How long will a cough or cold last?

How long will a cough or cold last?

I get this question all the time.

Most people want it gone now. (Or more likely, last week.)

Unfortunately despite our medical advancements over the years, we still have no cure for colds and coughs. Viruses do not get killed by antibiotics, and most colds and coughs are caused by viruses.

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

We have our standard instructions:

  • Fluids (water)
  • Rest
  • Saline washes to the nose
  • Blow the mucus out. If a child’s too young to blow his nose well, parents can suck the snot right out.
  • Honey for children over 12 months of age
  • Prop the head up during sleep
  • Prevent spread
But then we still have the original question: How long will a cough or cold last?
One of my favorite graphs depicting the timeline of a typical upper respiratory infection is from research done in the 1960’s, but since we don’t have any better treatment now than we did back then, I find it to hold true to what I experience when I get a cold and what I see in the office.
how long will cold and flu symptoms last
Days of Illness

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

A more recent review of medical studies showed that the many symptoms of illness linger for much longer than parents want to accept. From this study:
earache, sore throat, croup, bronchiolitis, cough, common cold
* Earache range 7-8 days, Sore throat 2-7 days

Bear in mind that children tend to get about 8 colds per year, often in the fall/winter months, so a second virus might start developing symptoms right as the first cold is finally going away.

There’s an important distinction between back to back illnesses versus a sinus infection requiring antibiotics. This is why doctors and nurses ask (and re-ask) about symptoms. The history and timeline of symptoms are very important in a proper diagnosis.

It isn’t the color of the mucus (really!) We don’t want people to unnecessarily take antibiotics. That leads to bacterial resistance, side effects of medicine, and increased cost to families.

So if you’re struggling with cough and cold symptoms in your house, follow these instructions.

To help determine when your child needs to be seen:

Urgently or emergently:

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

Routine office visits:

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

To help determine where your child should be seen, check out my old blogs on What to do After Hours and Urgent Cares for Routine Illnesses.

More reading:

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

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Help Us Help You! Make the most out of phone calls

Hello.  This is Dr. Stuppy.  I’m returning your call about…

That’s how my phone calls start, then they take various turns. Some are easy, some not so easy. I’d like to discuss what makes a phone call to the doctor’s office more productive, so we can help you better.

All examples are entirely fictitious, made up of 18 + years of phone call experiences.

Many calls start off like this:

Hi. This is Mary Sue. My son has a rash and I want to know what to do.

Me: ?????

I must ask many questions for more information.

Some callers don’t seem to know what to say, so they only answer direct questions.  How old is your son? When did the rash start? What does it look like? Has it changed? Does it itch or hurt? Any other symptoms? What have you used to treat it? Did that help? Has he had any new ingestions, lotions, or creams? Does he have a history of allergies? Anyone else with a rash that looks like this?

On and on…

Other calls start like this:

Hi.  Thanks for calling back. My son Jack is 3 years old. Well, really his birthday isn’t until next month, but he’s almost 3. He has had a fever for 2 days, maybe 3 days because he felt warm but he wasn’t acting funny or sick that first day he felt warm so I didn’t check his temperature. He actually was fussy last week, but I don’t think he ever had a fever then. I was thinking maybe he didn’t sleep well last week, but I don’t know why. I took his temperature and it was 100.3, that was on Tuesday around 7am. I gave Tylenol, and it went down to 97.9, but then 4 hours later it was back up to 99.7….

My thoughts so far: Get to the point.

Sorry, but that’s true. I care about my patients, but so far this phone call has taken me quite a bit of time and I really know nothing except this almost 3 year old has an elevated temperature (not even a true fever). I don’t even know what the parent’s main concern is.

just the facts, MA’AM.

When parents call, they need to summarize with pertinent facts. While they shouldn’t leave out important helpful information, they don’t need to mention every time they took a temperature.

Much like the evening news: they can’t do a play by play of every football game. There’s no time and it serves no purpose. A few highlights of the game and the score. That works well. People get a pretty good idea of how the game went.

It’s the same thing with phone calls to your doctor’s office or on call provider.  We have thousands of patients. Not all call, but during peak cold and flu season, there are many calls all day and night. The phone nurse or on call provider simply can’t spend 15 minutes chatting about every detail. That’s for your friend and you to discuss over coffee.

During the cold and flu season, it’s not uncommon for me to be on the phone with one parent when another call comes in. This is at the same time I’m trying get groceries or do other things I need to do for my family on evenings and weekends. (Being on call after hours doesn’t mean that I don’t have to work during the day.) I really don’t want to sit and chat. I don’t have time for play by play action. Again, I really care about my patients, but I can do a better job at answering your questions if you are clear and concise. 

Things that help us help you:

Know what’s going on.

When a parent calls and the child is at daycare or grandma’s so the caller doesn’t know details, we can’t really help. Yes, parents have called for advice when they’re on their way to daycare but don’t know any more than the child has to be picked up due to a symptom such as vomiting, fever or pink eye.

See your child first or have the person with the child call us. When you pick up the child, ask for details of their day. Learn how they ate/drank, how they acted, etc.

Sometimes you’ve been up several nights in a row with a sick child and things get jumbled in your head. It happens.

Write down the pertinent facts to get them straight if you need to.

Start with your child’s full name and birth date.

I can’t tell you how often parents jump right into their worries without stating who their child is. This is important not only for chart documentation of the call but also so we know how old your child is.

Include any significant past history, such as your infant was born at 28 weeks gestation, or your coughing 3 year old has a history of wheezing.

Give pertinent facts related to the concern.

If your child has a fever, give the number of days of fever, the maximum temperature, and how it was taken.

If you have given a fever reducer, share that.

Find a quiet place to talk.

When my kids were little they always wanted to be held when they were sick. I get it.

If you’re on the phone and they’re crying in your arms, it’s very hard to have a conversation.

Please find a safe place for your child to rest while we talk if possible.

If they won’t leave you or stay quiet, have another adult talk to us after they’ve been briefed about all the symptoms.

Summarize symptoms and treatments.

Briefly describe symptoms and what you have done to help them as well as how your child responded to the treatment.

Mention All treatments

If you use a vaporizer or saline for a cold, or have stopped dairy and used gatorade for vomiting, let us know. If you use a traditional home remedy, please let us know.

Let us know any medications your child typically takes in addition to ones you have tried for the current symptoms.

Signs and symptoms can be tricky to describe

When there’s a rash, it’s typically best for us to see it, but if you call about a rash describe it in terms of location, color, and size. Many find it helpful to relate to common objects, such as quarter-sized.

Note if there is a pattern to the symptoms, such as headache every day after school or barky cough only at night.

Summarize, don’t tell a novel

Leave out details that don’t help. Trends and generalizations work well.

If we want more details, we can always ask.

Avoid words that could be interpreted other ways, use facts.

Commonly misused words are “lethargic” and “fever.”

Lethargy in a medical sense is ominous. Many parents use it when their child is only mildly ill and tired. Describe what you’re seeing instead. Saying “Johnny won’t even wake enough to drink or hold his cup,” gives me the thought he is lethargic. Saying “Johnny wants to sit on my lap and read books instead of playing with his sister,” shows that he’s not well, but definitely not lethargic.

Fever is a temperature over 100.4 F. Many parents use the word fever if their child feels warm to touch. It’s more clear if you state that they’re warm to touch or what the thermometer says and how you took it.


Examples of good call starters:

Start with name, birth date, summary

I’m calling about Joe Smith, birth date 9.12.08. He has had a fever for 3 days, up to 101.3 under the arm. It comes down with ibuprofen, but is right back up in 6 hours. He also has sore throat and headache. He’s drinking well but not eating much for 3 days.

I know this child’s name, age, pattern of fever and associated symptoms. The only thing I need now is the parent’s concern – so far they’ve been doing everything right. What made them call today? What’s their question?

Describe

Sally Smith, birth date 9.12.17, has vomited 6 times in the past 12 hours. If I give formula it immediately comes up. She is now dry heaving and hasn’t had a wet diaper in 12 hours. She doesn’t have a fever but looks tired and it is hard to wake her to drink. She doesn’t have diarrhea. Her older brother had the stomach flu a few days ago but is now better.

Again, I know the child’s name and age and main problem – especially the fact that she sounds dehydrated. The parent didn’t use this word, but described dehydration (no wet diaper in 12 hours and it’s hard to wake her to drink). 

Include pertinent history

John Smith, birth date 9.12.17, was in the NICU for 2 months due to prematurity. He has been fussy all day and is now breathing fast and hard and is not able to drink more than a few sucks at a time. He doesn’t have a fever, but I’m really worried.

Here I know the child’s age and that he was significantly premature – a big risk factor. He’s distressed because he can’t feed. Note: I made this baby not have a fever on purpose. He’s sick even without a fever. 

Getting More Information

Knowing where to get reliable information is important. There’s a lot of bad advice online. Fancy websites aren’t always reliable.

Sites I recommend:

The AAP has many resources on HealthyChildren.

KidsHealth is another great resource.

My office’s website, PediatricPartnersKC, also has many pearls of wisdom. Often when we give advice it’s already stated on our site. Parents sometimes call multiple times because they can’t remember what we said. This is frustrating on both ends of the phone. We wrote it down and made it easily available for a reason. Use our site! (For patients in other practices, check out your own pediatrician’s site.)

Things that cannot be done by on call providers – at least not well:

Prior authorization for an ER or urgent care visit that is already done.

Prior authorizations are not usually needed, but if they are required, we should talk to you to be sure the visit is necessary before you go.

If I didn’t send you to the ER, I can’t fill out paperwork saying I did. That’s lying and using my license inappropriately. Often I would have chosen another location or given home care instructions to get you through the night.

Of course if you do talk to me (or one of my partners) overnight and we do send you to an urgent care or ER, we are happy to fill out forms if needed by insurance.

“Allow” you to leave a busy ER.

It sounds silly, but I have had many calls from the waiting room at ER/Urgent Cares with parents asking if I think it okay that they leave due to a long wait. If you thought it necessary to go in the first place, I would be open to a malpractice lawsuit if I told you to go home without being seen.

You should ask their triage nurse who can make that assessment.

Refill medications.

I typically expect that your child is seen prior to most prescription refills for best medical care. If it’s urgent that your child have a refill, such as an inhaler, they should be seen to evaluate the concern.

There are exceptions to every rule, but don’t be upset if the on call provider or phone nurse refuses to call out a prescription.

This is in the best interest of your child, not to be difficult. It’s easier to just call in the script than it is to argue this point, believe me. But easier isn’t better care, and that’s what’s important.

Make a diagnosis.

We cannot see the ear, listen to the lungs, or feel the belly over the phone. A physical exam and sometimes labs or radiology studies are needed to make a diagnosis. If your doctor claims to be able to diagnose by phone to call out prescriptions, I would suggest that they’re not doing the best of care.

An example of a poor diagnosis by phone:

Just this week another child was seen in my office for a sore throat that wasn’t better on the amoxicillin prescribed by a telemedicine doctor through their insurance company. The exam clearly showed blisters on the child’s throat. The sore throat was from these blisters, which are from a virus, not a bacteria.

The antibiotic was never needed. In this case the child simply didn’t get better as expected with a presumed case of Strep throat, but fortunately she didn’t get diarrhea or have an allergic reaction to the antibiotic. Who knows if this contributed to more bacterial resistance and superbugs?

Not only did the family waste money on an unnecessary treatment, they also exposed their child to a treatment that could have caused harm.

I worry with the increasing use of telehealth that we will see more problems related to improper diagnoses and delay of proper diagnoses – some of which could be significant.

Swallowed poisons or medicine / drug overdose.

The United States has a great poison control system. They can give rapid advice that most doctors don’t have easily available.

Call (800) 222-1222 if you suspect your child has ingested something. PUT THIS NUMBER IN YOUR PHONE RIGHT NOW.

A visit’s better than a phone call for:  

Difficulty breathing.

If a child is having difficulty breathing and you don’t have treatments at home that work, he needs to be seen as soon as possible.

Dehydration.

An infant who hasn’t urinated in 6-8 hours or an older child who hasn’t urinated in 12 hours might be dehydrated and should be seen as soon as possible.

Some fevers.

Temperature above 100.4 F in an infant under 3 months or in an under immunized child can be serious and should be seen as soon as possible.

Fevers lasting more than 3-5 days or with other concerning symptoms require an evaluation.

Fevers are scary and can make kids miserable. There is no “magic” temperature that we worry about more. Look at how your child is acting, not the thermometer, to determine if they are sick. Not every child with a fever needs to even be treated. There is benefit to letting the fever do its job!

Uncontrollable pain.

If you’ve used standard pain relievers and your child is still hurting, we cannot do anything by phone that will improve the situation. A careful exam might find a treatable cause of pain.

Most rashes.

Though these don’t necessarily need to be seen emergently unless there are other concerns, rashes cannot be evaluated on the phone and a physical exam is needed.

If your child is otherwise well appearing, treat the symptoms of the rash.

If he’s otherwise sick and you’re concerned, then he should be seen.

Chronic problems.

If your child has been dealing with anything for more than a few days, it might help to schedule a visit with your usual provider. This is especially true if it relates to a chronic condition, such as asthma, constipation, or other issue.

Many parents deal with a problem for months (or years) but have NEVER been in to discuss it specifically. They might mention it at another visit as an aside, but we never really talk about it in depth and give it the attention it deserves.

Diagnosis vs information.

If you want a diagnosis, we need to see your child.  We cannot tell if the ear is infected or if your child has Strep based on symptoms alone.

If you want advice of what to do with symptoms, we can generally give advice. Remember that the websites above can be helpful with this type of information too!

Behavior problems.

These are best discussed with your usual provider, not an on-call provider who doesn’t know your child. Most of these build up over time and are not emergent issues.

If it is an emergent issue, such as a child is in physical danger due to his actions or if a child is threatening another person, call 911.

If your child is suicidal, call the suicide hotline at 1-800-273-8255.

Injuries.

If your child has a significant injury, they often require prompt evaluation. Call 911 before calling your doctor’s office if your child is seriously injured.

Lacerations must be repaired as soon as possible, so don’t wait until office hours the next day if there’s a gaping wound!

Minor bumps and bruises can be handled at home, but if you’re not sure, give us a call to discuss what happened.

Help me help you!

Let me know what else you need to know to be an educated caller.

I’d be happy to answer questions about when to call, what to ask, and what to expect.

If I left any questions unanswered, please ask!


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Cough until 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.

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 teaspoon 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 (Dtap in infants and young kids and Tdap in tweens), 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, ideally at a location that routinely cares for children.

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

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The flu shot doesn’t work

I’ve seen a few kids this season who have influenza despite the fact that they had the vaccine. When the family hears that the flu test is positive (or that symptoms are consistent with influenza and testing isn’t done), they often say they won’t do the flu shot again because it didn’t work.

flu shot ineffectiveHow do they know it isn’t working?

Influenza can be deadly.

Most of the kids I’ve seen with flu who have had the shot aren’t that sick. Yes, they have a fever and cough. They aren’t well.

But they’re not in the hospital.

They’re not dying.

They tend to get better faster than those who have unvaccinated influenza.

Some kids still get very sick with influenza despite the vaccine.

That’s why there’s surveillance to see how it’s working.

When FluMist was determined to not be effective, it was removed from the market.

Studies are underway to make a new type of flu vaccine that should be more effective.

We know the shot isn’t perfect, but it’s better than nothing.

Maybe if you weren’t vaccinated you’d be a lot sicker.

Maybe you were exposed to another strain of flu and didn’t get sick at all.

I think it’s still worth it to get vaccinated each year (until they come up with a vaccine that lasts several seasons).

If everyone who’s eligible gets vaccinated against the flu, herd immunity kicks in and it doesn’t spread as easily. Historically only around 40% of people are vaccinated each year against influenza. We know that to get herd immunity we need much higher numbers.

Shot fears…

If your kids are scared of shots, check out Vaccines Don’t Have to Hurt As Much As Some Fear.

Don’t rely on Tamiflu to treat flu symptoms once you’ve gotten sick.

Tamiflu really isn’t that great of a treatment. It hasn’t been shown to decrease hospitalization or complication rates. It shortens the course by about a day. It has side effects and can be expensive. During flu outbreaks it can be hard to find.

Prevention’s the best medicine.

Learn 12 TIMELY TIPS FOR COLD AND FLU VIRUS PREVENTION.

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Cough Medicines: Which One’s Best?

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.

Of course I would never recommend giving a child a spoonful of pills.

I know it’s frustrating when your child is up all night coughing. It’s frustrating when my kids and I are up all night coughing.

do you know what we do in my house?

  • Humidify the air of the bedroom (during the dry months)
  • 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
  • Back rubs, hugs, kisses, & reminders that it will get better
  • 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:

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:

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.

The FDA has recommended against the use of cough medicines with codeine or hydrocodone for children for years, but just this month strengthened its position. New labels will now state that they aren’t for use in children under 18 years of age. The label will also warn about misuse adults and list the serious side effects and risks of these opioids.

In my opinion, why use it in older children and adults since it hasn’t been shown to work and we know there are risks?

What about antibiotics for the cough?

I’ve enjoyed following Dr. Christina Johns on Twitter for a lot of great advice like this!

Antibiotics may be used to treat bacterial causes of cough (such as some pneumonia or sinusitis) but antibiotics have no effect on viruses, which cause most coughs.

If your child has a cold, antibiotics won’t help.

Antibiotics won’t make the cough go away faster unless there is bacterial pneumonia.

They won’t prevent the cough from getting worse.

They carry risks.

In summary: over the counter and prescription cough suppressants and antibiotics shouldn’t be used for most coughs.

Cold and Flu Season is Upon Us!

Every year at this time, I think about how our kids are managed when they become sick. Not only what we do to treat symptoms, but how, when, and where patients get medical advice and care.

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

Illness doesn’t work that way.

Most childhood illnesses are viruses and they take a few weeks to resolve. There’s no magic medicine that will make it better.

  • Please don’t ask for an antibiotic to prevent the runny nose from developing into a cough or ear infection.
  • Don’t ask for an antibiotic because your child has had a fever for 3 days and you need to go back to work.
  • Don’t ask for an antibiotic because your teen has a big test or tournament coming up and has an awful cough.
  • Antibiotics simply don’t work for viruses. They also carry risks, which are not worth taking when the antibiotic isn’t needed in the first place.

Urgent cares are popular because they’re convenient.

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

Can it hurt?

  • Some kids will get unnecessary tests, x-rays, and treatments at urgent cares and emergency rooms that don’t have a reliable means of follow up. They attempt to decrease risk often by erring with over treating. The primary care office does have the ability to follow up with you in the near future, so we don’t have to over treat.
  • Urgent cares outside of your primary care office don’t have a child’s history available. They might choose an inappropriate antibiotic due to allergy or recent use (making that antibiotic more likely less effective). They might not recognize if your child doesn’t have certain immunizations or if they do have a chronic condition, therefore leaving your child open to illnesses not expected at their age. We know that parents can and should tell all providers these things, but the new patient information sheets in my office are often erroneous when compared to the transferred records from the previous physician. Parents don’t think about the wheezing history or the surgery 5 years ago every visit. It’s so important to have old records!
  • Receiving care at multiple locations makes it difficult for the medical home to keep track of how often your child is sick. Is it time for further evaluation of immune issues? Is it time to consider ear tubes or a tonsillectomy? If we don’t have proper documentation, these issues might have a delay of recognition.
  • Urgent cares and ERs are not always designed for kids. I’m not talking about cute pictures or smaller exam tables. I’m talking about the experience of the provider. If they are trained mostly to treat adults, they might be less comfortable with kids. They might order extra labs or x-rays that a pediatric trained physician would not feel are necessary.  This increases cost as well as risk to your child. Drug choice and dosing can be complicated for clinicians not familiar with pediatric care. We have been fortunate in my area to have many urgent cares available after hours that are designed specifically for kids, which does help. But this is sometimes for convenience, not for the best medical care.
  • CostAs previously mentioned, cost is a factor. I hate to bring money into the equation when it comes to the health of your child, but it is important, especially with the increasing rates of high deductible health insurance – you will feel the burden of cost. Healthcare spending is spiraling out of control. Urgent cares and ERs usually charge more. This cost is increasingly being passed on to consumers. Your copay is probably higher outside the medical home. The percentage of the visit you must pay is often higher. If you pay out of pocket until your deductible is met, this can be a substantial difference in cost. (Not to mention they tend to order more tests and treatments, each with additional costs.)

What about the walk in clinic at your primary care office? 

Many pediatric offices offer walk in urgent care as a convenience for parents who are worried about their acutely ill child.

If your doctor offers this, the care given is within the medical home, which allows access to your child’s chart. All treatments are within your child’s medical record so it is complete.

Staff follow the same protocols and treatment plans as scheduled patients, so your child will be managed with the protocols the group has agreed upon. Essentially primary care pediatricians have a high standard of care and want your child to receive that great care in the medical home as often as possible.

Telehealth

There are more and more telehealth options offered by insurance companies and physicians. This is a new area that has exciting potentials, but I’m concerned about inappropriate treatments. It can be a great tool to follow up on ongoing issues, but is not appropriate for many routine earaches, sore throats, and other issues that require an exam and/or testing.

I know it’s tempting to call in to get a prescription for a presumed ear infection or Strep throat, but think about how those diagnoses are made and remember that overuse of antibiotics increases risks to your child.

So what kinds of issues are appropriate for various types of visits?

(Note: I can’t list every medical problem, parental decisions must be made for individual situations. For a great review of how to determine if it’s an emergency, see Reliable keys to identify a medical emergency from Dr. Oglesby at Watercress Words.)

After hours (urgent care or ER- preferably one for children):

  • Difficulty breathing (not just noisy congestion or cough but increased work of breathing)
  • Dehydration
  • Injury (including but not limited to bleeding that won’t stop, a wound that gapes open, obvious or suspected broken bone)
  • Pain that is not controlled with over the counter medicines
  • Severe abdominal pain
  • Fever >100.4 rectally if under 3 months of age or underimmunized. (There is no magic temperature we “worry more” if an older child is vaccinated.)

Walk in clinic (or appointment) at your primary care provider’s office:

Being sick isn’t fun, but sometimes it just takes time to get better while using at home treatments. Use the healthcare system wisely to get the best care.
  • Fever
  • Earache
  • Fussiness
  • Cough
  • Sore throat
  • Vomiting and/or diarrhea
  • Any new illness

Issues better addressed with an Appointment in the Medical Home:

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

telehealth

  • If your primary doctor (or specialist) uses telemedicine as part of follow up care this can be a great use of telehealth.
  • Be careful of “free” or inexpensive telehealth options from other groups, including those from your insurance company. A quick and easy fix isn’t necessarily a safe, effective, or needed treatment.
Getting appropriate health care is important. If you aren’t sure what the best plan of action is, call your doctor’s office.
 

The sounds of coughing…

Parents often bring in kids with a cough but can’t describe what it sounds like. I sometimes get to hear it if they cough, but Murphy’s Law also says that a child who coughs often throughout the night and frequently during the day will have a 15 minute period of no cough at the exact time the doctor is in the exam room.

cough wheeze stridorIn all seriousness — coughs, regardless of the source — are usually worse at night, which means your doctor won’t usually get to hear the worst of it.

They can also change over time. For instance, croup often starts as a sudden barky cough that over days turns into a wet cough.

I often wish there was one place I could refer parents to so they could see what various coughs sound like, so I decided to put a list together. The internet is ripe with videos, but I have spent many hours watching videos that weren’t very helpful in order to find these. I’m sure I missed some of the best ones, so if you have one that you really like, please post in the comments below.

Regardless of how the cough sounds, if you’re worried about your child’s breathing or the sound of the cough, bring your child in to be seen.

Disclaimer: I have no ties to any of the videos below and am not responsible for any of the opinions or errors within them. Some are professionally done and others are videos parents uploaded. Some have advertisements which I do not endorse.

Croup

The initial seconds of this baby with croup stridor video show the typical croupy cough. At about 0:55 it shows the stridor that many kids with croup have. Stridor is a whistling sound as the baby breathes in (often confused with wheezing, which happens when you breathe out). It is common in croup and is caused by the swelling near the voice box. (Older kids and adults who get the same viruses that cause croup in younger kids often get laryngitis from the swelling near the voice box in a larger neck.)

This ER physician of TheEDExitVideo spends the first couple of minutes discussing what causes croup. At 2:27 sounds of stridor in an otherwise happy looking baby are shown. At 3:44 is a picture showing intercostal retractions (also seen with wheezing or other types of respiratory distress).

TheKidsDr also has a great informational video on croup.

Dry Cough

Dry cough can be from an irritation in the throat, asthma, acid reflux, or any common cold. It can also come from a habit cough (often seen after an illness and goes away with sleep only to return when awake). If you’re sitting here reading this and not sick, make yourself cough. That’s what a dry cough sounds like.

Laryngomalacia

Laryngomalacia wasn’t on my original list because it isn’t from a virus or bacteria causing illness, but it is a cause of noisy breathing in infants. It is caused by floppy tissues near the voice box (i.e. larynx). Linden’s Laryngomalacia – 3 Months shows this breathing. It is often worst when baby is excited or fussy.

For more information on this (even a video of a scope into the airway), check out Children’s Hospital of Philidelphia’s Laryngomalacia page.

Pneumonia

The cough with pneumonia can sound like a wet cough or dry cough, so no specific videos are for this cause of cough. The clues to pneumonia include a fever with cough, difficulty breathing between coughs, shallow breathing, shortness of breath with brief exertion, pain in the chest, rapid breathing, or vomiting after cough. Pneumonia can be caused from viruses and bacteria and can range in severity. Walking pneumonia generally means that the person is not sick enough to require hospitalization. Some pneumonias lead to severe difficulty breathing and require oxygen support.

Wet Cough

Wet cough can be from pneumonia or bronchitis, but also from postnasal drip with a common cold or allergies.

When kids “cough stuff up” it is usually the postnasal drip being coughed up, not mucus from the lungs coming up. The same is true if they “cough up blood”. This blood is usually from a bloody nose draining into the throat, not from lung tissue. (Note: bloody mucus can be from more serious causes and if your child has no signs of blood in the nose or is otherwise ill, he should be properly assessed by a physician.)

Wheezing

Wheezing is typical in asthma (and bronchiolitis). Many parents mistake the upper airway congestion sound that many kids make with postnasal drip as wheezing. Wheezing can sound like a whistle as a child breathes out. Ethan’s wheezing shows a baby with noisy breathing without distress. This Wheezing – Lung Sounds Collection video has the sounds one would hear with a stethoscope, but if you put your ear against your child’s back (without a shirt) you might be able to hear them. If you don’t hear wheezing, but your child is struggling to breathe, it does not mean there is no wheezing! Treat like you would if you hear the wheeze.

Asthma

Asthma Attack in a child starts with information on asthma, then at 1:50 video of what retractions look like.

Asthma attack shows the typical short breathing in phase with long exhale seen with an asthma attack. Also you can see the airway pulling in at the neck (retractions).

Bronchiolitis, often simply called RSV, but caused by many viruses

Bronchiolitis Cough, 3.5 months old shows a baby with a wet sounding cough, typical of bronchiolitis.

Bronchiolitis is a video from the ER physician Dr Oller. He reviews causes of bronchiolitis, how it’s spread, and how it affects the body. At 1:40 he discusses the natural progression of the simple cold into bronchiolitis. At 3:04 there is a picture of how we collect a nasal swab to help with diagnose of any viral illness.

Sick with Bronchilitis shows an infant with suprasternal retractions (sucking in at the base of the neck) and the typical cough associated with bronchiolitis. The man erroneously says “croupy”, see below for croup.

RSV and Infant Treatment shows the best treatment for babies with RSV (or any bronchitis): suctioning. Some babies need this deep suctioning in the doctor’s office or hospital. Others can get by with nasal aspirating at home. I’m not a fan of the bulb syringe for this. Here’s a good review of various aspirators.

Whooping Cough

Pertussis – Whooping Cough: A Family’s Story is an informational video on pertussis with the classic whooping cough in a child and pictures of a newborn with pertussis.

Silence the Sounds of Pertussis – Whooping Cough is a commercial for vaccinating, but it starts with the typical whooping cough sound.

Pertussis (whooping cough) shows a young infant with a cough from pertussis. Young infants do not always whoop, they stop breathing.

8 Year Old With Pertussis (Whooping Cough) shows a typical cough for an older child. Her positioning in front of the toilet shows that these kids often vomit from the force of the cough. The 2nd video from this same girl shows how normal and healthy kids can appear between episodes.

Final words…

Regardless of the sound of the cough or the ability to feel rattling in the chest, how kids are breathing is most important.

Coughs can often sound just awful but if the child is breathing comfortably and well appearing otherwise, it is probably not serious.

Conversely, some kids have a minimal cough but are suffering from difficulty breathing. If they are unable to talk and breathe or eat and breathe they should be seen. If the ribs suck in and out or the breathing is continuously more rapid than normal, they should be seen.

Don’t rely on the cough alone to decide how sick your child is. If they seem uncomfortable breathing it’s time for them to be evaluated.

Fever Is…

Fever is scary to parents.

Parents hear about fever seizures and are afraid the temperature will get so high that it will cause permanent brain damage. In reality the way a child is acting is more important than the temperature. If they’re dehydrated, having difficulty breathing,  or are in extreme pain, you don’t need a thermometer to know they’re sick.

Fever is uncomfortable.

Fever can make the body ache. It’s often associated with other pains, such as headache or muscle aches. Kids look miserable when they have a fever. They might appear more tired than normal. They breathe faster. Their heart pounds. They whine. Their face is flushed. They are sweaty. They might have chills, causing them to shake.

Fever is often feared as something bad.

Parents often fear the worst with a fever:

Is it pneumonia? Leukemia? Ear infection?

Fever is good in most cases. 

In most instances, fever in children is good. It’s a sign of a working immune system.

Fever is often associated with decreased appetite.

This decreased food intake worries parents, but if the child is drinking enough to stay hydrated, they can survive a few days without food. Kids typically increase their intake when feeling well again. Don’t force them to eat when sick, but do encourage fluids to maintain hydration.

Fever is serious in infants under 3 months, immunocompromised people, and in underimmunized kids.

These kids do not have very effective immune systems and are more at risk from diseases their bodies can’t fight. Any abnormal temperature (both too high and too low) should be completely evaluated in these at risk children.

Fever is inconvenient.

I hate to say it, but for many parents it’s just not convenient for their kids to be sick. A big meeting at work. A child’s class party. A recital. A big game or tournament.  

Whatever it is, our lives are busy and we don’t want to stop for illness. Unfortunately, there is no treatment for fever that makes it become non-infectious immediately, so it is best to stay home. Don’t expose others by giving your child ibuprofen and hoping the school nurse won’t call.

Fever is a normal response to illness in most cases.

Most fevers in kids are due to viruses and run their course in 3-5 days. Parents usually want to know what temperature is too high, but that number is really unknown (probably above 106F). The height of a fever does not tell us how serious the infection is. The higher the temperature, the more miserable a person feels. That’s why it’s recommended to use a fever reducer after 102F. The temperature doesn’t need to come back to normal, it just needs to come down enough for comfort.

Fever is most common at night.

Unfortunately most illnesses are more severe at night. This has to do with the complex system of hormones in our body. It means that kids who seem “okay” during the day have more discomfort over night. This decreases everyone’s sleep and is frustrating to parents, but is common.  

Fever is a time that illnesses are considered most contagious.

During a fever viral shedding is highest. It’s important to keep anyone with fever away from others as much as practical (in a home, confining kids to a bedroom can help). Wash hands and surfaces that person touches often during any illness. Continue these precautions until the child is fever free for 24 hours without fever reducers. (Remember that temperatures fluctuate, so a few hours without fever doesn’t prove that the infection is resolved.)

Fever is an elevation of normal temperature.

Normal temperature varies throughout the day and depends on the location the temperature was taken and the type of thermometer used. Digital thermometers have replaced glass mercury thermometers due to safety concerns with mercury. Ear thermometers are not accurate in young infants or those with wax in the ear canal. Plastic strip thermometers and pacifier thermometers give a general idea of a temperature, but are not accurate.

To identify a true fever, it’s important to note the degree temperature as well as location taken. (A kiss on the forehead can let most parents know if the child is warm or hot, but doesn’t identify a true fever and therefore the need to isolate to prevent spreading illness.) I never recommend adding or subtracting degrees to decide if it is a fever. You can look at a child to know if they’re sick.

The degree of temperature helps guide if they can go to school or daycare, not how you should treat the child.

Fevers in children are generally defined as temperatures above 100.4 F (38 C).

Fever is rarely dangerous, though parents often fear the worst.

This is the time of year kids will be sick more than normal. Kids get sick more than adults. With each illness there can be fever (though not always).

What you can do:
  • Be prepared at home with a fever reducer and know your child’s proper dosage for his or her weight.
  • Use fever reducers to make kids comfortable, not to bring the temperature to normal.
  • Push water and other fluids to help kids stay hydrated.
  • Teach kids to wash their hands and cover coughs and sneezes with their elbows.
  • Stay home when sick to keep from spreading germs. It’s generally okay to return to work/school when fever – free 24 hours without the use of fever reducers.
  • Help kids rest when sick.
  • If the fever lasts more than 3-5 days, your child looks dehydrated, is having trouble breathing, is in extreme pain, or you are concerned, your child should be seen. A physical exam (and sometimes labs or x-ray) is needed to identify the source ofillness in these cases.  A phone call cannot diagnose a source of fever.
  • Any infant under 3 months or immunocompromised child should be seen to rule out serious disease if the temperature is more than 100.5.

Menthol for Sore Throat, Colds and Coughs… Should we use it?

I am often asked about the use of Vick’s Vapo Rub (or other menthol products and refer to all brands in this post).

We see menthol for vaporizer dispensers, in cough drops, and the good ole jar of rub that mom used on our chests when we were sick.

But should we use it?

Cough drops

Menthol is a mild anesthetic that provides a cooling sensation when used as a cough drop. The menthol is basically a local anesthetic which can temporarily numbs the nerves in the throat that are irritated by the cold symptoms and provide some relief. (Interestingly, menthol is added to cigarettes in part to numb the throat so new smokers can tolerate the smoke irritation better. Hmmm…)

Menthol cough drops must be used as a lozenge and not chewed or swallowed because the menthol must slowly be exposed to the throat for the numbing effect. They are not recommended for young children due to risk of choking. Since science lacks strong evidence, but the risk to most school aged children is low and it is safer than most other cough medicines, I use the “if it seems to help, use it” rule for children not at risk of choking. Do not let any child go to sleep with one in his mouth. First, he might choke if he falls asleep with it in his mouth. Second, we all need to brush teeth before sleeping to avoid cavities!

Vaporized into the air

When it is put into a vaporized solution, menthol can decrease the feeling of need to cough. It should never be used for children under 2 years of age. They have smaller airways, and the menthol can cause increased mucus production, which plugs their narrow airways and may lead to respiratory distress. Infants can safely use vaporizers (and humidifiers) that put water into the air without any added medications.

The rubs for the skin

We’ve all seen the social media posts supporting putting the menthol rubs on the feet during sleep to help prevent cough. That has never made sense to me, and the link provided discusses that it is not a proven way to use the rubs.

Menthol studies show variable effectiveness. It has been shown to decrease cough from baseline (but the placebo worked just as well) and did not show improved lung function with  spirometry tests (but people stated they could breathe better) in this interesting study.  In other words, people felt better, but there really was no objective improvement.

Putting menthol rubs directly under the nose, as opposed to rubbing it on the chest, may actually increase mucus production according to a study published in Chest. In children under age 2, this could result in an increase in more plugging of their more narrow airways. There might be a concern with putting any petrolatum based product in or near the nose. There is a more recent study that does show children ages 2-11 years with cough sleep better with a menthol rub on the chest.

Note: There is a Vick’s BabyRub that does not contain menthol. Its ingredients have not been proven to be effective and some of the ingredients have their own concerns, but that does not fall into this discussion.

Cautions

Menthol products should never be used in children under 2 years of age. It can actually cause more inflammation in their airways and lead to respiratory distress.

Photo source: Angel caboodle at English Wikipedia [CC BY-SA 3.0 (https://creativecommons.org/licenses/by-sa/3.0) or GFDL (http://www.gnu.org/copyleft/fdl.html)], via Wikimedia Commons 

If a child ingests camphor (another ingredient along with menthol in the rubs) it can be deadly. It has been known to cause seizures in children under 36 months when absorbed or ingested in high concentrations. Menthol rubs sold in the US contain camphor in a concentration that is felt to be safe if applied to intact skin in those over 2 years of age. Mucus membranes absorb medicines more readily than intact skin, so do not apply to nostrils, lips, or broken skin. Do not allow children to handle these rubs. Apply only below their necks to intact skin.

Many people using the menthol rubs experience skin irritation. Discontinue use if this happens.