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."

10 Reasons Not To Get the Flu Vaccine, Reconsidered: Fight Flu!

Influenza is not a just a bad cold. People sick with with the flu can suffer from fevers, cough, sore throat and body aches. It can lead to complications, many of them severe, and death. Complications include pneumonia, ear infections, and sinus infections. Since 2010, influenza has resulted in between 9.2 and 35.6 million illnesses, between 140,000 and 710,000 hospitalizations and between 12,000 and 56,000 deaths each year. 

There's good news though. There's a vaccine to help prevent the flu.

There are many reasons people don't get the flu vaccine, but many of those reasons deserve a second thought.

1. The flu vaccine doesn't work. 

While it's true that the vaccine has variable efficacy, it's important to get the vaccine each year. The more people vaccinated, the less likely the flu will spread through a community. Take a look at this really cool representation of how herd immunity works. How it was developed is described on IFLS.

No one claims that the vaccines against influenza work perfectly. The influenza virus can mutate by shifting and drifting. Until there's a universal flu vaccine, we must rely on experts to look at the viral patterns and predict the strains that will be most predominant in the upcoming season and make a vaccine against those strains.

Despite not working 100% of the time, the flu vaccine has been shown to lessen the severity of illness and decrease hospitalizations and deaths. Even if there's not a perfect match, it can still help those who are vaccinated have a lesser illness. That's worth something.

2. I got the flu from the vaccine.

The influenza vaccine that is currently available cannot cause the flu. Only live virus vaccines can lead to forms of the disease. The vaccines available in the US this season are either an inactivated or a recombinant vaccine. These do not cause flu symptoms. The vaccines cannot mutate to cause symptoms. They simply don't work that way.

There are many reasons you could have gotten sick after a flu vaccine that were not due to the vaccine.

1. You were exposed to influenza before the vaccine had time to take effect and protect. 
2. You  caught a strain of influenza that wasn't covered in the vaccine. 
3. You caught one of a number of other viruses that cause flu - like illness. 
4. The vaccine did cover the type of virus you have but your body didn't make the proper protection from the vaccine so you were still susceptible. 

In each of these scenarios, you still would have gotten sick if you hadn't had the vaccine, but if you recently had the vaccine it's easy to understand the concern that the vaccine caused the illness.

The FluMist is a live virus vaccine, so it could cause mild symptoms of influenza viruses, but it is not recommended for use in the US this year.

3. I can prevent the flu by being healthy.

It is important to eat right, exercise, get the proper amount of sleep, and wash hands. All of these things help keep us healthy, but they don't prevent the flu reliably.

We cannot boost our immune system with megadoses of vitamins. (Vaccines are the best way to boost our immune system.)

Organic and non-GMO foods don't offer any benefit to our immune system over other healthy foods. If these things did as some claim, people generations ago would have been healthier since they ate locally grown organic foods, got plenty of fresh air, and exercised more in their day to day life than we do these days. Instead of being healthier, they were much more likely to die from infections. The risk of death between the first and 20th birthday had decreased from over 3 in 100 children in 1900, to less than 2 in 1000 children today. One of the major causes of death historically (and still today) is from influenza, but it has been shown that the flu vaccine reduces the risk of death. Why not help your body prepare for flu season with the vaccine?

4. Flu vaccines shouldn't be used during pregnancy -- they've never been tested and can lead to miscarriage.

Pregnancy is considered a high risk condition for severe complications of influenza disease and the vaccine can help prevent those complications. It is recommended that all pregnant women get vaccinated against influenza. If a pregnant mother gets the vaccine, it not only helps to prevent complications during pregnancy, but it also helps prevent influenza in newborns since they can't be vaccinated until 6 months of age.

There are some who assert that since the package inserts state the vaccines have not been studied in pregnancy that they aren't safe, but in the next breath they say that they aren't safe because a study showed a high rate of miscarriage after the vaccine.

The first part of the argument is one of the many ways the package insert is misused. Discussions about using package inserts properly are found at The Logic of Science, another at The Logic of Science, Skeptical Raptor, Harpocrates Speaks, and even this analogy of Package Insert Airline to vaccine package inserts.

Think about it... you can't argue that it's never been studied and then quote a study. It's been studied. A lot. The Vaccine Safety Datalink is a huge database designed to document adverse events associated with vaccination, allowing researchers access to a large amount of data.  

The flu vaccine has been safely given to pregnant women for over 50 years. Despite a recent small study suggesting a potential risk of miscarriage, the flu vaccine has been studied extensively around the globe and found to be not only safe but effective at decreasing the risk of influenza disease during pregnancy and beyond.

5. I have a chronic illness and don't want to get sick from the shot.

People with chronic illnesses (including diabetes, heart conditions, and asthma) are more at risk from serious illness from influenza disease. The influenza vaccine can prevent hospitalizations and death among those with chronic diseases. People with chronic diseases should be vaccinated, as should those around them to protect with herd immunity.

The flu shot cannot make anyone sick, even those who are immunocompromised. You do not need to avoid being around someone who is sick or immunocompromised if you've recently been vaccinated.

6. If I get the flu I'll just take medicine to feel better.

There is no medicine that makes people with influenza feel better reliably.

There is no medicine that decreases the spread of influenza to friends and family of those infected.

We can take fever reducers and pain relievers, but they don't treat the underlying virus. They suppress our immune system so we don't make as much inflammation against the virus, which decreases the symptoms and our body's natural defenses.

Cough and cold medicines simply don't work well.

As for antiviral medicines, I have written about Tamiflu previously and why I rarely recommend it.

Megadoses of vitamin C or other vitamins, homeopathic treatments, essential oils, and other at home treatments have not been shown to significantly help.

It is important if you get sick, you should limit contact with others. This means missed school and work for at least several days with influenza. Prevention with the vaccine simply is better than trying to treat the symptoms.

7. I don't like shots. (Or my child doesn't like shots.)

I'm a pediatrician. Most of my younger patients hate shots. Like really hate shots. They cry, scream, kick, try to run and hide -- you name it, they've tried it to try to avoid shots. They fear shots, but we can help them with techniques that lessen the pain, and they often say "it wasn't that bad" afterwards. For more on how we can help lessen the pain, check out Vaccines don't have to hurt as much as some fear.

8. I have an egg allergy so can't get flu shots.

In previous years there was a concern that people with egg allergy would have a reaction from the vaccine so it was not recommended, but it has been found to be safer and still appropriate to vaccinate with proper precautions.

People who have had only hives after egg exposure can safely get flu vaccines following standard protocols.

People who have symptoms of anaphylaxis with egg exposure that requires epinephrine (respiratory distress, lightheadedness, recurrent vomiting, swelling - such as eyes or lips) should still get the vaccine, but they should be monitored at the appropriate facility (doctor's office, hospital, health department) for 30 minutes to monitor for reactions.

9. Vaccines are only promoted to make people money. Doctors are shills.

Very little profit is made from any vaccine. Really. Some doctors and clinics lose money by giving vaccines. I often tell my own patients that I don't care if they get the vaccine at my office, the local pharmacy, or at the parent's office - whatever works for them best. I just want everyone vaccinated. This in the end will decrease my revenue because they will not come to the office seeking treatments for a preventable illness. But I am a pediatrician to take care of the health of children, not to make money. Pediatricians are consistently on the bottom of the list of physician salaries. If I was in it for the money, I would have gone into orthopedics or another surgical specialty.

There are many things to consider when addressing this argument and the Skeptical Raptor does it well, including links to more information.

10. The flu vaccine contains mercury.

While it is true that some flu vaccines contain thimerosal, not all do. Thimerosal was removed from the majority of childhood vaccines in 2001 due to lawmakers responding to constituent demands, not because it was shown to be a risk medically. Since the flu vaccine is not only for children, there are multidose vials that contain thimerosal. If that really bothers you, ask for a version without thimerosal. But since it was removed because people thought thimerosal caused autism and the rates of autism haven't gone down since it was removed, that's pretty strong evidence that it never caused autism. Just like the scientists said. It's a preservative that is effective. I would gladly get a flu vaccine with thimerosal, and have over the years, but the majority of flu vaccines given to children in the US are thimerosal free. Just ask.

Flu Vaccine Information and Recommendations for the 2017-2018 Season

• Both trivalent (3 strain) and quadrivalent (4 strain) vaccines are approved for use this year. There is no preference officially of one over the other, but the vaccine should be appropriate for age.
• No FluMist Nasal Spray flu vaccine is recommended. The nasal spray did not work well in the last few seasons it was used in the US. Until it is understood why it wasn't effective then how to make it effective, it will not be recommended.
• Pregnant women should be vaccinated to protect themselves and their baby. 
• Everyone over 6 months of age should be vaccinated. Children 6 months to 8 years who have only had one flu vaccine in their past will need two doses this season. This is because the first dose acts as a primer dose, then a booster dose boosts the immune system. Once the body has had a boost, it only needs a boost each year to improve immunity. 
• Infants under 6 months of age can gain protection if their mother is vaccinated during pregnancy and if everyone around them is vaccinated. They cannot get the flu vaccine until 6 months of age.
• People with egg allergy can be vaccinated. If there is a history of anaphylaxis to egg, they should be monitored for 30 minutes.
• The CDC is encouraging everyone to be vaccinated by Halloween if possible, but it's not too late to be vaccinated after that if not yet done this season. It takes up to 2 weeks for the vaccine to be effective. Flu season typically starts in January, but the peak can be as early as November and as late as March.
• It is acceptable and encouraged to give the flu vaccine along with other recommended vaccines needed.

Related blogs

Flu Vaccine Recommendations for the 2016-17 Year

Vaccines don't have to hurt as much as some fear

To Tamiflu or Not To Tamiflu...

Tamiflu: Guest blogger Dr. Mark Helm
Tamiflu Status Downgraded

How To Keep Your Family Healthy This Winter

Evolution of illness

Fever Is...

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

Cough Medicine: Which one's best?

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

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Fevers: How High is Too High?

Despite having fever information on our website and blogging about it many times, including here and here and here, parents often call in or bring their child in with excessive concern for fevers. (Note: paracetamol is the same as acetaminophen and Tylenol in the linked article.)

The information here is only for infants and children over 3 months who are otherwise healthy and vaccinated. If those criteria are not met, the child is in a higher risk category.

Fever is one of the biggest anxiety inducers in parents, and I want that to change. Yes, we should care for our children when they're sick, but we don't need to worry about the numbers on the thermometer.

Maybe one time I'll explain fever in a way that hits home so parents can stop focusing on the number and more on the child. Parents often tell us in detail what the temperatures are at various points of the day but omit how the child looks and acts. I care more about the child's behaviors than the thermometer's reading.

I know fever is scary. Kids are miserable. But the temperature itself is not what we treat. Treat the symptoms!

What is a fever?

The number on the thermometer can be confusing to parents. How the temperature is taken is as important as the number itself to determine if it is a fever. A fever is often defined as a temperature over 100.4 °F (38 °C) but it can vary based on how you take the temperature (rectal vs oral vs forehead).

This is simply the minimum temperature that is no longer considered normal. The American Academy of Pediatrics doesn't recommend treating fevers until the temperature is over 102°F unless the child is uncomfortable. Thermometers are not very accurate, so when you worry more about a temperature that is 0.5 degree higher than another temperature, it might not even be a significant difference. You could take the temperature twice in a row and get different readings. If your child is playful and the thermometer reads 101.5°F that is a very different story than if your child is barely moving, whimpering, and breathing fast with a temperature of 101.5°F. I wouldn't recommend any fever reducers for the first, but I would recommend the second get evaluated by a pediatrician or other medical provider.

Why do we care about fevers?

I think medical professionals help to foster this fear of fevers because we ask about them. It can be helpful to know the actual temperature because many kids are warm but not really running a fever.

• We are more contagious during a fever, which is why schools and daycares won't let kids stay if they have a fever. 
• The height of the fever doesn't indicate if the child has an infection requiring antibiotics or not, but it can cause increasing discomfort as it rises above 102°F. 
• The height of a fever does not cause fever seizures, but a rapid change in temperature can cause a seizure in a child that is susceptible to them.
• If a true fever lasts more than 3-5 days or is accompanied by other concerning symptoms, the child should be seen to look for a source. 

So how high is too high?

Fevers higher than 106°F (41°C) might be the answer parents are asking when they want to know what temperature is too high. It is at this point that brain damage from the temperature itself can occur due to hyperpyrexia (heat stroke). This is not common from a simple infection and other symptoms will be present, such as change in consciousness, vomiting, flushed skin, headache, rapid breathing, and very rapid heart rate. Emergent medical attention and cooling the body is important with hyperpyrexia, which differs from fever.

If your child does not appear very ill and the thermometer reads very high, it is likely the thermometer is in error.

What if the temperature doesn't go down to normal after using a fever reducer?

When parents give a fever reducer, they often worry that the temperature doesn't go back to normal. Returning to normal doesn't mean it isn't a serious infection and not returning to normal doesn't mean that it is a serious infection. Studies show the temperature tends to decrease by 1.8 to 3.6°F. Acetaminophen begins to work in 30 - 60 minutes and has its peak effect in 3-4 hours. The duration of action is 4-6 hours. Ibuprofen begins to work in under 60 minutes and has its peak effect in 3-4 hours. The duration of action is 6-8 hours. The goal should be to make a child more comfortable though, not to get the temperature to normal.

My personal opinion is that most children won't need their temperature taken to verify that they are better. They should be more comfortable. If they aren't, then it is wise to have a medical professional look at them.

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Fever Phobia

My partner went to the American Academy of Pediatrics National Conference last Fall and came home with all kinds of new information. Most of it was great. But she also told us about a new product that would be coming to market that is not so great. I personally feel that this new product will be dangerous. Not in the "it will hurt your baby directly" category, but in the "will increase parental anxiety and overtreatment" department.

What's this product?

It's called FeverFrida. It has a sticker that goes under a baby's armpit that measures a baby's temperature every 4 seconds and sends information by bluetooth to the parent so the parent can know all the temperatures. It sends an alert if the temperature is over 99F.

Can you say anxiety inducing???

Fever is our friend, people! It helps fight infection. If we get a virus or bacteria, our body elevates the temperature to kill the infectious agent. I know a lot of people worry when their kids have a fever. I wrote about that in Fever is... because it is a very common fear. But we shouldn't feed that fear. This device will feed the fear with alerts for non-fevers and a reading every 4 seconds. That's 15 readings every minute. That means 21,600 readings in 24 hours. And they encourage you to bring all those readings to your pediatrician. Please don't. I won't even humor you by looking at them. That will encourage the fear. I can't do that.

Pediatricians don't usually consider a temperature a fever until it is at least 100.4F rectally (99F under the arm), so why this gizmo alerts you right at 99F is beyond me. The American Academy of Pediatrics doesn't recommend treating a temperature under 102F unless there is significant pain. (Note: This does not apply to babies less than 2 months, underimmunized kids, and those with immune problems.) In other words, you treat the pain, not the temperature in most kids. Let the fever do it's job! So what is the benefit of having a temperature taken every 4 seconds?

The FeverFrida is from a company that I have recommended for years because they make a wonderful product called Nosefrida. The Nosefrida can get mucus out of babies and helps them get through upper respiratory infections. I do love this product despite how gross it seems to suck the snot out of baby's nose. (We do a lot of gross things as parents if they help!)

I'm disappointed that the company is trying to play on parental fears with the fever monitor. Save your money and watch your baby for symptoms and treat based on these tips.

If a child's temperature is usually low, how do we define fever?

My child typically runs a temperature around 97°F, so if the temperature is 99°F, is that a fever?

We get a variation of this question all the time.

Sometimes it's the opposite, such as my child usually runs hot, so can you write a note saying 101°F isn't a fever for him?

Short answer (both questions): No.

Long answer: Our body temperature is very complex. Your school district will define a fever with a number, but your doctor might have a different number. A fever is not defined by the change from a person's baseline temperature.

Disclaimer: All information on fever given is for healthy, vaccinated children over 3 months. Young infants, children with chronic disease, or undervaccinated kids do not apply to standard fever discussion and advice.

Most people think of a "normal" body temperature as an oral temperature of 98.6°F. Your temperature may normally be a degree or more higher or lower, which means 99.6°F is normal despite the fact that some daycares define this as a fever. Most often we associate high body temperatures with illness, but elevated temperatures also can be caused by environment temperatures being too high (or over bundled babies), dehydration, medications, poisons, cancer or overactivity. Your normal body temperature changes by as much as 1°F throughout the day, depending on how active you are and the time of day. Body temperature is very sensitive to hormone levels, so may vary with women’s monthly cycles. Our temperature tends to lower as we age - kids tend to have slightly higher temperatures than their parents, even when healthy. It is very common for children to get a fever when sick, but less common for adults. And the thermometer itself can vary in readings significantly, so the number may or may not be reliable, depending on the thermometer.

It is said that a child has a fever when his or her rectal temperature is 100.5°F or higher, which is about 99°F under the arm and 99.5°F and in the mouth. [This was edited 6/21/17 after some perceptive pediatricians found a typo.] This is by convention, but in actuality children’s normal temperatures may be higher than adults so these temperatures might be normal and only higher temperatures may actually indicate fever.

Parents often use the term "low grade fever" to indicate something less than 100.5°F. There is really no such thing. It's either a fever or it's not. A low fever in my mind means a temperature over 100.5°F that doesn't make the kid feel pathetic. Any temperature less than that simply isn't a fever. The child might be sick and temperature doesn't define illness, but it's not a fever.

There also isn't a medical definition of high fever. The temperature is the temperature and illness is better defined by describing all symptoms, not just the temperature. I guess if I had to define a high fever, it would be one that makes a person feel absolutely miserable. There is no magic number that defines this high fever or that tells us when to worry more. It's more important to look at the child than the thermometer to know if they're really sick or not.

Many parents have fever phobia, a condition where they worry that the fever itself will do damage. While a rapidly increasing temperature can cause fever seizures, these are more scary than dangerous. Fever seizures can occur with relatively low fevers if the change in temperature is rapid. It's not necessarily the high high temperatures that cause seizures. The brain will not be permanently damaged from most fevers (even high temperatures), though a fever can be a symptom of serious illness that can damage the brain, such as meningitis. But you would recognize that your child is more sick than the typical illness if they are having symptoms of such a significant illness. You would not use a thermometer to tell you that.

I do not recommend taking a child's temperature frequently. That causes excess worry in parents when the temperature increases by 0.5 degree, which could be a real change or just the thermometer's reading. Respond to your child, and don't rely on the thermometer. Never wake a comfortably sleeping child to take the temperature. Don't use sticky strip thermometers that tell your cell phone if there's a fever (yes, that exists, and it will lead to more parental anxiety than help keep children healthy.) Knowing the temperature helps to know if it is a true fever or not, but it should not direct you to give medicine or not. A temperature can be taken at times you need to know if there's a fever, since schools and daycares have rules to keep kids with fever away (though fever is not the only sign of illness and if your child's sick he might need to stay home despite temperature). It is sometimes helpful to know if a warm or hot child has a true fever, but you don't need to take it every hour to follow the trend with most illnesses. It's not even helpful to see how much medicine brings the temperature down. If a child doesn't improve, you will be concerned regardless of the thermometer reading. Taking a temperature once or twice a day is sufficient. I'd recommend taking it at times that it is likely to be its highest, such as in the evening or when fever reducing medicine has worn off.

The American Academy of Pediatrics recommends treating sick children for comfort, which is typically when the temperature reaches about 102°F or if they have pain somewhere. Not all earaches or sore throats cause fever, but you might consider a pain reliever to help symptoms. Most people feel uncomfortable as their temperature approaches 102°F. Only give fever reducers if the child needs it for comfort because the fever is actually helping the child fight off an infection - don't inhibit the immune system if your child is comfortable enough to sleep and drink without significant pain.

Never give a fever reducer to hide a fever so you can send your child to school or daycare. If they don't feel well, they shouldn't go because they'll spread the illness to other kids. A normal temperature because of a fever reducer does not mean that the child is fever free. You can only be fever free if the medicine has worn off and the temperature remains normal. The temperature should be normal off medicines for 24 hours before returning to school or daycare (or work for adults with fever).

So, with the original question, if a child is usually cooler than 98.6°F, when do they have a fever?

A temperature over 100.5°F is the general definition of fever, regardless of baseline temperature. In practical terms though, parents really want to know if a child is sick or not. You can tell when a child is uncomfortable by looking at him ~ you don't need a thermometer. It is not necessary to treat based on the thermometer reading. It is important to give a fever reducer/pain reliever when the child is uncomfortable so he can drink to stay hydrated and sleep. The goal is not to lower the temperature to “normal”, it's to make the child more comfortable.

If you are concerned about your child's illness, especially if he looks dehydrated, is having trouble breathing, is in uncontrollable pain, has symptoms you think might need antibiotics (such as UTI symptoms or Strep throat), or if the fever lasts more than 3-5 days (depending on age of child and overall symptoms), bring him to have an exam to look for sources of fever. 

Related blogs:

Fever is... 
Evolution of illness
But the snot is green
Adenovirus infections
To Tamiflu or Not to Tamiflu
Tamiflu: Guest blogger Dr. Mark Helm
Urgent cares for routine illness: Yes or No?
New Guidelines for treating Strep throat
Updated sinusitis guidelines
All about ears
Menthol for sore throats and cough
My child's cough sounds like...
Cough medicines: Which one's best?
How long with a cough or cold last?

P.S. I'd love to meet you on Twitter. Stop by and say "hi"!

P.P.S. If you've enjoyed this blog, go to the top of the page and enter your email address so you will get future posts direct to your In Box!

What should I do after hours when my child is sick?

Parents often fret about whether or not to go to the ER (or urgent care center or walk in clinic) for a child's illness or injury. This week the American Academy of Pediatrics released a position statement against walk in clinics. Many parents don't realize the difference between a pharmacy walk in clinic and an urgent care or ER staffed with pediatric - trained physicians, nurse practitioners, and physician assistants. I believe that urgent needs do arise after office hours, and we are fortunate in our area to have pediatric urgent cares and ERs that can fit that need.

This post is written with my own practice patients in mind. There are variances in what is available in any community and what  a pediatrician is comfortable seeing in the office and what they refer out. Please speak with your own physician about what to do after hours in your situation.

photo source: Shutterstock

I also know that many parents take their kids to walk in clinics for convenience. Sometimes even when our office is open. I think that really fragments the healthcare of the child and I cannot support going outside the medical home when unnecessary. I've blogged about this before. Please visit Urgent Cares for Routine Illnesses... Yes or No for more on that topic.

When to call for after hours advice

Over the years I have found most of my patient families to be very respectful of after hours phone calls. They recognize that I am trying to spend time with my family or that they woke me from sleep. They often apologize for bothering me (which isn't necessary, it is my job). Only on rare occasions do they call for things that should have been called during office hours or in true emergencies where they should call 911. It is a reasonable call if you need help managing the symptoms your child has, especially if you can't find your answer on our searchable website. If you want a diagnosis or prescription, your child will need to be seen and evaluated.

Things to avoid calling the on call provider about:

• To schedule an appointment. We don't do that. Leave a message at the office or request an appointment on our portal.
• To cancel an appointment. Leave a message at the office for the office staff.
• Any billing question. 
• To ask when we open. That information is on our website and our office outgoing voicemail message.
• To discuss a chronic issue that you have been working on with your primary provider -- unless symptoms have worsened and you need treatment advice.
• To discuss treatment from another office, such as a walk in clinic not in our office or a specialist that is managing a chronic illness. If you question something done by another provider, talk first with that provider. If you want to discuss it with your primary physician, call during office hours or send a message through our portal. 
• Prescription refills. It is a very unusual circumstance that we would call out a refill for you.
• A diagnosis and prescription. We cannot make a diagnosis over the phone and cannot prescribe a new medication for something that hasn't been seen.
• Rashes. See below.
• Symptoms that have been ongoing for days but not worsening. If symptoms have been stable for days, it can wait until we are open for your child to be seen.
• Routine growth, development, or behavior questions.
• Routine lab results. Sometimes our nurses call with lab results, but must leave a cryptic message. (Due to HIPAA laws they do not leave specific information on voicemail-- another reason to be sure each of your children are registered on our password protected portal-- we can leave specific details there!). If it is a result that requires notification of the parent urgently, they will tell the on call provider to call you or they will give you instructions to call back (with the knowledge of the on call person). If they say to call back during business hours, the on call person does not have your results on hand.
• To "document" suspected abuse. These kids should always be taken to a place that can see your child directly and has staff specifically trained for that purpose. We usually recommend an emergency room, such as the ones at Children's Mercy campuses. A phone call is hearsay and would not help your case.
• Directions to an urgent care or ER. I don't give good directions, just ask my husband. Call them, look online, or set a GPS.
• Prior authorization before going to the ER or an urgent care. We cannot do PA's after hours and they are not needed for insurance companies.
• To learn if a particular location is covered by your insurance. Call that location or check with your insurance company. We won't know. 
• To ask if an urgent care or walk in clinic provides a particular service, such as possible urinary tract infection in a toddler or stitches. We won't know. Call them for information about what they do.
• Anything that needs to be treated urgently. Calling us delays care. We can be notified later. Just go. 
• And one last request. Please don't call from the ER or urgent care waiting room to ask if it's okay to leave because the wait's too long. If you thought symptoms needed to be seen in the first place, I would never feel comfortable telling you to leave. Ask someone there who can see your child.

How can you find answers if you don't want to call after hours? 

• For our patients, using our online portal allows parents to ask routine questions at any time of day/night, as long as they can wait up to 5 business days for a reply. 
• Our website has a ton of information to treat many symptoms and parents can search there before calling. (Parents will often say, "I looked on the website but didn't find..." so I know they try! Thank you for trying!!! It not only helps the on call provider not be bombarded with another call, but you will often get more thourough advice, especially in the middle of the night.) 
• Online searches can be helpful ONLY if you know the site you are using. Besides our own website, you can use HealthyChildren, KidsHealth, or recognized hospital websites, such as CHOP.

• Remember: We are open 6 days a week and we offer walk in hours all open business hours. This allows you to come in to our office for most illnesses and minor injuries.

For more on how to get the best phone advice when you call our office or after hours on call provider, please read Help Us Help You.

Times to go to the ER or Urgent Care: 

The big question in a parent's mind is when does a child need to be brought to a walk in clinic or emergency room. If in doubt after reading this, call the on call provider for specific advice. Some generalizations to help make the decision:

• Any temperature over 100.5 in a baby under 2-3months of age. (I usually say at least 2 weeks after the 2 month vaccines.) A pediatric specific ER is best for this unless our office is open. (We can do the initial evaluation if we are open.)
• Any temperature over 100.5 in an under-immunized or immune deficient child. Be sure to tell the providers of the medical history that makes your child high risk. We can see these kids when we are open. An ER, ideally pediatric specific, is best for this when we are closed.
• Signs of dehydration. This includes no tears, dry mouth (not just lips), no urine in 6-8 hours. Dehydration can be managed in some urgent cares and all ERs. (Call the urgent care to see if it is within their scope of practice.) Walk in centers are NOT generally equipped to manage dehydration. Our office can see these kids if we are open. 
• A child who is urinating a lot but still seems dehydrated based on dry mouth, weight loss, sunken eyes, etc needs to be seen immediately. This is a sign of diabetes and needs to be seen in an ER if we are closed.
• Signs of respiratory distress. This includes breathing faster than 60 times / minute in children under 1 year, 50 times / minute in older children. This can be treated in our office when we are open, or in a pediatric urgent care or ER. Walk in centers should be avoided due to provider variations in competence with respiratory distress.
• Excessive pain. If you can't control the pain with simple measures, such as acetaminophen or immobilizing a hurt limb, it should be evaluated. ERs are more suitable if it is a possible surgical issue or if imaging will be required.
• Gaping skin. If an injury causes the skin to open enough that it looks better if you pinch it together, it probably needs to be repaired. Stitches, glue, or staples need to be put in as soon as possible because the longer the wound is open the more likely it will become infected and after several hours we can no longer close it up. ERs will always do wound repair. Some urgent cares will. Walk in clinics generally do not. During office hours we can do laceration repair, so you can save the trip to the ER if we're open!
• Altered mental status. If your child is so lethargic he can't lift an arm to drink, or doesn't seem to recognize you, or doesn't make sense when talking he needs to be seen immediately in an ER.
• Parental comfort. This is a vague one, but I am a big believer in the gut feelings of a parent. If you are worried and can't sleep, there might be something going on. Of course, you can't second guess every illness or injury, but if you are so worried you can't sleep: go.
• Call 911 and go to the ER if there is a severe illness or injury that may be life threatening.
• Go to the ER if you suspect your illness or injury might require surgery. 
• If you suspect an x-ray will be needed after an injury, use an ER or urgent care with the ability to do X-rays. During office hours our office can handle minor injuries. If you suspect a broken bone but the child is not in extreme pain, there is no obvious angling of the bone, and the skin is not broken over the area, it may be okay to wait until our office opens.
• A child who loses consciousness after injury or with illness generally should be seen. Call 911 if consciousness does not resolve quickly. (Note: many kids will "pass out" when standing in a hot room or singing, when toddlers cry hard, when kids see blood, or if they hyperventilate due to excitement or pain. They usually awaken quickly from these episodes. If they act normal after this brief passing out time, they can generally be seen in our office. Call for advice.)
• Eye injuries that involve a puncture to the eye, a possible fracture of the bone around the eye, unequal pupil size, bleeding from the eye, vision changes, or other serious concerns should be seen in an ER. (Minor eye injuries, such as a possible scratch to the eye, can be seen in our office or a pediatric urgent care.)
• Seizures should generally be seen in an ER (unless there is a history of seizures and home treatment is available). If your child is running a fever when the seizure starts, call for instructions. It might be appropriate to be seen in our office or a pediatric urgent care.
• Allergic reactions involving hives or facial swelling can be seen in our office when open, an ER or pediatric urgent cares unless difficulty breathing (in which case, call 911 and go to the ER). Even if your child has epinephrine available, they need to be seen after epinephrine is used.
• Severe difficulty breathing should be called to 911 to be taken to the ER.
• Severe headache should be seen in the ER.
• Severe abdominal pain that does not allow the child to move normally should be seen in the ER. This could be a surgical issue.
• If you are unable to drive your child safely for any reason but they need to be seen, call 911.

Typical things seen at urgent cares or walk in clinics are things that usually would be seen in our office when we're open. Many can wait until we're open if you can manage pain, hydration, and breathing at home.

• mild wheezing or difficulty breathing that isn't worsening
• minor burns and injuries
• abdominal pain that is minor without dehydration
• constipation
• pink eye
• ear aches
• sore throat
• vomiting and diarrhea without dehydration (as discussed above)
• fever in children over 3 months of age who are immunized and immune competent
• objects in ears or noses 
• insect bites
• mild allergic reactions
• cough and colds
• skin rashes
• urinary tract infections 
• sports physicals should ideally be done at your primary care office so that growth, development, safety, and other issues can be addressed
• vaccines should ideally be done at your primary care office to keep all records in one place. If your child gets a vaccine elsewhere, be sure to call the PCP office during office hours to update their chart.

A few common concerns that parents call about:

Fever

Parents typically spend a lot of time giving me a play by play of all the temperatures of the past week.  I really don't need to know every up and down of the temperature. What does it really tell me if a child has a fever? They are sick. That's about it. There is no magic temperature that I worry about for most kids over 3 months of age. If your child is younger than 3 months, is not up to date on recommended vaccines, or has an immune deficiency, they need to be seen for any fever over 100.5F. For other kids, I care more how a child looks and acts than the temperature itself. The goal of fever management is to keep a child comfortable and hydrated. The American Academy of Pediatrics recommends treating temperatures over 102F and for comfort. The goal is not to bring the temperature to normal, but to allow your child to feel more comfortable. For more on fevers, see my Fever blog as well as our website's Fever page.

Rashes

Rashes are notoriously difficult to describe. I have a hard time documenting them in the medical record and will sometimes simply take a picture to put it in the child's chart. Even a picture doesn't completely tell the story because it does not show the texture, temperature of the skin, or the evolution over time of the rash. After seeing the rash we need to look for other findings that could be associated with that type of rash (such as enlarged lymph nodes, swollen spleen, swollen tonsils, mouth ulcers, etc). In general a rash needs to be seen to be addressed. Phone calls for rashes (even during office hours) are not helpful. It only needs to be seen emergently if there are significant other concerns. If the rash bothers the parent more than the child, schedule an appointment.

Ear Pain

Earaches generally are not emergencies. If you can control the pain at home with an over the counter fever reducer, you can usually wait until office hours. The exceptions: other symptoms, such as dehydration, difficulty breathing, or Mastoiditis -- If the ear physically sticks out from the head more than normal, it is an emergency. For more on earaches, see our Ear Pain web page.

Vomiting and/or Diarrhea

Stomach bugs are very difficult to manage, but usually can be managed at home. Follow the instructions on our Vomiting and Diarrhea page. Signs of dehydration include: dry inside the mouth, extreme weakness, no tears, and decreased urine (except with vomiting from diabetic ketoacidosis - those kids make a lot of urine but they otherwise look dehydrated). If you think your child is dehydrated, he should be seen. Diarrhea that is bloody, severe abdominal pain, and painful urination with vomiting are other times that being seen as early as possible is warranted.

Sore Throat

Sore throats can be painful, but with good hydration and no signs of difficulty breathing, they can wait until office hours.

Medication dosing

Unfortunately many over the counter medicines don't have dosing listed for infants and young children. We have common medications on our Medication Dosing page. You can also ask the pharmacist when you purchase the medicine. I personally don't like to give dosing amounts over the phone, especially if you wake me from sleep. It would be too easy to give the wrong amount, which could be dangerous for your child. It is safer for you to always learn your child's dose when you buy the medication.

Continued illness despite treatment 

Sometimes parents call because they're frustrated that their child is still sick after a few days. Typically these are Sunday evening calls because the parent wants to get back to work Monday. I can't fix this over the phone. See Evolution of Illness for more on how illnesses evolve over time.

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

It is Thanksgiving morning as I write this. I am enjoying my quiet time as the family sleeps in. Extra time to blog because I'm not cooking today ... more on that later.

Wash hands to help prevent illness!

Yesterday was a typical day in our office for a day before a holiday. Sick kids came in with parents hoping for an insta-cure so they could enjoy the holiday with the extended family. A few wanted to fly back home with a febrile child and wanted our okay -- but of course didn't get it because even on an antibiotic they could spread illness if it is a virus, which most illnesses are. Some parents just called in because they were already out of town when their child got sick and they wanted to know what will make them better before the turkey celebration.

I'm sure most parents knew deep down that the answer would be "time". There is no insta-cure for most illnesses. Anyone with fever, cough, sore throat, or other ill symptoms should be kept away from the festivities. Even if the fever goes down with a fever reducer. Even if the last fever was before bed last night and it's down this morning. Fever can wax and wane and one needs to be fever-free (without a medication to bring it down) for 24 hours before we really consider it gone. People are most contagious when they are running a fever and the first few days of illness.

It stinks. I know. As a parent with a teen who has had a cough for over a week and is sleeping a disrupted 16-18 hours a day, I will miss Thanksgiving with extended family to avoid the spread of illness. Could we go? Sure. He hasn't run a fever all week. He's old enough that he can wash hands, cough into his elbow, and stay out of everyone's way. But he'd be miserable. And if one of the little ones got sick, I'd feel awful. Even if they got it elsewhere, I'd wonder if it was from him.

So I get it. It really stinks. Family from Tennessee and California are in town. We rarely see them and I want the cousins to get to know one another. But my teen isn't feeling well and I don't want the cousins to feel this way. I haven't started him on antibiotics to make him better faster because I know they wouldn't work. We are using a humidifier, lots of sleep, and waiting. He's refusing the nasal wash unfortunately... but I keep offering it!

This holiday season I wish everyone health, but if someone is sick, stay home. Don't spread the germs.

For more information on treating illnesses, see these links:

Fever
Cough and colds
Ear pain and infections
Wheezing in infants
Croup
Influenza
Tamiflu
Vomiting and diarrhea
Pink eye and other red eyes
Strep throat
Painful urination
Cough Medicines: Which One's Best?
Evolution of Illness

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.