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."

Cough 'til you puke...

This is the time of year it seems everyone's coughing. I've heard from more than one worried parent that their child coughs to the point of vomiting. In the medical world, we call this post-tussive emesis.

Post = after, tussive = cough, emesis = vomit

Kids tend to have a very active gag reflex, so they sometimes gag themselves and vomit with cough. This can be good, since it gets the mucus out of the back of the throat. You can try to teach older kids to hack and spit it out, cough and spit it out, gargle with salt water, and rinse mucus out of the nose.

Of course it's not fun to vomit after coughing because everything in the stomach comes up and makes a huge mess. Sometimes the vomit comes out of the nose, which can burn from the stomach acid. And vomiting can be very scary to kids.

Are there serious concerns when kids vomit from coughing? 

Yes. In medical school I learned that when kids cough to the point of vomiting we should consider whooping cough, pneumonia and asthma. In reality, I find that many kids with regular cough and colds can gag from cough, but I always consider the more serious options.

What should I do if my child vomits from a cough?

First, keep your cool. If a parent starts to get flustered, it makes the child more worried, which never helps.

Make sure your child's breathing is okay. Obviously he is coughing, but between coughs if the breathing rate is too fast or labored, he should be evaluated ASAP.

Rinse out your child's mouth (and nose if needed- saline drops or rinses work well for this). Vomit is just nasty tasting and can burn in the nose.

Treat the cough. If your child has asthma, give a breathing treatment or their rescue inhaler. If your child is over a year of age, you can use honey to help a cough. A tsp usually does the trick. Humidify the air with a vaporizer or humidifier. For more treatments see Cough Medicine: Which one's best.

When should my child be seen?

If your infant is under a year of age or your child has not had the whooping cough vaccines, he should be evaluated. Some babies with whooping cough stop breathing so many are hospitalized to monitor for complications. 

After a single episode of vomiting if your child's breathing is comfortable, just continue to manage at home.

If your child develops difficulty breathing or dehydration, he should be seen as soon as possible.

If your child continues to vomit after coughing but is comfortable between episodes, he should be seen during normal business hours at his regular doctor's office. 

Help! I'm sick and I have a baby at home.

When we have newborns we don't want to expose them to germs. We avoid large crowds, especially during the sick season. We won't let anyone who hasn't washed their hands hold our precious baby. We might even wash our hands until they crack and bleed.

But what happens when Mom or Dad gets sick? What about older siblings? How can we prevent Baby from getting sick if there are germs in the house?

In most circumstances it is not possible for the primary caretaker to be completely isolated from a baby, but there are things you can do to help prevent Baby from getting sick.

• Wash hands frequently, especially after touching your face, blowing your nose, eating, using common items (phone, money, etc) and toileting. Wash Baby's hands after diaper changes too. Make this a habit even when you're not sick... you never know when you're shedding those first germs!

• Wipe down surfaces. Viruses that cause the common cold, flu, and vomiting and diarrhea can live on surfaces longer than many expect. Clean the surfaces of commonly touched things such as doorknobs; handles to drawers, cabinets, and the refrigerator; phones; and money frequently when there is illness in the area. 

• Avoid touching your eyes, nose and mouth - these are the "doors" germs use to get in and out of your body. Pay attention to how often you do this. Most people touch their face many times a day. This contributes to getting sick.
• Resist kissing Baby on the face, hands, and feet. I know they're cute and you love to give kisses, but putting germs around their eyes, nose, and mouth allows the germs to get in. They put their hands and feet in their mouth, so those need to stay clean too. 
• Cover your cough. I often recommend that people cover coughs and sneezes with their elbow to avoid getting germs on their hands and reduce the risk of spreading those germs. When you're responsible for a baby, the baby's head is often in your elbow, so I don't recommend this trick for caretakers of babies. Cover the cough or sneeze with your hands and then wash them with soap and water or use a hand sanitizer if soap and water aren't available.
• Vaccinate. If you're vaccinated against influenza, whooping cough, and other vaccine preventable diseases, you're less likely to bring those germs home. Encourage everyone around your baby to be vaccinated. If you get your recommended Tdap and seasonal flu vaccine while pregnant, Baby benefits from passive immunity. See Passive Immunity 101: Will Breast Milk Protect My Baby From Getting Sick? by Jody Segrave-Daly, RN, MS, IBCLC to better understand passive immunity.
• Breastfeed or give expressed breast milk if possible. Mothers frequently fear that breastfeeding while sick isn't good for Baby. The opposite is true - it's very helpful to pass on fighter cells against the germs! Again see Jody Segrave-Daly's blog for wonderful explanation of how breast milk protects our babies. 
• Limit contact as much as possible. If possible, keep Baby in a separate area away from sick family members. Wash hands after leaving the area of sick people. If the primary caretaker is sick and there is no one available to help, wear a mask and wash hands after touching anything that might be contaminated.
• Insist on a smoke-free home and car. Even if someone is smoking (or vaping) in another room or at another time, Baby can be exposed to the airborne particles that irritate airways and increase mucus production. These toxic particles remain in a room or car long after smoking has stopped. If you must smoke or vape, go outdoors. Change your shirt (or remove a coat) and wash your hands before holding Baby.

It's never easy being sick, and being a parent adds to the level of difficulty because you not only have to care for yourself, but someone else depends on you too. As with everything, you must take care of yourself before you can help others. Drink plenty of water and get rest! Most of the time medicines don't help us get better, since there aren't great medicines for the common cold. Talk to your doctor to see if you might need anything. Don't be falsely reassured that you aren't contagious if you're on an antibiotic for a cough or cold. If you have a virus (which causes most cough and colds) the antibiotic does nothing. You need to be vigilant against sharing the germs!

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.

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

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?

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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.

What does plumbing have to do with pediatrics?

This post has nothing to do with pediatrics, yet everything to do with how the process of medicine is like plumbing.

photo source: Shutterstock

We have lived in our house about 15 years. Shortly after we moved in I suspected a leak behind our  shower wall. The floorboard in the bathroom was molded and the drywall above it warped. The tile would be dry, but the grout one tile out would get wet -- so it seemed unlikely the shower door wasn't closed properly. We had a plumber evaluate it but he didn't find anything amiss. I think he thought I was crazy.

Years went by and I still thought there were issues every once in awhile, but irregularly enough that I wasn't concerned to do anything about it. My engineer husband didn't seem too concerned. I think he also assumed we were being careless in the shower and allowing the door to leak.

We had another plumber look at it about 5 years ago when we were updating our bathroom. He confirmed that there is no leak, fixed the drywall, and replaced the floorboard. He bragged that our new caulking shouldn't mold due to a special something they put in it that makes it mold resistant.

I still had my suspicions, but what do I know? I'm not a plumber.

The new floorboard is again moldy. The new caulk seems to get moldy from behind -- I clean the outside very carefully and it only looks discolored from behind. It has started to crack, so I thought maybe the water gets trapped behind and allows it to mold.

Over the summer I was cleaning out my daughter's closet. We decided to remove a bookcase that was there. The carpet underneath was completely moldy. Since her closet abuts our shower, this confirmed my leaky pipe suspicion despite two qualified plumbers saying they are fine. (My daughter had a blast breaking down the bookcase so we could dispose of it!)

Recently I dumped a bucket of water after mopping into the bathtub that never gets used in the same bathroom. (I usually dump mop water into the kitchen sink.) When I moved on to clean the shower, I saw something unusual: there was dirty water seeping from behind the caulking and dripping into the shower. No one had showered yet that day. I brought my husband up to show him. I was convinced that the tub leaked. That would explain the intermittent nature of the problem! He said it's not possible for the water to go uphill and into the shower caulking above the base rim.

Hmmm....

It's been 15 years and it can't be a bad leak since the floor hasn't completely rotted out. We only see signs of water leakage intermittently. We know it will be an expensive repair, so we are saving up and waiting... a few more months won't matter, will it? And two plumbers have looked for a leak without success. I'm closely monitoring to see if I find a pattern to help find the leak when we open up the wall.

We still have several theories going on with pipe and roof leaks being the top two. But no definitive answer.

So. What does this have to do with medicine?

It parallels complex diagnoses. Most people are not informed consumers when it comes to how their body works. I'm not saying patients are not smart. I'm a well educated person, but I know nothing about plumbing. I am an uninformed consumer. My husband is an engineer, so has a little knowledge of how our house is put together, but it's just enough to give him false confidence. He has been in denial of a problem for most of the 15 years we have lived here. Two qualified plumbers failed to see a problem, despite my concerns. I didn't follow through on suspicions based on their expertise and recommendations.

Physicians spend many years learning anatomy, physiology, pharmacology, and more. Years more are spent fine tuning diagnostic processes with actual patients. We continually learn throughout our careers based on new research and experiences. Despite all this training, one physician can't know everything and sometimes must refer to a sub specialist to sort things out. And I know they sometimes don't figure it out. We all can't be the genius doc from House, who seems to figure out every obscure diagnosis in one short hour.

What does that mean for patients?

If you think there is a problem, be as specific as you can with your symptoms. This is really hard when kids are the patient. They often can't describe what they are feeling in significant detail. Write down any possible associations that you can come up with and have your physician review the list with you. If your physician doesn't come up with a source or diagnosis, keep asking questions if you are still worried. (Don't take 15 years to sort things out with a human body!) If you don't find answers despite persistence of symptoms, ask for a second opinion.

Sometimes what worries parents and patients really is nothing to worry about. Maybe it's a common issue that needs no treatment (like a newborn rash or intoeing). Maybe what you're already doing is the best known treatment there is. Depending on the severity and duration of symptoms, more or less might need to be done. I'm not advocating for the multi-million dollar workup for every symptom, but if you think something's wrong, be sure to talk to your doctor about it! Make sure they hear your concerns and if they don't have an explanation for things, ask more questions to find answers.

Top 10 Posts of 2013

My last post of 2012 was my Top 10 Posts of 2012. I think I'll keep the tradition going with the Top 10 of 2013.

photo source: Shutterstock

This past year I have written about everything from insurance to illnesses to common parental concerns. My most influential blog has been about the generic formulations of Concerta, with 11,875 readers. It has been shared on ADHD blogs, various Facebook and Twitter feeds, and found on Google searches. I never thought over 1,000 people would read one of my posts, let alone over 10,000! Thank you to all who are reading and sharing!

If you don't want to miss a post, be sure to sign up for an e-mail subscription on the right!

From #10 to #1:

10. My Child's Cough and Breathing Sounds Like… is a collection of videos I compiled to help parents describe their child's cough.

9. Allergy Tips reviews ways to avoid allergens when possible and how to treat symptoms.

8. Flu Vaccine 2013: The Story Unfolds discusses how coding and billing issues impacted our office use of flu vaccines this season.

7. But the Snot Is Green… once again argues why the color of mucus does not make the diagnosis of bacterial sinusitis and gives information on treating colds and coughs.

6. To Tamiflu or Not to Tamiflu  might be a little intense for some readers because it reviews the research on Tamiflu risks and benefits. I am happy it is among the top 10 because I want people to see that Tamiflu isn't that miraculous of a drug for influenza. I get far too many requests for it this time of year. 

5. Flu Shot Information 2013-14 Season explains the different types of influenza vaccine available for the season. 

4. Help! My Child Has ______ Up His Nose! shares a "secret" tip I use to get some unwanted objects out of a child's nose. 

3. Screen Free Week is a challenge to readers to go Screen Free for a week. I have no idea why it is ranked so high. That is a surprise to me. 

2. Cough Medicine: Which One's Best reviews various cough medicines and other treatments of cough.

1. Generic Concerta Not Working Like the Brand Used To?  was read about 10 TIMES as much as any other post. It was found most often by a search engine, not direct shares, which tells me that many families are struggling with this issue. This is the post I am most passionate about. Any of my ADHD patients who are treated with Methylphenidate ER/Concerta know how angry I am that the FDA allows this substitution. I am thankful that the blog can help spread the word so that parents who are concerned about their child's sudden altered response to a medication can learn what might be the cause. I had so many updates to the original post, I wrote a follow up: Update on generic Methylphenidate HCl ER.

Blogs that missed the Top 10 that I wish more people would read include: 

Evolution of Illness - I wish people would read this because we often fall into the trap of wanting a quick fix. Too many parents bring kids into the doctor for a fast remedy only to find that there isn't one.  Resolution of illness takes time. Sometimes kids get worse, only to have the parent accuse a doctor of missing something. It happens to all good docs once in awhile…

First Period Q&A with a Tween - I wish people would find this one because it has questions every young lady thinks about but is often afraid to ask.

It's [Sports, School, Camp, Yearly] Physical Time - I wish people would read this so they understand the value of well exams and the scheduling constraints most pediatricians face. Don't call at the last minute!

Insurance Confusion - I wish people would read this because dealing with insurance is one of the most stressful parts of my job. I want people to learn about insurance to avoid financial surprises and to be responsible with insurance use.

Private Discussions with the Pediatrician - I wish people would read this because I am often uncomfortable (and sad for a child) when a parent wants them to leave the room for us to discuss something privately. Pre-planning with a quick phone call or secure message before the visit can save the child from excess worry.

What kids need to be able to do to leave the nest - This is one of my favorites because it was written at a very emotional point of my life. My kids are growing up and I reflected on what I really want them to know.

New Ideas

While most of my blogs were article-style writings, I introduced a few different types of blog this year. 

My first (and to date only) attempt at a video blog was Nutrition For the Picky Eater. It was born from a talk I gave at an ADHDKC.org parent meeting. 

I also did a picture blog with Lawn Mower Safety. 

I had one guest blogger. Sleep expert, Kerrin Edmonds, wrote Common Sleep Myths. 

Busy times…

April was my busiest month blogging. Seven posts that month. It tends to be a slow month in the office.  Ironically it was also Screen Free Week, a time I should have been off the computer!

• Allergy Tips

• Generic Concerta Not Working Like the Brand Used T...

• Screen Free Week April 29-May 5, 2013

• Help! My child has ___ up his nose!

• Group Teaching With Physicals

• Waiting times...

• Feeding Your Newborn

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

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.