Baby 411 & Toddler 411 Blog

Fever Phobia in the news again: When to stay cool and when to call the doc

 

A new study published in the journal, Pediatrics, today reminds pediatricians to ease parents' fears about fevers. Here is a Q & A about the top parental concerns on fevers:

Q. Are acetaminophen or ibuprofen supposed to take the fever away?

There is a reason why these products (ibuprofen and acetaminophen) say they are fever REDUCERS and not fever ELIMINATORS on their packaging. At best, they will bring down a fever by a couple of degrees. So a child who has a fever of 104 will only go down to 102 with medication. This freaks parents out, who are under the impression that the medication should take the fever away completely (and thus, something must seriously be wrong). So, this new study is a good reminder to healthcare providers to explain fevers and fever reducing medication to nervous parents.

Q. Should parents stop using fever reducing medicines altogether?

We are not telling parents to stop using these products. We are simply educating them about what results to expect. What I always tell families is that fever is not a problem--it's a clue--and we need to figure out WHY the fever is there. A previous study showed that 91% of parents believe fever can cause harmful effects such as death and brain damage. We've got to arm parents with accurate information so they don't stay up at night worrying about an old wives tale.

Q. So, what fevers need immediate medical attention? 

Here are my tips for immediate medical attention:
1. Age 0-4 weeks: any fever of 100.4 or higher taken rectally IS an emergency in this age group. It requires immediate evaluation done in a hospital setting. That is because they are at risk for bacterial infections due to issues surrounding birth or abnormalities a baby might be born with (e.g. kidney/bladder issues).

2. Age 4 weeks -3 months: Any fever in this age group also requires immediate medical attention to determine the source of the fever.

3. Age 3 months to 6 months:
Fever of 102 or greater needs medical evaluation or fever AND one of these:
a) lasting over 3 days in a row
b) a new fever after recent illness
c) no obvious symptoms of viral illness with the fever
d) unconsolable
e) petechiae rash (purple flat specks--see our rash-o-rama in bonus material on our website)

4. Age 6 months and up:
Fever of 104 or greater or any of those symptoms listed above with fever.

Less urgent:
-Persistent fever every day for more than 3 days straight even with obvious source of infection

After six months of age: it's not the degree of the fever, it is what the child looks like! It is hard to be seriously ill if your child is laughing, smiling, and running around your living room. However, if your child still looks like a wet noodle even after fever reducing medicine kicks in, it is time to call the doctor.

Flu is here.

It's that time again. The influenza viruses (both A and B strains) are making their cross country tour. Unlike last year's really strange H1N1, this year is shaping up to be a pretty typical flu season. The southern states and atlantic states are in full flu swing with Alabama and Louisiana having the highest number of cases this week. Northerners have been spared of major flu activity thus far...but it's coming, folks!

I've seen a ton of kids with flu this week. Most of it is Influenza A, and of that, the CDC tells us it is primarily H3N2 strain (not H1N1) this year. Fewer kids are testing positive for Influenza B. This year, it doesn't make too much difference whether it is A or B strains since both are treatable with antiviral medications (Tamiflu or Relenza). But, the medications are most effective if treatment is started within the first 48 hours of symptoms.

Bottom line: If your child has a fever of 102 or above, bodyaches, chills, headache, and looks like a wet noodle...get a doctor's appointment sooner rather than later. The runny nose, cough, and sore throat show up later on in the illness.

Check out the CDC's flu surveillance for more info.

 

RSV: Is your child wheezing?

RSV. Officially, it stands for Respiratory Syncytial Virus. But, if you are a parent with an RSV infected child, you might think it stands for Really Stinky Virus.

‘Tis the season for Wheezin’…RSV is a very common winter respiratory infection. It’s clear when RSV has made its appearance in town because infants and young children come in with tons of snot, coughing, and wheezing. We call these kids “happy wheezers”. Unlike someone with asthma, most RSV infected children have no difficulty getting a good breath in and getting an adequate amount of oxygen. But, there are certain kids at risk…newborns and formerly premature babies can encounter the most trouble with RSV.

Winter babies. Some newborns who get infected with RSV have trouble catching their breath. That’s called apnea and it is not a good thing. That definitely buys a ticket for admission to the nearest children’s hospital until it is certain that the baby is able to breathe. Believe it or not, I actually tried to time my pregnancies so I wouldn’t have a baby born in the peak of RSV season. (Yes, only a pediatrician would worry about this kind of stuff).

Preemies beware. If you have a baby who was born prematurely (particularly one born before 35 weeks of pregnancy), the NICU staff probably warned you about RSV. Premature babies, especially those who required respiratory support or who had chronic lung disease, may really struggle to breathe with an RSV infection. Those kids also need hospitalization. That’s why former premature babies should receive a monthly injection of an RSV immune globulin to protect them during RSV season. (That medication is incredibly expensive, which is why full term babies are not eligible to get it.)

Marathon cough. With most respiratory infections, a cough typically lasts for 10-14 days. With RSV, a child might be coughing for 3-4 weeks. You read that right. RSV is unique. It makes the tiny airways in the lungs, called bronchioles, swell. So, an RSV infection is also known as “bronchiolitis”. And that tiny airway swelling is what makes little ones cough and wheeze—for weeks—until the swelling goes away.

What to do?  Unfortunately, RSV is a virus. And that means we don’t have a miracle antibiotic to make it go away. The virus (and the residual bronchiole swelling) has to run its course. But, you should check in with your child’s doctor if he appears to have difficulty breathing. Do asthma medications help? Usually not. Most kids do not respond to the standard array of asthma treatments, although a small percentage do. If your child is truly struggling to breathe, his doc will likely administer a breathing treatment to see if it will help. Kids who wheeze with RSV may be more prone to wheezing again in their lives. That doesn’t mean your child will necessarily develop asthma, though, just because he wheezes with RSV.

Boomerang fever. Because there is just so much darn snot with RSV, many kids will end up getting an ear infection in the course of their recovery from RSV. If your child develops a new fever or becomes super cranky, it’s time to check in with his doc.

Flu vaccine during pregnancy provides dual protection

Flu shots have been recommmended during pregnancy because pregnant women are at greater risk of getting really sick with the flu. That’s what happens when you are living as an immune compromised pregnant person! (Don’t worry, it’s the body’s way of accepting your little growing baby inside you that contains foreign DNA —so it’s not permanent.)

But, emerging data suggests that the flu shot provides dual protection for both mother and baby-to-be. A new study performed at Yale New Haven Hospital shows that babies under six months of age whose moms received flu vaccine during pregnancy did not need to be hospitalized for flu illness over 90% of the time. In short: flu vaccine during pregnancy seems to protect babies who are too young to receive flu vaccine themselves.

Our recommendation: Get the flu shot, ladies! The inactivated flu shot is safe to give during any trimester of pregnancy.

Update on whooping cough booster for adults 65 and up

One of our readers suggested we provide additional information regarding the new ACIP (Advisory Committee on Immunization Practices) guidelines on giving Tdap (whooping cough booster shots) to adults ages 65 and up. While ACIP made these recommendations, the Centers for Disease Control will be confirming this updated recommendation in February 2011. What does that mean for you? Well, some health departments and providers may not offer the vaccine to those folks until CDC rubber stamps it. Other practices (like mine) accept the ACIP guidelines and will offer the vaccine to adults in that age group who want to get protected.

Here are the details: ACIP recommendations are not considered final until they are published in the Morbidity and Mortality Weekly Report (MMWR). When they become available they will be listed on the CDC website:
http://www.cdc.gov/vaccines/pubs/acip-list.htm

The new Tdap recommendations are expected to be released with the 2011 adult vaccine schedule, which is currently expected in February 2011.

More information on these updates can be found on the CDC website:
http://www.cdc.gov/vaccines/recs/acip/downloads/mtg-slides-oct10/11-1-AdultSchedule.pdf

You can also sign up to receive vaccine-related updates from the CDC by going to:
http://www.cdc.gov/emailupdates/index.html

For more information about Tdap, please visit the CDC website:
http://www.cdc.gov/vaccines/vpd-vac/combo-vaccines/dtap-td-dt/tdap.htm

Grandparents need whooping cough booster shots too

 Over 70% of babies get whooping cough from a family member. That's why the Advisory Committee on Immunization Practices now recommends that adults ages 65 and up who will be around a baby under a year of age get their Tdap booster shot. Previously, the Tdap vaccine (tetanus, diphtheria, pertussis) was only offered to those under age 65. So, grandparents: roll up your sleeves for your Tdap (and flu shots, too) before you visit your precious little ones over the holidays!

Croup is here

 

I hope everyone had a wonderful day of celebration, family time, football, and rest yesterday! Unfortunately, germs don't take a vacation. So, I am in the office today seeing kids who are spending their holiday feeling crummy. The biggest player this week is croup. Croup is caused by a handful of viruses, but it's different than the common cold. I always know when croup season has arrived when my little patients cough like a barking seal and sound like Demi Moore or Darth Vader. Here is some handy info:

Q. Why is croup special compared to the common cold?

A. Croup-causing viruses like the upper airway, right where the voice-box resides.  A swollen voice-box causes the barking cough and hoarse voice.

Q. Why do kids have a problem with it?

A. The smaller your airway is to begin with, the smaller it will be when it is swollen from a viral croup infection. Your airway gets larger as you age. Kids under age three are the most affected. And, adults (yes, like you) are the least affected. So, a baby might have trouble catching his breath with croup and an adult might just have a hoarse voice (or “laryngitis”).

 Q. How long does the virus last?

A. Croup is a 3-Night illness. For some unknown reason, croup is always worse at night and not really a problem during daylight hours (when your doctor’s office is open). At least it doesn’t last as long as most winter respiratory viral infections!

Q. When is croup a serious problem?

A. It’s a problem if your child makes a really high-pitched noise as he breathes—kind of like Darth Vader (called “stridor”) and looks like he is struggling to catch his breath. Here is a good example of stridor.

 Q. What should I do if my child sounds like Darth Vader?

A. Take your child into the bathroom and steam it up by running a hot shower. The steam helps relax the airway enough so your child can breathe comfortably. Alternatively, you can try walking out into the cold night air or opening up the freezer and letting your child breathe that air in (if you live in a warm locale like I do). If your child breathes more easily after that, great! See his doc the next day for evaluations and treatment. If he continues to have trouble, head to the nearest emergency room.

Q. Does my child need antibiotics for croup?

A. No. Because croup is caused by a virus, there is no antibiotic to make the infection go away. Time is the cure. But, if your child has stridor (a.k.a Darth Vader) on the first night, you have two very long nights ahead of you! Using a prescription steroid medication by mouth or by injection will help reduce the swelling in the airway. If your child has significant trouble breathing, he may also need an aerosolized breathing treatment given in a medical office or hospital setting.

Do all ear infections need antibiotics?

The Journal of the American Medical Association published a report last week that reviewed the existing scientific literature on the standard treatment of ear infections with antibiotics. The purpose? To see if healthcare providers should be giving even fewer antibiotic prescriptions than they already are. There are a growing number of highly antibiotic-resistant bacteria so we've got a potentially big problem on our hands—no medicine to treat these germs! So, we are trying to hold off on using our antibiotic "ammunition" unless we really need to.

So, what did the report find? Up to 80% of ear infections will clear up on their own without antibiotics.  This isn't really a newsflash for most clinicians. We know that a good number ear infections will clear on their own without treatment (particularly in older kids).But, will that change how doctors and parents approach treatment of ear infections?

Here's what I currently do in my own practice. For children who are over 2 years of age, I offer the wait and see approach. I will hand a parent a prescription (ideally Amoxicillin and not a bigger gun antibiotic) and tell them to fill it if the child is not improving. However, if that older child is running a significant fever (like 102 or higher) and has other signs of a systemic infection, not just an ear infection, I would treat that child at the time of diagnosis. For kids under 2 years of age (especially if they are running a fever), I treat ear infections when there is no question that the baby has a really bad ear infection! Those kids are not verbal enough to tell a parent if they are feeling better and have a higher risk of complications from an ear infection (e.g. mastoiditis—a very serious complication where the bacterial infection invades the skull bone and requires surgical drainage and IV antibiotics) that I don't feel comfortable waiting around to see if they improve without antibiotics.

What people need to realize is that antibiotics are not risk-free. Besides the emergence of superbugs, diarrhea, yeast infections, allergic reactions are all possible (and unpleasant side effects). And, that is why I am more likely to refer to an ENT doctor for possible PE tubes than continuing to throw antibiotics at a child with recurrent ear infections.

On the other hand, ear infections are really miserable!! Most adults have no idea how much they really hurt unless they have had one beyond childhood. So here's the bottom line: look at the scientific evidence and discuss it with your doctor. If you feel comfortable supportively caring for your child at home and waiting to see if your child improves before filling that prescription, that is usually the best course. If treating with antibiotics will help shorten the duration of that pain for some kids, it is not something we can completely discount.

 

 

 

 

Expecting 411/Baby 411 doc & USA Today team up on Monday

How can I keep my kids healthy this winter? Can my child get the flu nasal spray instead of a shot? Will the flu vaccine cover for H1N1? Can I get the flu vaccine if I am pregnant or breastfeeding? If you have any of these burning questions (or others), here is your chance to get the answers. Participate in a live chat with Dr Ari Brown and Liz Szabo of USA Today via twitter on Monday, November 15, at 2-3 PM EST. Here is the link for more information.

Sore throat 411

Strep Throat: See the little red dots on the roof of the mouth? That's a classic sign of it!

Mom, my throat hurts…heard this one recently?

It's that time again for my “Bug O’ the Week” blog. My "busy season" in the office is October to April.  So, I'll be giving you the periodic run-down of the infections I’m seeing in my office over the next several months. Although there is some variability across the country as to when these usual suspects arrive, I guarantee that they will hit your town at some point this winter.

 This week’s bug/bugs: Sore throat infections

There are several viruses that cause a sore throat. Right now, there are two different viruses that my patients are coming down with.

 Bug #1: The common cold (Rhinovirus) This is one we are all familiar with. Here are the typical symptoms: runny nose, cough, and sometimes a sore throat. A child might run a fever at the beginning of the illness for a few days, but not always. Symptoms can last for 10-14 days. Good times. You do not need to be worried if your child still has a runny nose or a cough that lingers for a while. No antibiotics are necessary to treat this illness.

 Bug #2: Adenovirus Never heard of this one? Well, it’s actually a very common viral illness. Adenovirus causes a sore throat, sometimes associated with pink eye (the whites of the eyes will look red). Kids often run a fever with it. In little ones who are too young to say that their throat hurts, fever and a lack of interest in eating may be the only obvious symptoms. But, if you take a look at your child’s throat (if he lets you), you will see that the tonsils are red and swollen. No antibiotics are needed because this is a viral infection, not a bacterial one.

 Bug #3: Strep Throat. To make things even more confusing, Strep Throat is also going around. That is a bacterial infection that DOES need to be treated with antibiotics. It’s more common in kids over two years of age who are old enough to tell you their throat hurts. If your child has a sore throat without a cough, runny nose, or pink eye, he should see his medical provider. (Take a look at the picture in this blog for a nice, but gross, example of what Strep looks like. If your child's throat looks like this, book an appointment!)

So what’s a parent to do for a child who is miserable with a sore throat?

1. Ibuprofen or acetaminophen for kids over six months of age (Be sure your baby sees his doctor to confirm the diagnosis if he is under six months of age to use acetaminophen).
2. Push the fluids. Don’t worry about eating solid food right now.
3. Try popsicles, smoothies, or a milkshake if your child resists drinking.

Lots of TLC from you!