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Daily Dose

What's making Your Child Sick?

1:30 to read

As our office is getting ready for the onslaught of “sick season” I am already getting numerous phone calls from concerned parents about illnesses in their schools.  One thing that is the same each year….once kids go back to school, whether it is daycare, preschool or elementary school, young children start to get sick.  Parents wonder why this is the case and is it REALLY normal?

 

It is very normal for otherwise perfectly healthy little children to catch just about everything that is “going around”. Once a child is a toddler they play in close contact with their friends and put “germy” hands and toys into their mouths, so a younger child catches more viral illnesses than a 5 or 6 year old.  In fact, it is not uncommon for a toddler to catch 10 -12 viral illnesses in one year. That means they are sick at least once a month if not more. But, the good news is most of the illnesses are self limited and resolve with minimal treatment with over the counter fever control medications, fluids, rest and a lot of tender loving care!

 

But, with the advent of many rapid in office tests that allow a doctor and parent to know within hours which virus is causing their child’s  cough and cold, I am actually seeing more and more worried parents. I got a call yesterday from a mother who had gotten a “note/email” from her child’s school that there was a child who had rhinovirus.  Rhinovirus is just one of many viruses that cause the common cold!!  There is really no need for a school to let parents know that there is a child who has a cold.  But if you hear the words rhinovirus, metapneumovirus, adenovirus, or parainfluenza virus (which has nothing to do with the flu), it sounds pretty scary.

 

Although being able to swab a child’s nose to determine which virus is causing their fever, cough and runny nose is fairly easy, and it may be helpful in certain situations (such as a child who has a compromised immune system, or a premature baby with lung problems), for the “normal healthy child” identifying the name of the virus is not necessary, and most importantly it typically does not change how the doctor or parent will care for the child.  

 

So… I would encourage doctors to be judicious in ordering these tests and parents to understand why they are NOT routinely done.  The social media chain of identifying which child has which virus is not helpful and may make an already anxious parent, even more anxious. 

 

Bottom line, wash your hands, get a flu shot and get ready for a lot of coughs and colds in the next few months!

 

 

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Daily Dose

Don't Fear A Fever

1.30 to read

Fever......I talk about it every day, even in the summer months, but during the winter I sound like a skip on a CD explaining the “facts that we know” about fever.There are so many falsehoods surrounding fever, and many have been passed around for years. 

To begin with, FEVER is simply a symptom, it is not a disease.  We pediatricians define a fever as greater than 100.4 degrees Fahrenheit.  Now I know many people say, “but my child’s body temperature runs lower than 98.6, therefore they have a fever when their body temperature is 99.8 degrees.”.  What about, “my thermometer must be off because my child felt hot and the thermometer only read 99.9 degrees.”  Yes, these are often heard statements by parents in my office, who are convinced that their child has a fever, even when they don’t.  That is not to say that you might not feel great when you have a cold and your body temp is 99.8, but you don’t really have a fever.

Fever frightens parents, especially with young children and over the course of parenting most of us figure out that fever is not “scary”.  I sometimes say “look at fever as your friend”  as this means that your child’s immune system is working.  When you are sick and all of those white cells go to work, they  release all of their “disease fighting chemicals”  which ramps up the body to fight the infection and fever develops.  See, it is just a symptom of many different things going on within our body when we are sick.  Other symptoms, especially at this time of year include, cough, congestion, sore throats, vomiting, diarrhea. What really stinks is when your child has ALL of these symptoms at one time.....they just feel yucky!

Another myth, fever causes brain damage and that “the higher the fever the greater chance of brain damage”. This is NOT true.  High fever usually makes your child feel worse, but their brains are just fine. Yes, febrile seizures do sometimes occur (my own son had them), but even a febrile seizure does not cause brain damage.  Febrile seizures are scary for a parent to watch, but they may occur with any degree of fever. That is to say  a seizure may occur with a fever of 101 degrees or 104 degrees, doesn’t really make a difference.  A febrile seizure does not necessarily mean your child is any sicker than another child who does not have a seizure with their fever.  I know sounds crazy, but very true.

This is just the first part of the fever story.....more fever facts to come this week.

Daily Dose

What is Stomach Flu?

1.30 to read

I have seen a lot of patients in recent weeks with complaints of “stomach flu”.  Just to be clear the “stomach flu” really is not FLU at all and has nothing to do with “flu/influenza”.  The stomach stuff is actually called gastroenteritis, and is typically caused by a virus.  If you have been watching the news, you have heard about yet another cruise ship where many passengers and crew have been sickened and the boat had to return to port. 

Most gastroenteritis causes vomiting, diarrhea, and stomach cramps.  It is pretty miserable.  The most common cause of the stomach “bug” is a virus called norovirus. Norovirus is now the most common cause of gastroenteritis in the United States. Rotavirus was previously the most common cause of viral gastroenteritis, but since the rotavirus vaccine has been introduced for infants, rotavirus has now been surpassed by norovirus.  Viruses are really smart, sneaky and strong (which is called virulent in medical terms). 

Norovirus makes you feel awful (who likes to vomit?)  and is very easy to pick up. Where it takes exposure to many viral particles to get sick from some viral illnesses, a recent study in The New England Journal of Medicine found that as few as 10-100 norovirus particles may cause disease. It is a very efficient virus and may even be acquired by breathing in the viral particles. (gross example, someone vomits and you are in the room and breathe the virus -  think about your child spewing vomit). 

Norovirus peaks in the 6-18 month old child. By 5 years of age 1 in 6 children will have seen their doctor for vomiting/diarrhea caused by norovirus. 

The key to combating norovirus is hydration.  The virus typically lasts several days with vomiting usually shorter than the diarrhea.  Treat vomiting with frequent sips of clear liquids and increase the volume of liquid over time. Once your child is tolerating liquids and vomiting has stopped you can let them eat. If your child is over the age of 1 year and diarrhea is a big problem, I would restrict dairy for a couple of days as well. Probiotics may help as well. 

Knowing that norovirus can be transmitted by hand to mouth as well, good hygiene is important....especially after the bathroom...so make sure those little hands are washed.

Daily Dose

Coxsackie Virus is Going Around

1.15 to read

Coxsackie virus is rampant once again! I have seen too many kids to count (TMKTC) with symptoms of coxsackie virus and the classic skin rash associated with “hand, foot and mouth disease”.  Many parents are telling me that their day care centers are having outbreaks which is what typically happens at this time of year.   

Like many viruses, coxsackie can make some children quite miserable, while others have very few symptoms but never the less are contagious and shed the virus to others. Viruses are just plain ‘ole contagious, even with the best precautions to help prevent spreading the illness. Best prevention continues to be hand washing! 

The classic symptoms of “hand, foot and mouth disease” are a fever, sore throat, and a rash which looks like small red spots or even a bit of a blister, occurring on a child’s palms, soles and often in their throats causing pain. We are also seeing many children who have a rash on their buttocks, and legs as well.  The rash is often confused for a diaper rash if there are no other associated symptoms.   

Coxsackie virus typically lasts from 3 -7 days.  While some children are terribly cranky and uncomfortable and will even drool rather than “swallow their own spit”, other seem to not even notice the rash on their hands or feet.  The treatment is totally symptomatic, which means acetaminophen or ibuprofen for fever and discomfort and keeping your child hydrated.   

Most kids don’t have a great appetite when they have a sore throat (do you?), so I am a big believer in popsicles, Slurpees, ice cream, fozen yogurt, shaved ice.....the list is long. You just want to make sure your child is hydrated during the illness so “food rules” get thrown out for a few days.  If they have a fever they need to stay home until they have been fever free for 24 hours, and they may then return to school,  day care, and other activities. 

Thankfully, adults rarely get this illness, as we have developed some immunity over the years.  Interestingly, there was just an article about a trial of coxsackie virus vaccine given to children in China which proved to be quite successful in preventing serious coxsackie disease......stay tuned for more about this in the coming years.  

Daily Dose

RSV is Here

1:15 to read

RSV (respiratory syncytial virus) is here and seems to be hitting hard this year. RSV causes 64 million upper respiratory infections worldwide each year and some days it seems that every child in Dallas/Ft. Worth under the age of 2 has RSV. While there is has not been a lot of flu reported to date, RSV is being widely reported across the U.S. so I am sure your pediatrician’s office is busy as well. RSV season usually lasts until spring, so there are more weeks ahead.

RSV is a pesky virus and for most people causes symptoms of a “common cold”. Lots of congestion, runny nose, fever and a cough.  Bothersome, but not life threatening. But for some, especially those under 2 years of age, and for children with underlying medical conditions such as prematurity, heart disease, lung problems and other chronic medical issues, RSV may be more severe. While almost everyone under the age of 2 acquires RSV, 25-40 % may go on to develop wheezing and an illness known as bronchiolitis. In some cases RSV causes respiratory distress and a baby/child may need to be hospitalized for supportive care including oxygen…and in really severe cases an occasional child may require ventilatory support in the intensive care unit.

The local news in our area has been reporting that the ERs and hospitals are overwhelmed.  So what do you need to know about the course of RSV and when do you need to go to the doctor or ER? In a young child the illness starts off with a runny nose and congestion, but may progress to a frequent cough and wheezing.  While most children are uncomfortable and cranky, they handle the virus without any noticeable difficulty with their breathing. But, some children will develop signs of respiratory distress where their breathing is rapid, short and their chest wall pulls in and out (retractions) and their tummies move up and down with each breath. This is called “working to breath” and are signs of respiratory distress….which requires immediate medical care.

You also need to watch your child’s color…as some babies and children may turn dusky blue when coughing.  Most parents complain that their child turns bright red when they cough, but while some babies may only have a bit of a cough they may turn blue when they cough or even seem to gasp. Red is good, your child is oxygenating, but blue is bad! This is another reason to seek immediate care.

Lastly, make sure that your child stays hydrated….so if they have a good moist mouth, drool, tears and wet diapers (may not be soaking) you are keeping up with their fluid needs.  This is important as your baby/child will probably not nurse or take a bottle or fluids as well when they are sick .

Because RSV is a virus it is NOT treated with antibiotics. While there is a test to identify RSV it is not routinely recommended, as the treatment is symptomatic. The test may be run in certain situations when a child is hospitalized. Simple treatments such as suctioning your child’s nose, using a cool mist humidifier and treating fever with acetaminophen or ibuprofen (depending on their age) are all helpful As always, call your doctor if you have questions or concerns. 

What’s on the horizon…hopefully a vaccine one day!

Daily Dose

Dealing with Warts

1.30 to read

Warts are one of the most common skin lesions seen in pediatric practices. Warts also drive parents and some kids crazy!  According to one study up to about 1/3 of school children have warts.  

Warts are viral infections of the skin which are caused by human papilloma viruses (HPV).  There are more than 100 types of HPV and different types of HPV cause different types of warts. The most common warts on hands and knees are caused by HPV types 1,4, 27, 57.  These are not the HPV types that cause sexually transmitted infections 

Some people seem to be more prone to getting warts than others, and it is not uncommon to see several children in one family dealing with warts. The HPV virus is spread through skin to skin contact or through contaminated objects or surfaces. In other words, they are hard to prevent.  HPV can also have a long incubation period, so when parents ask, “Where and when did my child get this wart virus?”, my answer is typically, “not even the CIA will be able to tell you that”.  

I many cases if the warts are left alone they may resolve on their own in months to years (one study showed two thirds remission in 2 years) ......but with that being said, most teens (especially girls) want those warts to “be gone!” 

There are several different ways to treat warts and one of the most effective is with over the counter (OTC) products that contain salicylic acid.  Salicylic acid acts as an irritant that activates an immune response against HPV.  There are tons of different OTC products and in many studies there was not one product that proved superiority over another, so I would buy an “on sale” salicylic acid for starters. I know from using these on my own children that you have to be consistent and persistent in their use....but it did work. 

If OTC products don’t seem to be working the next step for those who are determined to try and get rid of the wart,  is to head to the doctor who may try freezing the wart with liquid nitrogen or using cantharidin.  Unfortunately, there is typically a little pain involved with these products. 

Like so many other things, sometimes it may pay to just to wait it out and see if the virus just gives up and goes away!

Daily Dose

Home From School

1:30 to watch

I continue to talk about it being  the “sick season” and thankfully it is now February!  Parents are all tired of having sick children and I can now at least assure them that we are halfway to the end of upper respiratory and flu season.

 

But, with that being said that means I am still seeing children with RSV, Flu and every other virus I can think of. Remember, the majority of the illness I see every day in my office is VIRAL.  It really doesn’t matter if you can put a name to the virus, as the treatment is the same. Rest, fluids, fever control and watch for any respiratory distress or symptoms of dehydration. As I told one young mother who said that her other child had been tested for RSV (by another doctor), testing the child I was now seeing will not make any difference in how we treat the illness. So, why make the child uncomfortable when doing the swab and also drive up health care costs, for no change in treatment recommendations.  I think people are confused about what the test actually does….it does not change how a child is treated, and it also causes a lot of “alarm” as the mother of one patient goes home to tell her friends that her child has RSV and then the school starts sending out emails and parents become more anxious and alarmed that they may have been exposed….as they are every day all over our city.

 

So…when do you know it is time to keep your child home from day care or school as we all know these viruses are spread at home, school and work as well.  

 

If your child has a fever over 100.5 degrees (by any method of taking their temperature) they should not go to day care or school for at least 24 hours after becoming fever free (without fever lowering medication).

 

If your child is vomiting, 2 or more times in the last 24 hours, they should stay home. Some young children may vomit after coughing as well, but if infrequent they may attend school. 

 

Diarrhea as defined by two or more loose, watery stools that are “out of the ordinary stool pattern” for your child. Any child having diarrhea that does not stay contained within a diaper should stay home. A child who has blood in their stool should not attend day care or school (and should see the doctor).

 

Children with strep throat may return to school after 24 hours if they are fever free and have received the appropriate antibiotic therapy.  (Newer article suggests 12 hours if they are feeling well).

 

Your child does not need to stay home due to a cold, cough, runny nose (of any color) or scratchy throat if they do not appear ill and do not have a fever. Look at how your child is behaving…some times a day of rest may be needed (even when you get sick, right?) 

 

Most importantly, it is not necessary to name the virus that your child might have, but to follow the guidelines for keeping them home (as well as out of stores, church, and after school activities) until they are feeling better. Wash hands, cover coughs and yes….still get the flu vaccine. It is not too late…the ground hog even said we still have a lot of winter left.

 

 

 

Daily Dose

RSV is Going Around

RSV is here and can be one of the scariest illnesses for parents of young babies. Dr. Sue tells you what this virus is and the best ways to treat it. Whew, this is a  busy week! Busy for you too, I'm sure. I've seen many coughs, colds and another baby with RSV.  RSV is the acronym for respiratory synctial virus, which is a winter-time upper respiratory infection that causes colds and coughs, but also an illness known as bronchiolitis.

Bronchiolitis is an inflammation of the lower respiratory tract that is seen in infants and young children, often due to a viral infection. At this time of year, throughout the country,  the most common cause of bronchiolitis is RSV.  RSV is seasonal virus, and is  typically seen from November until April, but in recent days and weeks, the number of  young children coming to my office with coughs and wheezing just sky rocketed. Once you hear the frequent, tight, wheezing coughs in the hallways, and listen to a few wheezy babies, you know that RSV has arrived. Unfortunately, in my area it looks like it is going to be a busy RSV season. RSV is a viral infection, and like so many other viruses, including influenza, some years the virus just seems worse than others.  In the last few days I have already admitted several babies who had RSV bronchiolitis, and have required hospitalization for supportive care with oxygen supplementation. Fortunately, they are doing well and no one required intensive care. At this time of year, every parent I see who has brought in their sick, coughing, wheezing baby hears basically the same thing. “Your baby probably has RSV which is a viral infection, somewhat like a cold .” When you say RSV, they all cringe, but you need to understand what you are looking for. When older children and adults get this infection, we get a nasty cough, lots of congestion and have a dreaded winter cold.  But, when a baby gets this infection the virus may cause inflammation and constriction of the lower respiratory tract which results in wheezing and in some cases difficulty breathing. The key point is “difficulty breathing”. Babies who are having difficulty breathing will not only have a frequent tight cough, but they will also exhibit signs of “increased work of breathing”.  This means that you may notice that the infant is retracting, which means that they are using their rib muscles or abdominal muscles to help them breath.  This is a visible sign of respiratory distress, and you will see their chest cage move in and out as they work to breath. Babies may also grunt with each breath, or cough so hard that they turn dusky or blue. All of these symptoms are significant and are need for concern and a visit to the pediatrician.   With that being said, most babies handle the virus and will cough and wheeze and have a lot of mucus and secretions, but will not exhibit signs of respiratory distress. They may appear “pathetic” and cough a lot and be up and down at night due to cough and congestion, but they will not show signs of retracting or increased work of breathing. When your baby has a cold and cough it is imperative that you look at their chests. That means turn on the lights, lift up their jammies or unzip their onesie and look at how they are breathing. Is their chest sinking in with each breath?  Can you see their ribs moving in and out as they are retracting?  Are the using their abdominal muscles to help them breath?  Can you hear a wheeze or grunting or are they just congested and coughing? Lastly, look at their color. A baby who is coughing and turning red in the face is good, a baby with a  dusky or blue face or lips or mouth is bad. It is basic:  red is good, blue is bad! For infants who are showing signs of respiratory distress, they may need to be hospitalized for supportive care, and supplemental oxygen. (there is are recent study about using hypertonic saline treatments for hospitalized babies. It looks interesting).  Because RSV is a virus, antibiotics won’t help.  There are no medications to “fix” the problem.  It is once again “tincture of time” for the illness to run its course. That may mean several days to a week in the hospital for some babies. That's your daily dose for today. We'll chat again tomorrow. Send your question to Dr. Sue.

Daily Dose

More on Ear Infections

1:30 to read

It is winter and fortunately while there is not much flu to date, there are certainly colds and coughs throughout the country.  It seems that every child I see has a runny nose.  Remember, a toddler will get anywhere from 5-10 colds a year for a couple of years as they start to have playmates and pass those pesky viral upper respiratory infections back and forth.  But for some young children, (especially those in daycare) those frequent colds may lead to recurrent ear infections (otitis).

Otitis media is an infection of the middle ear. In children, an ear infection typically follows a common cold, which may be caused by a plethora of viral illnesses. It seems that the virus changes how the middle ear “functions” (lots of complicated science about cilia, and mucous and eustachian tube function) which then leads to secondary bacterial infection and an acute ear infection.  It typically takes a few days to weeks of a cold, before developing an ear infection. I tell my patients, “you don’t usually see an ear infection in a young child on day 1 or 2 of a cold”.  If everything else seems okay, you might want to watch your child for a few days before having their ears checked.

The guidelines for treating acute otitis media (AOM) changed several years ago after studies showed that not all ear infections were caused by bacteria, especially in older children, and that with “watchful waiting” many ear infections would improve on their own.  So, for children between the ages of 6 -23 months of age with bilateral or unilateral ear infections and signs and symptoms of pain (tugging on the ear, rubbing the ear, irritability and sleep interruption) and fever the recommendation is to treat the infection with antibiotics.  The recommendations get a bit trickier for children who do not have bilateral infections and who are considered to have “non-severe” AOM, in which case the doctor and parent may discuss the pros and cons of antibiotic therapy and in some cases may decide to defer the use of antibiotics for 48-72 hours and observe the child for worsening of symptoms or failure to improve at which time an antibiotic may be started.  “Watchful waiting” has helped to decrease the number of antibiotics prescribed for children.

For the younger children 6 - 23 months who are more likely to be “sicker” than an older child with AOM,  the first line antibiotic to be prescribed is still Amoxicillin (unless the child is known to be penicillin allergic). Amoxicillin is the gold standard , “pink medicine” that many parents remember from their childhood…..tastes like bubble gum and needs to be refrigerated.  For children who have had recurrent ear infections other antibiotics know as “second line” drugs may be used.  Again, there are pros and cons to many antibiotics as well in terms of taste, how often they need to be given and side effects….so discuss this with your own pediatrician.   

For children 2 and older I am a big believer in “watchful waiting” and pain control.  So many of these children will do well with over the counter acetaminophen and ibuprofen as well as topical ear drops for analgesia.  I would guess that in my practice (not a valid scientific study) about 80% of my older patients do not fill a prescription for antibiotics….which as you know is a good thing (no one wants to be on an unnecessary antibiotic).  

Unfortunately, there seems to be a “group” of children (typically the younger ones) who get recurrent AOM and spend many of their winter months in the pediatricians office.  More about those infections in another post.

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