Evolution of Illness

When kids are sick, parents understandably want them to feel better quickly. They want a sound night’s sleep. They want to be able to return to work/school. They want to see a happy, healthy child again. They come to our office hoping for answers and a cure.

Sometimes there is no quick fix, just treating symptoms and time.

sickness, cough, cold, getting worse

It’s been about 15 years, but I remember the frustrations of having a sick baby when my daughter had bronchiolitis. Some of the details are muddy, but I remember the feelings of inadequacy because I couldn’t help her feel any better any faster. I knew the illness tends to get worse before it gets better and there is little we can do to alter its course, but knowing this it didn’t make me feel any better as the mom who was helpless.

I lost sleep for several nights as I watched her pant (not breathe, but pant). I resorted to giving asthma-type breathing treatments because my son had wheezing so we had everything we needed to give a treatment at home with a nebulizer. We did these treatments several times despite the fact that they didn’t seem to help her much. (Guidelines now say to not use bronchodilators for most infants with bronchiolitis but even then we knew it didn’t help much.) It was probably the humidified air from the nebulizer that helped more than anything. But the vaporizer in her room and the saline to suction her nose wasn’t helping, so I wanted to at least try the asthma medicine.

She kept wheezing.

We brought her in to the office three days in a row to have someone else check her. I can’t check oxygen levels at home and needed someone to objectively examiner her.  So three days in a row we went in for repeat exams.

She was able to maintain her oxygen level and stay hydrated despite breathing 60-70 times per minute for days. I still don’t know how. I remember wishing her oxygen level would drop enough that we could hospitalize her ~ not critically ~ just enough. Then she’d be on monitors and maybe I could sleep a bit knowing someone else was watching her. Thankfully she never got that sick and eventually we were all sleeping again, but it took a long time for that.

So I understand the frustration when we tell parents things to do at home and ask that they come back in  __ days or if ___, ____, ___ symptoms worsen. It really isn’t that we are holding out on a treatment that will fix the illness, it’s just that we don’t have a quick fix for many illnesses. We need to be able to examine at different points in the evolution of the illness to get a full picture of what is going on.

The exam can tell us a lot, but it doesn’t predict the future. One minute ears can look normal, the next they develop signs of an infection. I cannot say how many times I’ve heard a parent complain that someone else “missed” something on exam that I now see. Yes, sometimes things can be missed, but I suspect that most of the times the exam has simply changed.

I learned this phenomenon as a resident on the inpatient unit. I had a patient who had been admitted for an abdominal issue. I did a physical on the child in the morning before rounds, including looking at ears, which were normal. Late that afternoon the nurse paged me because he developed a fever. He had a new symptom, so another exam was indicated. This time the ears were red and full of pus. Within hours this child had developed a double ear infection. I examined the ears both times and they were definitely different.

I understand the frustration (and expense) to take kids back in to be seen if symptoms worsen, change, or simply just don’t resolve at home. If symptoms change, we need to re-evaluate, which includes an exam. Medical providers cannot look into the future to see what will develop. It is not appropriate (or effective) to put kids on an antibiotic or iv fluids to prevent the illness from taking its natural progression. Sometimes we need time to see how the illness progresses to see what other treatments might be needed.

When you hear that your child has a viral illness, do not take that to mean it’s “just a virus” and there’s nothing to be done. There are many supportive measures that can be done and things to monitor to be sure your child isn’t getting sicker. Dr. Jamie Friedman discusses the topic of Just a Virus and Dr. Chad Hayes also covers the difference between “just a virus” and the potential risks of a viral illness in “Just a Virus:” What Your Doctor Meant to Say.

When parents call back and want something else done, they are often upset that we want to see the child again. I hear many types of complaints.

  • Money is probably the biggest issue. It is not because we want your co pay. The “we” I use here is not just my office and I am not speaking of any particular situation. With online doctor rating sites, social media sites, and knowing doctors around the country, I write with many examples in mind. I’ve seen online complaints that doctors are just money hungry, trying to get someone to come back in just so we can charge more money. It is true that we charge for every visit. We are not able to waive the copay because we did “something wrong” or “missed a diagnosis” the first time. Each is a separate visit with updated information and a separate exam. Insurance contracts dictate that a separate copay is charged. We must adhere to legal contracts or it would be considered insurance fraud.
  • Increasing our numbers for “production” is sometimes brought up. It is not because we want to fill our waiting room with more children to increase the waiting time for everyone else. We don’t want to waste your time or ours. But we need to see a child to know what is happening at that moment to be able to give any valuable advice and treatment.
  • We want to see your child again because we need to see your child to know what to do. Maybe now the child’s symptoms have changed. Maybe not, but without the history and exam we do not know. The exam might now show wheezing, low oxygen levels, a new ear infection or sounds of pneumonia. Sometimes the exam still is overall normal, but the fever’s been going on long enough without any identifiable cause, which requires lab and/or x-ray evaluation.

Please remember that if you get a different answer at a different visit, it doesn’t mean that the first assessment was wrong. Usually it is due to a progression of the illness, and things change.

Human bodies are not static.

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. During cold and flu season kids get sick. A lot.

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?

Extra tests = Extra costs

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.

No history

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).

It’s easy to fail to 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!

Records in one place

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?

When should you consider ear tubes or a tonsillectomy?

If we don’t have proper documentation, these issues might have a delay of recognition.

Not all locations are good with kids

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.

Cost

As 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.
 

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.