies done in children. In adults guaifenesin compared to placebo did not show a statistically different response. 
• Mucolytics more effective than placebo from day 4-10 in kids. (one study) In adults cough frequency was decreased on days 4 and 8 of the cough. (Note: I am not sure what OTC mucolytic was studied. I am only aware of pulmozyme and mucomyst, both used by prescription in children with cystic fibrosis.)
• Antihistamine-decongestant combinations offered no benefit over placebo. (2 studies) One of two studies showed benefit in adults. The other did not.
• Antihistamine shows no benefit over placebo. (one study) In adults antihistamines did not help either.

Another Cochrane Review in 2012 once again failed to show any real benefits of cough medicines, especially given the risks of side effects.

What about some specific studies on OTC medicines? I cannot report them all here, but here's a few:

A study comparing dextromethorphan (the DM in many cough medicines), diphenhydramine (AKA benadryl), and placebo in 2004 showed no difference in effectiveness of controlling cough for sleep. That means the placebo worked just as well as the medicines. Insomnia was more common in those who got dextromethorphan.

Does guaifenesin help? It is thought to thin mucus to help clear the airways. It does not stop the cough. Studies vary in effectiveness and are typically done in adults, but it may be helpful in children over 4 years of age. Do not use combination cough medicines though, for all the reasons above.

In 2007 honey was shown to be a more effective treatment than dextromethorphan or no treatment. Another study in 2012 showed benefit with 2 tsp of honey 30 minutes before bedtime. A side effect of honey? Cavities... Be sure to brush teeth after the honey!

What side effects and other problems are there from over the counter cough medicines?

As stated above, the dosages for children were extrapolated from studies in adults. Children metabolize differently, so the appropriate dosage is not known for children. Taking too much cold medicine can produce dangerous side effects, including shallow breathing and death.

Many cough medicines have more than one active ingredient. This can increase the risk of overdosing. It also contributes to excess medicines given for problems that are not present. For instance if there is a pain reliever plus cough suppressant, your child gets both medicines even if he only has pain or a cough. Always choose medicines with one active ingredient.

Accidentally giving a child a too much medicine can be easy to do. Parents might use two different brands of medicine at the same time, not realizing they contain the same ingredients. Or they can measure incorrectly with a spoon or due to a darkened room. Or one parent forgets to say when the medicine was given and the other parent gives another dose too soon. 

And then there's non-accidental overdose. There is significant abuse potential: One in 20 teens has used over the counter cough medicines to get high. Another great reason to keep them out of the house!

Side effects of cough medicines include:

• Nausea and vomiting
• Stomach pain
• Confusion
• Dizziness
• Double or blurred vision
• Slurred speech
• Shallow breathing
• Impaired physical coordination
• Rapid heart beat
• Drowsiness
• Numbness of fingers and toes
• Disorientation
• Death, especially in children under 2 years of age and those with too high of a dose

What about prescription cough suppressants? 

In 1993 a study comparing dextromethorphan or codeine to placebo showed that neither was better than the placebo. Codeine belongs to a class of medications called opiate analgesics and to a class of medications called antitussives. When codeine is used to reduce coughing, it works by decreasing the activity in the part of the brain that causes coughing. It can make breathing too shallow in children. Codeine has several serious side effects which could be life threatening in children. Combination products with codeine and promethazine (AKA phenergan with codeine) should never be used in children under 16 years. In my opinion, why use it in older children and adults, since it hasn't been shown to work?

How about antibiotics for the cough?

Antibiotics may be used to treat bacterial causes of cough (such as some pneumonia or sinusitis illnesses) but antibiotics have no effect on viruses, which cause most coughs. If your child has a cold, antibiotics won't help.

Updated Sinusitis Guidelines

photo source: Shutterstock

This month the American Academy of Pediatrics updated the guidelines for management of sinus infections in children (1-18 years of age) in the June edition of Pediatrics, available online.

Many parents bring kids in to the doctor for green or yellow runny noses because they're worried about bacterial sinusitis. Sinuses can be infected with viruses or produce mucus from allergies, so not all sinus infections are bacterial. Most of these kids do not need antibiotics to get better, but the guidelines help determine who might benefit from them and when to change an antibiotic if not improving. The guidelines are based on duration of symptoms and severity, not the color of the drainage, how much drainage there is, or fancy testing. Only infections caused by bacteria need antibiotics. Overuse of antibiotics can lead to resistance (so when there is a severe infection it becomes more difficult to treat), side effects (such as diarrhea), or allergic responses.

Unfortunately, a physical exam is not helpful in distinguishing a simple viral cold and cough from a bacterial sinus infection, but is needed to identify other problems that might complicate the picture, such as pneumonia or an ear infection. The inside of the nose can be swollen and various shades of pink, red or blue in sinus infections from bacteria or other causes. How often have I palpated those sinuses to see if tender, yet I know from personal experience that mine hurt when my allergies flare-- certainly not a reason for antibiotics!

I wish there was a simple test, but nose swabs for culture have not been found to be accurate in predicting bacterial cause of the infection. Imaging studies are not needed to help diagnose sinusitis because the inflammation seen in pictures can be from other causes, not just bacterial.

Most cases of runny nose, fever, and/or cough are due to a viral illness. The nasal discharge usually starts clear, but can become thick and discolor over time for several days. It often goes back to a thinner, clear color before resolving without antibiotics. Fever in a typical viral illness tends to be the first several days, and may precede the other symptoms. Fever usually resolves by day 3, when the nasal discharge and cough tend to worsen.  Symptoms tend to peak between the 3rd and 6th day, then resolve after about 10 days. (Though some studies show longer.) Back to back infections are common in kids, especially during the winter months, which can be confused with one prolonged sinus infection.

Guidelines to diagnose and treat acute bacterial sinusitis in a nutshell:

• Symptoms in a child with upper respiratory infection suggest acute bacterial sinusitis if: 

• there is persistent illness (nasal discharge or daytime cough) of 10 days without improvement. This persistence can be difficult to distinguish from back to back viral illnesses, so a careful review of symptoms is important.

 or

• there are worsening symptoms (nasal discharge, cough, fever) after initial improvement. (New in the 2013 guidelines.)

or

• there is severe onset (fever over 102.2F and discolored nasal discharge for at least 3 consecutive days). Several viral infections, notably influenza, can cause severe onset of symptoms, but a clue to the bacterial nature is the combination of fever with mucus in the initial days, since the fever usually comes before the mucus in many viral illnesses. 

• Observation without antibiotic is acceptable with a persistent infection over 10 days for another 3 days if there was not a severe onset or worsening of symptoms. (This differs from the 2001 guidelines to use an antibiotic for symptoms of 10 days.)
• Imaging is not recommended to diagnose routine sinusitis. Plain x-rays, computed tomography (CT), magnetic imaging (MRI), and ultrasounds (US) cannot distinguish between viral, bacterial, or allergic nature of the inflammation. 
• If there is a suspicion of extension of the infection outside of the sinus cavities, such as into the eye orbit or central nervous system, a contrast-enhanced CT scan is indicated. These might be suspected if the eyelid is swollen and the mobility of the eye is decreased, sensitivity to light, severe headache, seizures, or other neurologic changes. 
• When antibiotics are indicated, amoxicillin or amoxicillin with clavulanate (Augmentin) is the first line choice unless there are documented allergies to penicillins. If there are allergies or failure to respond to the amoxicillin, a cephalosporin may be used. There are other good choices, but studies do not show that azithromycin (Zithromax) or trimethoprim sulfamethoxazole (Bactrim) are good choices because they aren't effective against the most common bacteria of bacterial sinus infections. The duration to take an antibiotic is not well identified. Recommendations vary from 10 to 28 days, or 7 days from the time symptoms go away. This will vary by prescriber's preference and experience.
• If there are worsening of symptoms or failure to improve within 72 hours of initial visit, a repeat evaluation is recommended. If no other source of symptoms is found on physical exam, adding an antibiotic (if not previously initiated during the observation period) or changing the antibiotic is recommended. 
• There was not enough evidence to support other treatments, such as decongestants, antihistamines, nasal corticosteroids, or saline rinses. More studies in children are needed to validate whether these are effective or not. There's always more to learn!

Adenovirus Infections

photo source: Shutterstock

It's been a relatively sick winter season, and I keep hoping it is winding down.  But as one season winds down, another starts.

This week my eyes have been watering and burning and my nose is a little stuffy. (I think my nose would be worse if I didn't do twice daily nasal washes - I am a true believer in them!)

But my eyes are driving me nuts. I first thought it was due to allergies since earlier this week I knew that local pollen counts were up, but as I consider what I'm seeing in the office, I wonder if I have a mild adenovirus. (Yes, even doctors have a hard time determining what is going on. This is why I say to never trust someone when they say "it's just my allergies." Make them wash their hands!)

We start to see adenovirus this time of year. I don't test for it but when I start seeing certain trends, I suspect it's here.  It causes many types of symptoms, different in different people.

Red eyes without mucus discharge is one common finding. It is not "pink eye" or bacterial conjunctivitis, but we have many kids sent in from schools and daycares because they think it's "pink eye." I usually just write a note that eye drops are not needed and they can return to daycare since it is a virus.

I have seen quite a few red eyes this week...

Other symptoms are much like a common cold: fever, runny nose, cough, swollen glands, and sore throat. It can cause wheezing in infants and croup (yes, we're seeing those now too).

Sometimes vomiting and diarrhea are due to adenovirus - and right now we are blaming all the stomach problems on the new Sydney Norovirus, but it could be something more typical too.

Prevention is key with any illness. Continue to wash hands and surfaces well all year long, not just when the flu is in the news. Keep sick family members home if they are sick to avoid spreading germs to others.

Most children with adenovirus can be treated at home.

• Treat with a pain reliever/fever reducer as needed for comfort. Remember it is not how high a fever is, but how a child acts that is most important (as long as they are over 3 months and immunized). 
• Push fluids. 
• Use a humidifier or vaporizer if the air is dry to help the airway. 
• Use saline rinses or sprays in the nose as tolerated. 
• Kids over 1 year can use honey for cough. I don't recommend cough medicines since they haven't been shown to work, are expensive, and have side effects. 
• And for those red, burning, watery, itchy eyes: cool compresses. Since allergy season overlaps with adenovirus season and they symptoms are very similar, you can try age-appropriate allergy medicine to see if it helps the red, itchy, watery eyes. Watch for yellow mucus discharge of the eyes. Since kids rarely wash their hands before rubbing their eyes, they are more likely to secondarily infect their eyes with repeated rubbing of irritated eyes. 
• Wash hands frequently!

When to see your doctor:

• Sore throat and fever in children should be evaluated for Strep throat by a throat swab and test during business hours. Strep throat can look exactly like a sore throat from adenovirus or other viruses, so it needs to be tested before appropriate treatment can be determined.
• If there are breathing problems such as rapid breathing, ribs sucking in and out, child is not able to complete a sentence due to shortness of breath, or other concerns your child should be seen ASAP.
• If your child looks dehydrated (no tears, dry mouth, poor urine volume) he should be seen ASAP.
• If the eyes are red with discharge, your child should be seen during business hours to see if antibiotic eye drops are needed. 
• A child with symptoms of a urinary tract infection (symptoms may include fever, painful urination, frequent urination, blood in urine, or urinary accidents) should have their urine tested for infection. If symptoms are mild, you can wait until business hours, but if associated with high fever, vomiting, or other concerns, bring in for assessment ASAP.

For more reading:

KidsHealth Adenovirus

CDC - About Adenoviruses

Sick, Sick, and More Sick.

Photo source: Shutterstock

It isn't news that we are experiencing a rough winter as far as illnesses go. Flu is all over the news. Schools have high rates of absenteeism. You hear coughs wherever you are in public places.

A few nuggets of information that might help you treat your family this sick season:

Fever

Fever is a symptom of illness and makes us feel achey and miserable, but the number on the thermometer does not necessarily correlate with the diagnosis or treatment needed. Look at your child. If they are happy with a fever, over 3 months and immunized, let it run its course. If they complain of pain (or if your immunized infant over 2-3 months is fussy) give a pain reliever/fever reducer. Push fluids to avoid dehydration. Treat other symptoms as needed. Don't worry if the temperature on the thermometer goes up ~ worry if your child is in severe pain, having difficulty breathing, or looks dehydrated.

Cough

Coughs do not need medicine generally. Honey (for those over 1 year) has been shown to be safer and more effective than other cough suppressants. Adding humidification to the air does wonders to loosen mucus and ease breathing.

If the cough is accompanied by rapid breathing, sucking in of the ribs or abdomen, or followed by vomiting, your child should be seen by a medical practitioner for further evaluation and treatment.

If your child has a history of asthma or other wheezing, it is okay to see if the rescue medicine (albuterol or levalbuterol) helps the cough. If not, it either is really bad wheezing that needs further evaluation or a cough. And don't forget your prevention medicine if you use it!

If your child has been exposed to whooping cough and develops a cough, please see your medical provider for evaluation and treatment.

Water's Power

Water is good for most illnesses. Increase fluids to prevent dehydration and help the body repair itself. Sips of water can help a sore throat and ease a cough. Add humidification to the air when the weather is cold and dry. Use saline to clear the mucus from the nose and open nasal passageways. Never underestimate the power of water!

Tamiflu 

Tamiflu is recommended for certain high risk people who are exposed to or sick with influenza. Prophylaxis can be given to prevent illness in children over 1 year of age who have known exposure within the past 48 hours if they meet high risk indications. Treatment of illness can be given to those over 2 weeks of age if they meet high risk criteria. There are shortages beginning this season and resistance can easily develop, so its use should be limited to those who truly need it.

High risks include: less than 2 years, lung disorders, immunologic disorders (immune compromised), chronic metabolic disease, and neuromuscular disorders.

If influenza symptoms have been present for more than 48 hours, it is not indicated unless there are special circumstances.

Tamiflu shortens the symptoms of influenza by 26 hours, about a day. It can help prevent the spread of the virus. It can have side effects, most commonly nausea and vomiting, but also more serious rashes and neurologic symptoms (confusion, delirium, and hallucinations).

Flu Vaccine

Vaccination is the best prevention against influenza. It does not make people get the flu. It is safe and indicated for everyone over 6 months of age. Thank you to all my patients who were vaccinated this year!  Although it is not 100% effective, it should lessen the risk of influenza to you.

Please don't wait to see if it will be a bad season before deciding if it's worth it to get the vaccine. Once the season has started it is less effective because it takes your body about 2 weeks to build immunity. Waiting also puts you at risk for being left out if there are shortages. Our office gave more vaccine than ever this year, but we still ran out earlier than ever this year.

If your family still needs the vaccine, check your local health department and pharmacies.  When we start vaccinating again this summer for next season, be sure to get your family vaccinated! (We will publicize availability on our website, Facebook page, and by email to those registered on our website.)

Vomiting and/or diarrhea

Vomiting and diarrhea can result from many viruses, usually NOT influenza. Treat with an electrolyte solution (such as Pedialyte, Gatorade's G2 - less sugar than regular). Give small volumes frequently. When kids get thirsty, they might gulp and then vomit, so put only 1 teaspoon in a small cup or syringe, or give a popsicle made of the electrolyte solution. Juice, carbonated lemon/lime drinks, and other high sugar drinks should be avoided.

Dairy increases stomach upset, and I generally say to avoid all milk products (except human milk) for 48 hours after the last vomiting or diarrhea. Breast milk can sometimes be tolerated, but it must be given slowly too, so often breast feeding should be stopped. Pump and give the expressed milk by the teaspoon in a syringe.

Evolution of Illness

When kids are sick, parents understandably want them to feel better quickly. They want a sound night's sleep. They want to be able to return to work/school. They want to see a happy, healthy child again. They come to our office hoping for answers and a cure.

Sometimes there is no quick fix, just treating symptoms and time.

This is the season we are seeing a lot of sickness. It's been about 11 years, but I remember the frustrations of having a sick baby when my daughter had bronchiolitis. Some of the details are muddy, but I remember the feelings of inadequacy because I couldn't help her feel any better any faster. I knew the illness tends to get worse before it gets better and there is little we can do to alter its course, but knowing this it didn't make me feel any better as the mom who was helpless.

I lost sleep for several nights as I watched her pant (not breathe, but pant). I resorted to giving asthma-type breathing treatments (because my son had wheezing so we had everything we needed to give a treatment at home) despite the fact that they didn't seem to help her much. It was probably the humidified air that helped more than anything. But the vaporizer in her room and the saline to suction her nose wasn't helping, so I wanted to at least try the asthma medicine. She kept wheezing. We brought her in to the office 3 days in a row to have someone else check her. I can't check oxygen levels at home and needed someone to objectively examiner her.  So three days in a row we went in for repeat exams. She was able to maintain her oxygen level and stay hydrated despite breathing 60-70 times/minute for days. I still don't know how. I remember wishing her oxygen level would drop enough that we could hospitalize her, not critically, just enough. Then she'd be on monitors, and maybe I could sleep a bit knowing someone else was watching her. Thankfully she never got that sick, and eventually we were all sleeping again, but it took a long time for that.

So I understand the frustration when we tell parents things to do at home and ask that they come back in  __ days or if ___, ____, ___ symptoms worsen. It really isn't that we are holding out on a treatment that will fix the illness, it's just that we don't have a quick fix for many illnesses. We need to be able to examine at different points in the evolution of the illness to get a full picture of what is going on.

The exam can tell us a lot, but it doesn't predict the future. One minute ears can look normal, the next they develop signs of an infection. I cannot say how many times I've heard a parent complain that someone else "missed" something on exam that I now see. Yes, sometimes things can be missed, but I suspect that most of the times the exam has simply changed.

I learned this phenomenon as a resident on the inpatient unit. I had a patient who had been admitted for an abdominal issue. I did a physical on the child in the morning before rounds, including looking at ears, which were normal. Late that afternoon the nurse called because a fever had started. New symptom, so another exam was done. This time the ears were red and full of pus. Within hours this child had developed a double ear infection. I examined the ears both times and they were definitely different.

I understand the frustration (and expense) to take kids back in to be seen if symptoms worsen, change, or simply just don't resolve at home. If symptoms change, we need to re-evaluate, which includes an exam. Medical providers cannot look into the future to see what will develop. It is not appropriate (or effective) to put kids on an antibiotic or iv fluids to prevent the illness from taking its natural progression. Sometimes we need time to see how the illness progresses to see what other treatments might be needed.

When parents call back and want something else done, they are often upset that we want to see the child again. I hear many types of complaints.

Money is probably the biggest issue. It is not because we want your co pay. The "we" I use here is not just my office and I am not speaking of any particular situation. With online doctor rating sites, social media sites, and knowing doctors around the country, I write with many examples in mind. I've seen online complaints that doctors are just money hungry, trying to get someone to come back in just so we can charge more money. It is true that we charge for every visit. We are not able to waive the co pay because we did "something wrong" or "missed a diagnosis" the first time. Each is a separate visit with updated information and a separate exam. Insurance contracts dictate that a separate co pay is charged. We must adhere to legal contracts or it would be considered insurance fraud.

Increasing our numbers for "production" is sometimes brought up. It is not because we want to fill our waiting room with more children to increase the waiting time for everyone else. We don't want to waste your time or ours. But we need to see a child to know what is happening at that moment to be able to give any valuable advice and treatment.

We want to see your child again because we need to see your child to know what to do. Maybe now the child's symptoms have changed.  Maybe not, but without the history and exam we do not know. The exam might now show wheezing, low oxygen levels, a new ear infection or sounds of pneumonia. Sometimes the exam still is overall normal, but the fever's been going on long enough without any identifiable cause, which requires lab and/or xray evaluation. 

Please remember that if you get a different answer at a different visit, it doesn't mean that the first assessment was wrong. Usually it is due to a progression of the illness, and things change. Human bodies are not static.

Oh, what a (sick) season!

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This cold and flu season has started early and hit hard! The number of kids we are seeing with severe illness, such as prolonged fevers (over 5 days over 101.5F) and difficulty breathing, are not typical for this time of year. On more than one occasion we have tried to admit a sick child, only to be told there are no available beds. While we are familiar with this in January, this started in November and is more common this month. I feel the need to review a few helpful tips.

What are we seeing right now? A bit of everything. Fever. Vomiting. Diarrhea. Strep throat. Influenza (fever, cough, sore throat, body aches). Bronchiolitis (from RSV and other viruses). Pneumonias. Asthma flare ups. Sore throats from viruses. Whooping cough. Mild colds and coughs. Basically, if you ask if it's going around, chances are the answer right now is "yes".

Wash hands and surfaces! First and foremost is control of spreading infection. You never know when someone is shedding a virus before they feel sick. If you are taking care of sick kids, you are at risk of getting sick along with them. Wash hands and surfaces often. Don't share food and drinks, even with your family! Avoid touching the eyes, nose, and mouth. These are where germs enter to make you sick! When's the last time you cleaned your phones and keyboards?

Fever can be a good thing. We worry in infants under 3 months, those who are immune compromised, or those that are not up to date on vaccines ~ they should always have a medical exam with fevers. If a fever lasts longer than 3-5 days kids should also be seen. For everyone else, we treat symptoms, not the thermometer. If a child is playful at 101F, no need to treat other than pushing fluids and watching carefully. Usually by 102F kids start feeling body aches and feel better with treatment. Watch your child's symptoms, don't worry about the actual degree on the thermometer. Use either acetaminophen or ibuprofen, but most pediatricians don't recommend alternating. Follow dosing charts for weight, and if weight is not known, use age. For dosing charts, see our Medication Dosing page.

Stay home if sick. Again, this is paramount for controlling the spread of all the germs. Don't try to mask symptoms with a fever reducer so you can send kids to school or you can go to work. Stay home and rest!

Never underestimate the power of water. If there is vomiting, an electrolyte drink in small volumes frequently is best. For most colds and coughs, simply drink more water. If there is congestion, runny nose, or cough, add water to the air with a vaporizer or humidifier while you sleep. Even if you have a home humidifier, using an additional one in the bedroom helps. Use saline in the nose. Drops are okay for infants. Older children and adults can learn to flush the nose with saline. Check out Nasopure for tips on learning how to do this and videos to see that it's not as bad as it sounds. (I am not associated with or paid by Nasopure. I just like their product.)

Antibiotics don't make viruses go away any faster. Please don't ask for a prescription if cold and cough symptoms just started within the past 10 days. Unless there is an identified infection requiring antibiotics, they won't help. Even some things we often treat with antibiotics don't need them. Many ear infections and sinus infections are viral and will resolve without antibiotics. At your office visit ask about the need for antibiotics if your child has one of these infections.

We cannot make any diagnosis over the phone. As descriptive as you are on the phone, there is no substitute for examining a child. I encourage people to go to their medical home as often as possible and use other urgent care centers or emergency rooms for true urgent/emergent needs. Going to the same office for sick visits helps to track infection rates to identify kids who might need another treatment, such as ear tubes for frequent ear infections. Even if you get good care elsewhere, it is hard to keep track of dates they were sick and which medicines were used. With most pediatricians open extended hours these days, it is usually possible to be seen by someone you know and trust in a familiar setting.

Some illnesses need multiple visits. I know this is time consuming (and expensive with many insurance plans) but illnesses progress, symptoms change, and exams change. Just because your child was seen a day or two ago and it was "just a cold" doesn't mean it won't progress into an ear infection, pneumonia, or dehydration over time. Unless your child is really sick, you don't need to bring them in at the first sign of a runny nose or fever. Try home therapies first. Coming in early doesn't stop the progression of illness. Preventative antibiotics are not recommended, even if your child has a history of frequent ear infections.

We are in the middle of a whooping cough epidemic. Unfortunately whooping cough can mimic mild colds at the beginning, but the cough can last for several months if not treated in the first couple weeks. A small percentage of people who have been vaccinated still develop whooping cough, though it may be milder it is still contagious. If you child has been exposed to whooping cough and develops any cough, visit your doctor for evaluation and treatment. If your child develops a cough that is followed by a whoop or a cough followed by vomiting, he or she should be evaluated for whooping cough. Be sure kids and all care givers are up to date on vaccine. Typical pertussis vaccine is given at 2, 4, 6, and 12-18 months, 4-6 years, and 11 years. If not given at 11-12 years of age, the Tdap should be given to all teens/adults once. Get vaccinated!

Our influenza season has started earlier than usual and is predicted to be a bad season. Flu vaccines are the best prevention against influenza, so yearly vaccination for all over 6 months of age is recommended. We gave more influenza vaccine than ever in our office this season, but we are out of stock. If your family has not been vaccinated, check with your health department and other locations offering flu vaccines.

If you need information on treating specific illnesses, use our tips on Illnesses and Symptoms, but please see someone at your usual physician's office as well if you are concerned. 

Cold and Flu Season is Upon Us!

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As cold and flu season approaches, I have been thinking about how our kids are managed when they become sick.  Not only what we do to treat symptoms, but how, when, and where patients get medical advice and care.


We are a busy society.  We want things done now.  Quickly. Cheaply. Correctly.  Resolution so we can get back to life.


Illness doesn't work that way.  Most childhood illnesses are viruses and they take a few weeks to resolve. There's no magic medicine that will make it better.

Please don't ask for an antibiotic to prevent the runny nose from developing into a cough or ear infection.  

Don't ask for an antibiotic because your child has had a fever for 3 days and you need to go back to work.  

Don't ask for an antibiotic because your teen has a big test or tournament coming up and has an awful cough.  

Antibiotics simply don't work for viruses.  They also carry risks, which are not worth taking when the antibiotic isn't needed in the first place.

Many parents in this community have grown accustomed to using after hour urgent cares  because they are convenient.

Convenient isn't always the best choice.  Many times kids go to an urgent care after hours for issues that could wait and be managed during normal business hours.  I know some of this is due to parents trying to avoid missing work or kids missing school, but is this needed?  Can it hurt?

Some kids will get unnecessary tests, xrays, and treatments at urgent cares that don't have a reliable means of follow up.  They attempt to decrease risk often by erring with over treating.  Our office does have the ability to follow up with you in the near future, so we don't have to over treat.  

Urgent cares don't have a child's history available.  They might choose an inappropriate antibiotic due to allergy or recent use (making that antibiotic more likely less effective).  They might not recognize if your child doesn't have certain immunizations or if they do have a chronic condition, therefore leaving your child open to illnesses not expected at their age.  We know that parents can and should tell all providers these things, but our own new patient information sheets are often erroneous when compared to the transferred records from the previous physician... parents don't think about the wheezing history or the surgery 5 years ago every visit.  It is so important to have old records!

There is some evidence that treating things too soon does not allow our bodies to make immunity against the germ.  A great example of this is Strep throat.  Years ago we would go to a doctor when our sore throat didn't get better after a few days.  They would swab our throat and send the swab for culture, which took 2 days. We would treat only after that culture was positive.  That delay in treatment allowed our bodies to recognize the Strep and begin making antibodies against it.  Now kids are brought in the day they have symptoms, and if the rapid test is positive, they immediately start antibiotics.  The benefit? They are less likely to spread Strep to others and they can return to school 24 hrs after starting the antibiotic.  The negative? They might be more susceptible to recurrent illness with Strep, so in the end are potentially sick more often and end up missing more school.

Receiving care at multiple locations makes it difficult for the medical home to keep track of how often your child is sick.  Is it time for further evaluation of immune issues?  Is it time to consider ear tubes or a tonsillectomy?  If we don't have proper documentation, these issues might have a delay of recognition.

Urgent cares and ERs are not always designed for kids.  I'm not talking about cute pictures or smaller exam tables.  I'm talking about the experience of the provider.  If they are trained mostly to treat adults, they might be less comfortable with kids.  They often order more tests, xrays, and inappropriate treatments due to their inexperience.  This increases cost as well as risk to your child.  We have been fortunate to have many urgent cares available after hours that are designed specifically for kids, which does help.  But this is sometimes for convenience, not for the best medical care.

Cost.  As previously mentioned, cost is a factor.  I hate to bring money into the equation when it comes to the health of your child, but it is important.  Healthcare spending is spiraling out of control.  Urgent cares and ERs charge more.  This cost is increasingly being passed on to consumers.  Your co pay is probably higher outside the medical home.  The percentage of the visit you must pay is often higher.  If you pay out of pocket until your deductible is met, this can be a substantial difference in cost.  (Not to mention they tend to order more tests and treatments, each with additional costs.)

What about our urgent care in our office?  We offer a walk in urgent care as a convenience for parents who are worried about their acutely ill child.  It is within the medical home, which allows us access to your child's chart. We can keep all treatments within this medical record so it is complete.  Our staff follow the same protocols and treatment plans as scheduled patients, so your child will be managed with the protocols our physicians and midlevel providers have agreed upon.  Essentially we have a high standard of care and want your child to receive that great care.

So what kinds of issues are appropriate for various types of visits?  
(note: I can't list every medical problem, parental decisions must be made for individual situations)

After hours urgent care or ER:

• Difficulty breathing (not just noisy congestion or cough)
• Dehydration
• Injury
• Pain that is not controlled with over the counter medicines
• Severe abdominal pain
• Fever >100.4 rectally if under 3 months of age
  

Pediatric Partner's Urgent Care:

• Fever 
• Ear ache
• Fussiness
• Cough
• Sore throat
• Vomiting and/or diarrhea
• Any new illness

Issues better addressed with an Appointment in the Medical Home:

• Follow up of any issue (ear infection, asthma, constipation) unless suddenly worse, then see above
  
• Chronic (long term) concerns (growth, constipation, acne, headaches)
  
• Behavioral issues
  
• Well visits and sports physicals (insurance counts these as the same, and limits to once/year)
• Immunizations - ideally done at medical home so records remain complete 

If your child gets a vaccine at any other location, please send us documentation (including the date, brand, lot number, and place administered) so we can keep the records complete.

Remember our website offers answers to questions and many treatments to try at home for various illnesses and conditions!