Meningitis Basics: What you need to know.

Meningitis occurs when a virus or bacteria causes inflammation of our brain or spinal cord. We use several different vaccines to prevent a few types of meningitis, but it’s all very confusing. Recent commercials have raised questions about what these vaccines are and if they’re needed.

Today we’ll go over what meningitis is and what types of germs cause it. Next time I’ll discuss some of the new meningitis vaccines in more detail.

What is meningitis?

Symptoms of MeningitisBoth viruses and bacteria can cause meningitis, but not everyone with these germs gets meningitis. Most people have less severe symptoms when they get these infections.

Not everyone gets all the symptoms listed below when they have meningitis. Some of these symptoms are common to many less serious infections, but if your child has these symptoms and appears more sick than normal, he or she should be evaluated immediately.

Symptoms of meningitis include:
  • fever
  • stiff neck
  • body aches and pains
  • sensitivity to light
  • mental status changes
  • irritability
  • confusion
  • nausea
  • vomiting
  • seizures
  • rash
  • poor feeding

Viral meningitis

Viruses are the most common cause of meningitis. Thankfully viral meningitis tends to be less severe than bacterial meningitis.

Most people recover on their own from viral meningitis. As with many infections, young infants and people who have immune deficiencies are most at risk.

There are many types of viruses that can cause meningitis. It’s likely that you’ve had many of these or have been vaccinated against them.

Non-polio enterovirus

The most common virus to cause meningitis is one from the non-polio enterovirus family.

Fever, runny nose, cough, rash, and blisters in the mouth are all symptoms that kids can get from this type of virus.

Most kids are infected with this type of virus at some point. Adults are less susceptible, and can even have the virus without symptoms.

There is no routine vaccine given for non-polio virus strains.

MM(R)V

Measles, mumps and chicken pox viruses can cause meningitis.

We vaccinate against these typically at 12-15 months of age, so it is uncommon to see these diseases. The MMR and varicella vaccines can be given separately or as MMRV. (Rubella is the “R” and can lead to brain damage in a fetus, but does not cause meningitis.)

Influenza

Influenza can cause meningitis, which is one of the reasons we recommend vaccinating yearly against flu starting at 6 months of age.

Herpesviruses

Herpesviruses can cause meningitis. Despite the name, most of these are not sexually transmitted.

This family of viruses includes Epstein-Barr virus,which leads to mono most commonly. Cold sores from herpes simplex viruses are also in this group. Chicken pox (or varicella-zoster virus) is another of these blistering viruses.

Bacterial meningitis

Bacteria that lead to meningitis can quickly kill, so prompt treatment is important. If you’ve been exposed to bacterial meningitis, you may be treated as well, but remember that most people who get these bacteria do not get meningitis.

Most people who get bacterial meningitis recover, but some have lasting damage. Hearing loss, brain damage, learning disabilities, and loss of limbs can result from various types of meningitis.

Causes of bacterial meningitis vary by age group:

Newborns

Newborns can be infected during pregnancy and delivery as well as after birth. They tend to get really sick very quickly, so this is one age group we take any increased risk of infection very seriously.

Bacteria that tend to infect newborns include Group B Streptococcus, Streptococcus pneumoniae, Listeria monocytogenes, and Escherichia coli.

Mothers are routinely screened for Group B Strep during the last trimester of pregnancy. They are not treated until delivery because this bacteria does not cause the mother any problems and is so common that it could recur before delivery if it’s treated earlier. This could expose the baby at the time of delivery. If a mother does not get adequately treated with antibiotics before the baby is born, the baby may have tests run to look for signs of infection or might be monitored in the hospital a bit more closely.

Once the mother’s water breaks, we time how long it has been because this opens the womb up for germs to infect the baby. If the baby isn’t born during the safe timeframe, your delivering physician or midwife might suggest antibiotics. After delivery your baby might have tests done to look for signs of infection or might be monitored more closely in the nursery.

It is very important that sick people stay away from newborns as much as possible. Everyone should wash their hands well before handling a newborn.

Babies and children

As children leave the newborn period, their risks change. Streptococcus pneumoniae, Neisseria meningitidis and Haemophilus influenzae type b (Hib) are the bacteria that cause disease in this age group.

Thankfully we have vaccines against many of these bacteria. Infants should be vaccinated against S. pneumoniae and H. influenzae starting at 2 months of age. (Note: H. influenzae is not related at all to the influenza virus.)

Vaccines against N. meningitidis are available, but are not routinely given to infants at this time. High risk children should receive the vaccine starting at 2 months of age, but it is generally given at 11 years of age in the US.

Teens and young adults

Neisseria meningitidis and Streptococcus pneumoniae are the risks in this age group.

Thankfully most teens in the US have gotten the S. pneumoniae vaccine as infants so that risk is lower than in years past.

Tweens and are routinely given a vaccine against A, C, W, and Y strains of N. meningitis. A vaccine against meningitis B is recommended for high risk people and can be given to lower risk teens. This will be discussed further in my next blog.

Older adults

Streptococcus pneumoniae, Neisseria meningitidis, Haemophilus influenzae type b (Hib), group B Streptococcus and Listeria monocytogenes affect the elderly

Talk to your parents to be sure they’re vaccinated and follow the vaccine recommendations for yourself too. Vaccines are not just for kids!

‘NI, Leptomeningitis purulenta cerebralis. Alfred Kast’ . Credit: Wellcome Collection. CC BY

 

Hand, Foot, and Mouth Disease

Hand, foot, and mouth disease is a very common illness, but there is a lot of confusion about it. It is caused by several different viruses in the enterovirus group. It can make kids (and some adults) miserable, but like most viruses we don’t have a specific treatment to fix it. There are things we can do to help kids stay more comfortable and to decrease spread.

Daycares in my area often make unreasonable demands of when to let kids return, which makes me aware that they aren’t aware of how it’s spread and how to control the spread as much as possible. Do they realize that many adults can have the virus and spread the disease without having any symptoms themselves?

How can you recognize hand, foot, and mouth?

Hand, foot, and mouth disease can look different in different people.

Of course the name gives a clue: there’s often a rash on the hands and feet, and in the mouth. If there is  a classic rash, you’ll know what you’re dealing with. The rash can look like red spots or blisters, classically on the palms and soles, but it can extend up the arms and legs. I often call it hand, foot, mouth, and butt disease because bumps in the diaper region are common. You might not recognize the blisters unless you can get a good look in their mouth to see blisters on the gums, tongue, or throat.

Some kids will be fussy and eat less than normal.

Many, but not all, will have a fever. Don’t fear fever.

This photo shows typical blister-type lesions around the mouth of a toddler. Notice the drool at the chin. Many kids have these blisters on their throat, which makes it painful to swallow. They often refuse to eat or drink – or even swallow their saliva!

Hand Foot Mouth Disease

Are there any serious complications?

Most kids recover completely within a week or so, but some can have a more significant illness.

Some kids refuse to eat or drink and may require hospitalization for dehydration.

A rare complication is viral meningitis, an inflammation around the brain. Symptoms can include fever, headache, stiff neck, and irritability. Viral meningitis might require hospitalization to help with comfort measures or to treat with antibiotics while ruling out bacterial meningitis.

Even less commonly children can get encephalitis or a polio-like paralysis. Encephalitis is an inflammation of the brain. Symptoms include fever, seizures, change in behavior, confusion and disorientation, and related neurological signs depending on which part of the brain is affected.

One consequence I tend to see every few years is fingernails and/or toenails falling off weeks after recovery from hand, foot, and mouth disease. While this is not serious and the nails eventually grow back normally, it can be distressing to parents. Simply knowing that this might happen can hopefully stop your worry before it starts!

How is it spread?

Most enterovirus infections in the US are during the summer and fall. Enterovirus infections are common worldwide. Most kids have been infected by the time they’re school aged. Pets do not get infected with enteroviruses.

The virus easily spreads from person to person. This happens through contact with saliva, nose and throat secretions, fluid in blisters, or stool of an infected person. The virus can spread from mother to infant prenatally and in the newborn period.

Enteroviruses may survive on environmental surfaces for periods long enough to allow transmission from fomites.

Respiratory tract shedding usually only occurs for 1-3 weeks, but the virus can exist in the stool for months after infection. Careful hand washing after all diaper changes is essential. In most cases it is not possible to keep kids home from daycare until they are “no longer contagious.”

Infection and viral shedding can occur without signs of clinical illness, especially in adults. This means many parents and daycare providers can unknowingly spread the virus to susceptible infants and children.

The incubation period (time from infection until symptoms show) for enterovirus infections is typically 3 to 6 days.

What treatment can be given?

Because this is caused by a virus, there is no specific medicine that is needed to make it go away.

Fluids are very important. Some kids refuse to swallow due to pain, so they are at risk of dehydration. Giving pain relievers, such as acetaminophen or ibuprofen, can help to decrease the pain and improve how well they will drink. Offer cold drinks, smoothies, and popsicles if age appropriate.

Older children and adults can use throat lozenges or mouth sprays that numb the pain.

Magic Mouthwash

A mixture of liquid diphenhydramine (a common antihistamine) and a liquid antacid, such as Maalox, in a one-to-one ratio can help alleviate pain. Give the amount that equals the diphenhydramine dose per weight.

For example, if a child’s dose is 2.5 ml of diphenhydramine, mix 2.5 ml diphenhydramine with 2.5 ml of the liquid antacid. If a child can swish, gargle, and spit the mixture, it can help numb the sores. When younger children swallow the mixture, it may also help if it coats the sores in the mouth adequately.

Control measures to prevent hand, foot, and mouth disease

Hand washing, especially after diaper changing, is important in decreasing the spread of enteroviruses.

Don’t share foods or drinks. Avoid contaminated utensils.

Wash toys and disinfect surfaces regularly.

Chlorination treatment of drinking water and swimming pools may help prevent transmission.

Can kids get this more than once?

Since there are several different viruses that cause hand, foot, and mouth disease, it is possible to get it more than once. Keep washing those hands, toys, and surfaces!

Common risks from shots: real and perceived

Parents want to keep their kids as healthy as possible, but with the overwhelming amount of information found on media these days, it’s hard to know what is safe and what risks really are when it comes to vaccines. What are the common risks from shots?

Nothing we do is without risk.

risks from vaccines
There are many unfounded fears about vaccines. What are the real risks?

The most risky thing most of us do daily is to get in a car and drive somewhere.

We can minimize the risk by wearing a seatbelt and putting our kids in the proper sized car seat, obeying the traffic laws, and adjusting our driving to the road and weather conditions, but there is always the chance of an accident.

For most of us, the risk of an accident is outweighed by the benefits of getting to where you need to go.

 

Some people want you to think we give kids green toxin-laden vaccines from huge syringes (at least if you look at the photos like I show above). But no, vaccines don’t look green, and we don’t inject them like most stock photos show.

Vaccines have risks, but more benefits.

The benefits are many, including preventing early death from infection. The risks are often overblown, but do exist.

What about package inserts?

You might have read somewhere that you should read the package insert of vaccines before allowing your child to get a vaccine, like there’s some big secret everyone’s trying to hide.

No one’s hiding anything. They’re available online.

The problem isn’t hidden information, it’s people mistaking what is written for something that it’s not.

The package insert has a lot of information, but it’s designed for legal reasons, not consumer information sharing.

Some groups who try to warn people about vaccines encourage the reading of package inserts to learn risks of the vaccines.

This can lead to undue fear and confusion because not all problems recorded in the adverse reactions section of the package insert are due to the vaccine.

If someone fell out of a tree and broke his leg after a vaccine and reported it during vaccine trials, “broken leg” could be listed as a reaction. It does not mean that the vaccine broke the leg or caused the broken leg in any way, but it is reported in a way that can make it look like there is a cause and effect relationship.

More realistically, it is common for people to have headaches or congestion, so these types of things get reported for most medicines in their package inserts. It does not mean the medicine caused the headache or congestion, just that people had those symptoms during the study period.

For a more detailed description of package inserts, see Package Inserts – Understanding What They Do (and Don’t) Say.

Common Risks from shots that are known

The risks of all vaccines are similar. Specific risks can be found on the Vaccine Information Sheets, which are designed to educate consumers about risks and benefits.
These risks include:
Pain with injection

This is very subjective.

Most babies cry, but typically as soon as they are cuddled by a parent they quickly calm down.

Toddlers are more prone to longer crying times, but that often starts unrelated to the vaccine and is not solely due to pain. It’s often due to their frustration and/or fear of being in the doctor’s office.

Older kids often will say the pain was less than they feared, but some do complain for several minutes. Moving the arms or legs that were injected can help ease this pain.

You can do many things to help kids tolerate the shots with less pain.

Fever

A mild fever can occur for a day or two after many vaccines.

Most kids do not need any fever reducers for this. The fever reducers might even reduce some of the effectiveness of the vaccine, so are not routinely recommended after vaccines.

If the temperature is over 102F or the child is very fussy with the fever, it is okay to use a fever reducer. These higher fevers are not common after vaccines, but are possible.

Fussiness or feeling mildly ill

Infants can be fussy for a few days and older kids might say they feel tired or have a headache.

Some kids (and adults) will feel like they’re getting sick, but it never evolves into an illness and it stays mild.

Extra sleep would be beneficial, but typically no treatment is needed.

Non-stop crying

While unusual, it is possible that an infant will cry for hours after one or more vaccines.

If this occurs, you can try a pain reliever.

If the crying doesn’t stop, have your child examined to identify if something significant is causing the crying.

Seizure

It is not common to have a seizure after a vaccine, but whenever a child under 5-6 years of age has a fever, it’s possible to have a fever seizure.

Most fever seizures are from viral illnesses, some of which are prevented by vaccines.

Vaccines rarely cause fever seizures, but if the temperature increases rapidly after a vaccine in a susceptible child, it’s possible.

If a child has a fever seizure, it is scary to watch but does not lead to permanent brain damage.

Interestingly, studies show that delaying the MMR past 15 months increases the risk of seizures.

Any child who has a first time seizure should be evaluated for potential causes and treatments.

Pain, tenderness and swelling
vaccine side effect redness
This is my arm 2 days after a Tdap. The area was swollen, warm and red. The redness has irregular borders, looking lacy in appearance, which is common in shot reactions. I didn’t need any pain relievers. The muscle was sore from the tetanus, but the redness wasn’t uncomfortable.

Some vaccines, such as DTaP and Tdap, are more prone to swelling and redness than others.

The most swelling tends to happen after several doses of these vaccines, such as with kindergarteners, tweens, or adults.

My son’s arm was so swollen after kindergarten shots that he couldn’t fit into some of his shirts with narrow sleeves, but it was a normal shot reaction.

With a shot reaction the inflammation begins a few hours after vaccination, peaks 24 to 48 hours afterward and resolves within one week.

Tenderness is usually at its worst during the first few hours and resolves as the reaction enlarges.

The amount of swelling and redness is more significant than pain or tenderness with a classical vaccine reaction.

Infection of the injection site

Very rarely the area can become infected (cellulitis) but this is exceedingly rare now that most childhood vaccines come in single dose syringes.

Cellulitis can evolve rapidly — often within 12 to 24 hours.

Diagnosis is based on the symptoms of redness, pain, swelling and warmth, usually with fever and ill appearance.

Most redness and swelling is a normal shot reaction and not a sign of infection. If your child seems ill along with a painful red and swollen area where the vaccine was injected, it might be wise to have your doctor take a look at it.

Risk vs Benefit

The risks above must be weighed against the benefits of vaccinating.

In my family, we vaccinate against all recommended vaccine preventable diseases by following the standard schedule.

I advise that most people do the same. There are those who cannot receive vaccines due to age or health status, and they depend on us all to vaccinate.



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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. His temperature 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.

Dr. Christina has a great blog discussing commonly used terms that can be confusing to your physician and alternative word choices.

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. There’s no fever but she 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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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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Fever: How High is Too High?

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

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

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

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

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

What is a fever?

The number on the thermometer can be confusing to parents. How the temperature is taken is as important as the number itself to determine if it is a fever. A fever is often defined as a temperature over 100.4 °F (38 °C) but it can vary based on how you take the temperature (rectal vs oral vs forehead). This is simply the minimum temperature that is no longer considered normal.

The American Academy of Pediatrics doesn’t recommend treating fevers until the temperature is over 102°F unless the child is uncomfortable. Thermometers are not very accurate, so when you worry more about a temperature that is half of a degree higher than another temperature, it might not be a significant difference. You could take the temperature twice in a row and get different readings. If your child is playful and the thermometer reads 101.5°F that is a very different story than if your child is barely moving, whimpering, and breathing fast with a temperature of 101.5°F. I wouldn’t recommend any fever reducers for the first, but I would recommend the second get evaluated by a pediatrician or other medical provider.

Why do we care about fevers?

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

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

So how high is too high?

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

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

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

When parents give a fever reducer, they often worry that the temperature doesn’t go back to normal. Returning to normal doesn’t mean it isn’t a serious infection and not returning to normal doesn’t mean that it is a serious infection. Studies show the temperature tends to decrease by 1.8 to 3.6°F.

  • Acetaminophen begins to work in 30 – 60 minutes and has its peak effect in 3-4 hours. The duration of action is 4-6 hours.
  • Ibuprofen begins to work in under 60 minutes and has its peak effect in 3-4 hours. The duration of action is 6-8 hours.

The goal should be to make a child more comfortable, not to get the temperature to normal.

My personal opinion is that most children won’t need their temperature taken to verify that they are better after a fever reducer. They should be more comfortable. If they aren’t, then it’s wise to have them evaluated professionally.



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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.

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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.