Practical at home tips for illnesses

When your family gets sick, what can you do before running to the ER or clinic?

When cold and flu season is in full gear, it’s helpful to know common things that can help us prevent and treat whatever is in town. Many of the viruses that run around each season don’t have specific treatments, but there are things that we can do at home to treat symptoms and keep people more comfortable. There are also things we can all do to prevent the spread to other family members or back into our community.

What can be done to feel better?

Remember that nothing can be done to treat most viruses. Our body’s immune system will take care of that, but we can do things that help us feel better during the illness.

It’s hard to make them better, but we can make them feel better

Most cough and colds last several weeks. Vomiting and diarrhea can last a couple weeks as well.

During the cold and flu season, it can seem like kids are sick every day for months because they catch one on top of the other. Some of these days they might simply have a runny nose, and those days can last most of the year in young kids.

It’s when they seem uncomfortable or distressed that we need to do more. Treat the symptoms that bother them.

Identify the symptoms that are concerning, such as difficulty breathing or dehydration, and seek treatment at your doctor’s office for those.

What about fever?

Notice I did not list fever as one of those symptoms.

Doctors don’t do anything special for fever in vaccinated children over 2 months of age.

Fever can accompany other symptoms that may be concerning, but it in itself is not the concern unless it is a newborn, unvaccinated child, or one with a chronic condition that you’ve been warned has increased risks.

Comfort measures

Pain control with acetaminophen or ibuprofen may be helpful. Follow the package directions for weight. Dosing for kids under 2 years of age can be found on my office website or you can ask your physician.

Remember the goal is not to bring temperatures to normal, but to keep kids comfortable. If they’re in pain from sinus pressure, a headache, sore throat, body aches, or earaches, it is okay to give a pain reliever even with a normal temperature.

Get the mucus out

Suction your infant’s nose before feeding and before putting him down to sleep. This helps clear the mucus from the airway and makes breathing easier. Encourage nose blowing for those old enough to know how to blow.

Use saline to irrigate the nose. They sell drops, sprays, and nasal wash systems to be used, depending on age and personal preference. 

Hydrate

Encourage your family members over 6 months of age to drink more water than normal when sick. Kids often won’t eat well when they’re sick. That’s okay. It is important that they drink well though so they can stay hydrated.

Young infants should not drink water, but you can encourage more of their milk or formula when they have cough and colds.

If your child has vomiting or diarrhea, avoid cow’s milk products. These often lead to more vomiting. Breast milk can be offered in small amounts frequently to infants who are breastfeeding. Electrolyte solutions (with sugars and salts) can be given to infants and children for hydration.

Clean air

DO NOT let anyone smoke around your child or in your home. Smoke can make the wheezing and coughing worse, even if done in a separate room in the home.

Smoke residue on hair and clothing can cause irritation to your child’s airways. I can usually identify smokers or people who spend time with smokers when they’re in my clinic. (Thankfully that isn’t often.) It isn’t unusual for me to start coughing when they’re in a clinic room with me. If you must smoke, go outside and wear a jacket that can be removed to minimize what is on your shirt when you go inside and hold your baby.

I’ve even started coughing when around someone who was vaping. I know people claim that the vapor is safe around others, but my lungs don’t like it. Keep it away from your kids. Talk to your kids about the risks of vaping so they don’t start the habit.

Rest

Encourage those who are sick to get extra rest. We often sleep poorly at night and need daytime naps to get enough sleep when we’re sick. 

Dry air

A cool mist vaporizer or humidifier can help your child breathe easier. Change the water every day. Clean the machine per the manufacturer recommendations. 

Infection control

It just isn’t possible to keep kids from being contagious when they have a virus. They love to touch everything and share germs, so keep them home until they’re well enough to return to normal daily activities.

Stay home!

Our health department now recommends that everyone with influenza stays home for 7 days following the start of symptoms.

How long should you stay home? It varies by illness. www.questforhealthkc.com

You can return to work, school, and activities with other illnesses when the fever is gone (without using fever reducers) for 24 hours, there’s no vomiting or diarrhea, and you’re generally feeling well enough to return. If not, stay home and rest or visit your doctor.

Cover the cough!

Cover your cough properly - don't use your hands! www.questforhealthkc.com

Teach kids to sneeze and cough into their elbow or a tissue. Wash hands after handling tissues. 

Wash, wash, wash

Good handwashing can help decrease the spread of viruses.

Wash hands often. If soap and water isn’t available, use hand sanitizer. The more things you touch, the more often you should wash.

Teach kids to wash properly. Have them rub soap on their hands for 15 – 20 seconds- be sure they scrub palms, backs of hands, fingers, spaces between the fingers and even under the fingernails. 

Wash

  • Before preparing food
  • After toileting or changing a diaper
  • When they’re obviously soiled
  • Before eating
  • After sneezing or coughing into hands or wiping nose
  • Before and after touching eyes
  • When taking care of a wound wash your hands before and after washing and treating the wound
  • Often when taking care of someone who is sick
  • After touching trash or soiled objects

Consider having separate towels for each family member in your bathrooms to decrease the spread of germs when they wipe their mouth after brushing their teeth.

Hand sanitizer is a good option when washing isn’t available, but it is not helpful against some germs, so handwashing is preferred.

Use lotion as needed to keep your skin moisturized. Dry skin damages the barrier that helps prevent germs from getting into our bodies.

Germs can live on objects and surfaces for 2 or 3 hours – sometimes longer. Clean your child’s toys often with soap and water.

Don’t touch your face. Eyes, ears, and noses are the doors into our body.

Avoid handshakes and other hand to hand contact. Try a fist bump or wave!

Help prevent the spread of germs. Don't shake hands. Offer a fist bump or wave. #infectionpreventiontip

Avoid taking young children to large groups of people during the cold and flu season, especially if people are showing signs of illness.

Vaccinate.

We can help prevent many of the most serious illnesses by staying up to date on our vaccines.

Everyone over 6 months of age should get a flu vaccine. There are very few contraindications to a flu vaccine and many benefits. Really.

And finally… avoid kisses that spread illness!

For more:

Fever Is

When is a fever too high

Tamiflu

Evolution of illness

Cough Medicine: which one’s best?

Cough sounds

How long will a cough or cold last?

RSV has a bad rap… for good reason

Strep throat: new school guidelines

Sore throat: strep vs viral

How to use nose sprays correctly

Improper use of antibiotics

Why wait to see your usual doctor?

RSV has a bad rap, for good reason

Bronchiolitis (often called RSV) is an infection of the respiratory tract that leads to wheezing and difficulty breathing. Learn why it’s scary to many parents and what you can do about it.

Bronchiolitis is an infection of the respiratory tract that leads to wheezing and difficulty breathing, most often in infants and children under 2 years of age. It’s often called simply “RSV.” While it’s often caused by a virus called Respiratory Syncytial Virus (RSV), it’s not always. Let’s talk about what it is and what we can do about it.

Symptoms of bronchiolitis

Bronchiolitis often starts off just like a common cold, with a runny nose or congestion. In older children and adults it progresses just like a cold. Because it is.

In infants and young children symptoms can progress to make them more significantly sick. Day 3-5 of illness often is the worst.

Symptoms include (but not everyone has all):

  • Rapid heavy breathing (more than 60 breaths per minute – always count for a full minute in babies because they can pant or hold their breath, which throws the count off)
  • Wheezing (tight breathing with a whistling sound)
  • Retractions (the skin between ribs suck in during inspiration)
  • Nasal flaring (where the nostrils widen with breathing)
  • Belly breathing (the abdomen moves up and down more than usual)
  • Fever
  • Cough (which can occasionally cause vomiting)
  • Lots of mucus from the nose and mouth (lots!)
  • Decreased appetite (which can lead to dehydration, so offer frequent liquid feedings)

If you’re wondering what type of cough your child has, check out The sounds of coughing.

Causes of bronchiolitis

Most cases of bronchiolitis are due to viruses.

RSV is a common cause, which is why the condition is often simply called RSV. Most of us have had RSV by the time we’re 3 years old. It doesn’t always cause the symptoms of bronchiolitis. Sometimes it just looks like a common cold, especially in older kids and adults. This is why it’s really important to protect young infants around people who are just a little sick.

Bronchiolitis can be caused by many of the viruses that cause upper respiratory tract infections. Rhinovirus, metapneumovirus, adenovirus, influenza, parainfluenza, and coronavirus are some of the other culprits.

Who’s at risk?

Symptoms tend to be worst in babies who are higher risk. This includes infants who were born prematurely, those who have certain heart defects, the very young, or those with other chronic conditions.

Infants are more at risk of having simple cold viruses cause the more severe symptoms of bronchiolitis. Their narrow airways contribute to this because they become plugged with mucus more easily than larger airways.

All viral illnesses are more common among infants who are in daycare or around lots of people. The more people, the more likely they’ll be exposed to a person sharing germs. Infants also put their hands and toys in their mouth often, which helps them get germs into their body.

Those who are around cigarette smoke are also more at risk because of the chronic airway irritation caused by smoke. Even babies who are around people who smoke prior to being with the child can get third hand smoke exposure from hair and clothing.

Prevention

Standard infection control protocols can help avoid spread.

Wash hands frequently or use hand sanitizer. Teach kids to get all parts of their hands clean. Wash hands even when you’re not feeling sick… we share germs before we know we have them and we need to protect ourselves from catching new ones!

Avoid being around people who are sick and when you’re sick, stay home! If you’re the one who’s sick, check out Help! I’m sick and have a baby at home.

Have separate towels (or disposable towels) in the bathroom. After brushing your teeth, you don’t want to wipe on a towel that was used by someone who’s brewing germs!

Don’t kiss babies on their face, hands, or feet. The top of the head is best!

Stop the spread of germs! Don't kiss the face!

Avoid cigarette smoke – even second hand and third hand smoke (on surfaces) can cause airway irritation. This irritation makes it harder to fend off germs, which leads to more infections.

Germs can live on surfaces and objects for 2 or 3 hours or longer. It’s a good idea not to share toys because babies put them in their mouth all the time. Clean your child’s toys often with soap and water.

Cover coughs and sneezes properly.

Coughs spread germs. Cover!

Testing

Virus testing

There are tests that can be done on mucus from the nose to see which virus is the culprit, but they aren’t usually required.

Knowing if it’s RSV or another virus doesn’t make the symptoms change. We treat symptoms.

Testing can be used for infection control measures when babies are admitted to the hospital, but aren’t always necessary.

Tests are expensive, and unless they change something we’ll do, they aren’t generally recommended. Why waste your money? (Even if you think insurance will cover it, the money comes from somewhere… you’ll pay more in premiums if you spend more.)

Oxygen levels

It is common to check oxygen levels when kids (and adults) are sick. Pulse oximeters are an inexpensive tool to help us assess how well a person is compensating when having trouble breathing.

Chest x-ray

Most infants and children with bronchiolitis do not need a chest x-ray, but they are sometimes used to assess for pneumonia or foreign bodies (such as a swallowed coin) that can cause wheezing.

Blood work

Blood tests are not usually needed to diagnose or treat bronchiolitis but they can help to identify if there’s a need for antibiotics due to a bacterial infection. Sometimes we check blood if we’re worried about dehydration.

Treatments

The virus must run its course and symptoms can last several weeks, so what can you do to help ease symptoms?

Home treatments

Comfort measures

You can use fever reducers if your baby is uncomfortable. These include acetaminophen if your baby is over 2-3 months and ibuprofen or acetaminophen if your baby is over 6 months. I don’t recommend fever reducers before babies get their 2 month vaccines because you can mask symptoms of serious disease. See your physician if your unimmunized child has a fever!

Remember that a fever is the body’s immune system at work, so your goal is comfort, not getting rid of the fever.

More on how to recognize if a fever is too high and the scary facts of fever.

Suck out the snot!

Babies with bronchiolitis often seem as if their nose is a faucet. All that mucus interferes with breathing and feeding. They can’t blow their nose, but you can suck it out!

I’m not a fan of bulb syringes as a nasal aspirator. I find that they have too narrow of a tip to get an effective seal in the nostril until you force it up so far that it causes trauma in the nose. They also run out of suction power before the mucus is all out, which means you must break the seal, empty it out, and resume. This gives your child a chance to suck back some of the mucus you brought forward. Not to mention some of the really gross photos I’ve seen of what grows inside those things!

Here’s a review of various nasal aspirator types and brands. I like the review in general and have no ties to it. She does link to sales, but you can buy from your favorite retailer.

Use one of the aspirators to suction your infant’s nose as they need it. It’s especially helpful before feeding and before they go to sleep, but think of how often you blow your nose when you’re sick. It can be helpful quite often!

Use saline

Saline can help thin out mucus and decrease the swelling of nasal tissues.

It can be used with or without sucking afterward. I talk a bit more about the benefits of saline in How to use nose sprays correctly.

Elevate the head

Raise the head of the bed to help with drainage of mucus. Don’t put your infant on a pillow because that can obstruct breathing. Raise the head of the bed by putting something solid under the legs of the bed or roll a blanket or towel and place it under the mattress at the head of the bed.

I remember many nights of sitting up holding my children when they were sick so they could be upright and sleep. That doesn’t mean I slept well, but that’s what moms do sometimes. You do need to be careful with this – babies can be dropped if a parent falls asleep holding them.

Fluids

Encourage your child to drink fluids in small amounts. This can be breast milk or formula, or water for older infants and children.

Many babies tire out drinking, so they need to drink more frequently than normal to get in a decent volume.

If your baby isn’t drinking well and looks dehydrated, talk to your physician.

Humidify the air

A cool mist vaporizer or humidifier can help your child breathe easier.

Change the water every day.

Clean the machine per the manufacturer recommendations to prevent it being a source of germs.

Things to avoid

Never use menthol products around infants. They have been shown to increase mucus production and worsen symptoms, especially in children under 2 years.

Don’t demand antibiotics. It cannot be cured with antibiotics. No viral illness can.

Decongestants thicken mucus and can lead to more difficulty breathing, sleep disturbances and irritability.

Hospital treatments

Historically we have tried medical treatments when infants present with bronchiolitis. These include breathing treatments with bronchodilators, steroids, and more.

A single treatment with a bronchodilator can be used to see if there’s response to decrease wheezing, but should not be continued if there’s no benefit.

Steroids have not been shown to help unless there’s a history of asthma.

Oxygen is a standard treatment that can help if the oxygen level is low or to ease the work of breathing.

Intravenous (iv) fluids are often required if hydration from feedings is not successful.

Suctioning is a primary treatment in the hospital setting, much like at home.

When should kids be seen?

Infants and children should be seen relatively quickly if the following criteria are met:

  • Infants under 2 months of age should be assessed by a physician. They often require hospitalization because of the risk of apnea. Apnea is when they stop breathing and is a risk of very young infants with bronchiolitis.
  • Respiratory rate over 60 breaths/minute consistently. It’s common to breathe faster with a fever, so if you can bring it down and their breathing is less labored, that’s okay. They also temporarily breathe faster after eating or crying. Again, if it slows within a few minutes, that’s okay.
  • Dehydration. Signs of dehydration include no tears, thick/pasty or no saliva, or fewer than 3 wet diapers in 24 hours.
  • The color of the child’s lips or skin looks blue.
  • The infant looks uncomfortable or is inconsolable.
  • Infants under 3 months (or an under-vaccinated child) with a temperature over 100.4F.

If your child simply isn’t getting better after several days or if earache develops, make an appointment during regular office hours.

Sudden Barky Cough? Think Croup

The barky cough of croup is distinctive. It’s not a typical wet or congested cough. It’s like a seal bark. The good news is we can often treat it at home.

Many parents get scared when they hear the barky cough of croup. I’ve even been scared when my own children have it. I know what it is, but their breathing gets so labored that it’s scary.

Sounds of coughing

Parents describe many coughs as “croupy” but most of the time they’re mistaking a wet, mucous-filled cough for croup.

It can be difficult to sort out all the various sounds of coughing, which is why I previously gathered a number of videos into one blog.

The barky cough of croup is distinctive. It’s not a typical wet or congested cough. It’s like a seal bark. The good news is we can often treat it at home.

What is croup?

Croup is a distinctive set of symptoms that occur due to inflammation around a young child’s voicebox in the larynx and trachea.

Many people describe a croupy cough as a seal bark sound. They often make a hoarse or squeaky sound called stridor when they inhale.

Croup often starts suddenly in the middle of the night. 

What causes croup?

Croup is usually caused by viruses and tends to be most common in the Fall. The viruses that cause croup are common and usually cause runny nose or congestion and sometimes cause a fever. 

One child may get full-blown croup, but another will get a simple cold with the same virus. Some kids seem to get croup often, while others may never get it.

Can older kids get croup?

Croup is most common in kids less than 5 years of age, but older kids can occasionally get it. 

Older children and adults tend to get laryngitis with the same viruses that cause croup. Their airways are bigger, so the swelling that occurs near the voicebox isn’t as severe.

Croup is tricky

Croup often looks like a simple upper respiratory tract infection or cold during the day. Nothing to worry about…

In the middle of the night you will hear a sudden barking sound, much like a seal barking. A child with croup looks distressed and very sick at night, but seems much better the next day. 

For many kids, it’s just one night of this scary cough, but it can last several nights in others.

Some kids continue to have what is called stridor or trouble talking during the day. Stridor is a hoarse sound that you can replicate by breathing in while tightening your vocal cords. It sounds like a squeak or wheeze as kids breath in. Stridor is due to the swelling near the vocal cords that’s found in croup.

This is a simple yet very helpful video to hear the sound of croup and for management tips. 

How is croup diagnosed?

Croup is what we call a clinical diagnosis. No lab or x-ray is needed.

A doctor or nurse will ask questions about various symptoms, and if we hear the classic cough or stridor, it supports the diagnosis.

How is croup treated?

If you recognize croup, there are many at home treatments you can try. 

Cool air

Taking kids outside into the cool night air often helps soothe the airway. 

If the weather isn’t appropriate, you can open your freezer door and let them breathe in that air. (This has never been my favorite advice because it means a sick kid will be breathing on the frozen food and then there’s the wasted energy…)

Steam

The airway can also be soothed by taking kids into a bathroom, closing the door, and turning the shower to the hottest setting. Just sit in the bathroom – not in the shower. 

Usually after 10-15 minutes breathing normalizes. 

One thing I learned when my son first had croup: don’t leave the bathroom as soon as breathing calms down. Turn off the shower and just sit there for awhile. We had a rebound croup that was less scary, but unnecessary, when we tried to get him back to bed quickly. Letting the room get closer to the home’s normal air quality before going back into the hall and bedroom is time well spent.

Humidifiers and vaporizers

When we’re sick in the dry weather months, I always recommend adding a vaporizer or humidifier to the bedrooms. This is especially helpful if a child is at risk for croup due to age.

What about medicine?

Fever/pain relievers

If kids are uncomfortable, you can use acetaminophen or ibuprofen as a pain reliever. These do not help the cough, but they can help with comfort.

Steroids

Since steroids decrease inflammation, they are often used when kids get croup. These can only be used with a prescription and your doctor’s instructions. See your doctor if you’re interested in any prescription medicine.

Breathing treatments

Croup is often mistaken for wheezing, but it is not treated with a bronchodilator like asthma.

The swelling near the voicebox is much different than the smaller airway narrowing that occurs with wheezing, and the bronchodilators (albuterol or levalbuterol) work on the smaller airways. 

If kids have asthma, they can wheeze from the same virus that leads to croup, and in that case their asthma medicine helps.

In the hospital or ER setting some kids will get a breathing treatment of epinepherine. This should only be done in a supervised setting so they can be properly monitored.

Antibiotics

Croup is usually caused by a virus, so antibiotics don’t help.

There is also something called spasmotic croup, but that also is not treated with antibiotics. 

When should kids go to the ER or their doctor?

Since croup is worst at night, most of the kids who need to be seen end up in the ER. If your child has stridor during the day, they can be seen at their usual doctor’s office. 

If the above home treatments don’t work after about 15-20 minutes, you should take your child to be seen.

Kids who seem very anxious due to breathing difficulties will also benefit from a proper medical exam and treatment.

Trouble swallowing along with difficulty breathing should be evaluated by a physician.

If you notice that your child seems better leaning slightly forward while sitting, he should be seen.

Any child who is not up to date on vaccines, especially the Hib vaccine, should be seen with labored breathing. Epiglottitis is now rare, thanks to vaccines, but if a child isn’t vaccinated, it is still possible to get this. It can cause stridor, fever, difficulty breathing, and other similar symptoms to croup. Be sure the physician knows your child isn’t vaccinated!

Don’t look for quick fixes for your cold! There’s no quick fix

We all have been sick and wish for a magic cure. Sometimes it seems we find the right fix, but it was just coincidental. I see many people who want antibiotics to fix a viral illness because “it always works” but I want to try to show why this isn’t usually the case. Using antibiotics for most colds and coughs isn’t necessary and can lead to problems.

My urgent care experience

This blog is generally about pediatric health, but sometimes the principles are similar in adult medicine, so I’m sharing a personal story.

I was visiting my parents out of town and came down with fever, chills, and a sore throat. Due to the fatigue and shaking chills, I wasn’t sure if I’d be able to drive the 4 hour trip home the following day. I decided to go to a walk in clinic to see if there was a treatment to help get me on my feet again.

Although it’s less common for adults to get Strep throat, I wanted to have my throat swabbed because I had been exposed to just about everything at work.

If it was just a viral illness, fine. I’d tough through it with fluids and a fever reducer for the body-shaking uncomfortable chills.

But a child had gagged and coughed in my face earlier that week when I was doing a throat swab – and he had Strep. If I had Strep (as I hoped), then an antibiotic would treat the cause and I’d be back in shape in no time.

I could technically call out an antibiotic for myself, but I didn’t want to do that. That is poor care and I would never recommend treating anyone with a prescription without a proper evaluation.

I followed my own advice and went to a walk in clinic since I was out of town. If I was at home, I would have gone to my primary care physician because I believe in the medical home.

The provider walked into the exam room looking at the nurse’s notes saying it sounded like I had a sinus infection. (I use the term provider because I don’t recall if he was a physician, NP, or PA.)

What?

He hadn’t even examined me or gotten any history from me other than answers to the cursory questions the nurse asked. Not to mention that my symptoms had just started within the past 24 hours and didn’t include any form of nasal congestion or drainage.

I’m a physician and know that sinusitis must have persistent symptoms for much longer than 24 hours. But I kept that thought to myself for the moment.

He did a quick exam and started writing a script to treat my sudden onset of fever without cough/congestion.

He literally started writing the script as he was telling me, once again, that I had a sinus infection.

Now I couldn’t stay quiet any longer.

antibiotics are not a quick fix for virusesI said I really just wanted a throat swab to see if it was Strep. I didn’t want an antibiotic if it wasn’t Strep throat.

He argued for a bit about the validity of rapid Strep testing.

I argued that I did not meet the criteria for a sinus infection and that the rapid strep tests are indeed fairly reliable (not perfect).

As a pediatrician I won that argument easily. In the end I was swabbed.

The test was negative. I most likely didn’t have Strep throat after all.

He still gave me a prescription for a commonly used antibiotic called a Z-pack, which I threw away.

avoid unnecessary antibiotics
Antibiotics are not a quick fix for viruses and carry risks.

Did I get better?

I felt better the next day, so if I had just taken the z-pack, I would have thought it worked.

Ironically, the Z-pack is not a very good antibiotic against Strep, the one reason I would have taken an antibiotic. Resistance rates are high in my area, so unless a person has other antibiotic allergies (which I do not) I would not choose it for Strep throat.

But my body fought off an unnamed virus all by itself. That’s what our immune system does. Pretty cool, right?

No. Not cool.

Well, yes… it is cool that we can get better with the help of our immune system and no antibiotics. But not cool that a less knowledgeable person would have taken the prescription without question.

Unfortunately, I think many people trust the medical care provider, even when he or she is wrong.  Even smart people don’t know how to diagnose and treat illnesses unless they’re experienced in healthcare, so anyone could be fooled. Especially since we’re vulnerable when we’re sick. Even more so when our kids are sick. We want to do anything to help them.

False security in an unnecessary treatment.

Many parents come into my clinic wanting an antibiotic for their child because the child has the same symptoms as they have and they’ve been diagnosed with a sinus infection, bronchitis, or whatever. They’re on an antibiotic and are getting better, so they presume their child needs the same.

Most of the time they both likely have a viral illness, and the natural progression is to get better without antibiotics, but it’s hard to get buy in to that when a parent’s worried about a child. Even harder when the parent is certain that their antibiotic is fixing their viral illness.

Confirmation bias.

Confirmation bias is the tendency to process information by looking for, or interpreting, information that is consistent with one’s existing beliefs.

A false belief is reinforced when we think we get better due to an antibiotic. It doesn’t prove that the antibiotic worked, but our minds perceive it as such.

We want to believe something works, and when it appears to work, it affirms our false belief.

The wrong treatment plan.

In my example, not only did I not have a sinus infection, but if I did have a false negative Strep test and actually needed an antibiotic for Strep, the Z-pack wasn’t a good choice.

False negative tests mean that there is a disease, but the test failed to show it. False negative tests are the reason I usually do a back up throat culture if I really think it is Strep throat and not a virus.

If the wrong treatment is given, not only do you fail to treat the real cause, but you also take the risks associated with the treatment for no reason.

Doesn’t the doctor (or NP or PA) know the antibiotic won’t work?

Yes, they know (or should know) how antibiotics work and when they’re indicated. But unfortunately, there are other factors at work when quick fixes are chosen.

Top 3 reasons that lead to patients getting unnecessary prescriptions:

1. Time

One problem is that it’s much easier to give a prescription rather than taking time trying to teach why a prescription isn’t needed.

The faster they see a patient, the more patients they can see and the shorter the waiting time is, which makes people happy.

I see many unhappy parents who follow up with me because their child is still sick and the “last doctor” did nothing. I have previously blogged about the Evolution of Illness so will not go into it in depth here.

2. Experience

Sometimes it’s hard for physicians, NPs, and PAs to not try something to make a sick person better. After all, that’s why we do what we do, right? We want to help. We’ve all heard of patients who get progressively ill because an infection wasn’t treated quickly and we don’t want to “miss” something.

While missing a significant illness can happen, it’s not common. Common is common. Most upper respiratory tract infections are viral. It’s knowing how to recognize worrisome symptoms that comes from experience.

Physicians (MD, DO)

Physicians spend years of not only classroom training, but also clinical training to learn to recognize warning signs of illness. Even a brand new physician has at least 2 clinical years during the total 4 years of medical school. Then they spend at least 3 years of residency seeing patients in a supervised capacity before they can work independently. That’s at least 5 years of 60-80 hour work weeks.

The physicians in my office, including myself – now 18 years in practice – still ask for help if we feel it could be beneficial. Sometimes a second set of eyes or putting our heads together helps to put things into a clearer picture.

Trust that if we say it’s a virus, it’s a virus. We know that bodies can still be significantly sick if it’s Just A Virus, but most of the time you can manage symptoms at home. Listen to what we say are warning signs that indicate your child should be reassessed. Bring your child back if symptoms worsen or continue longer than typical. Symptoms can worsen, but taking an antibiotic does not prevent that progression in most cases.

Be sure to question if you do not understand or agree with an assessment or treatment plan, as I did in my example above. It is essential to have this type of communication for the best care.

Nurse Practitioners (NPs) and Physician Assistants (PAs)

I love the NPs in my office. They do a fantastic job and make patient access easier. They see a lot of sick kids and do a great job treating when needed and giving “just” advice when that is what is needed. (That’s usually harder, trust me.)

They are always able ask questions if they don’t know what to do or for a physician to see a patient if a parent wants a second opinion.

I do not want this to become an argument if NPs and PAs are good. They are needed in our healthcare system to help patients get seen in a timely fashion. I welcome and appreciate them as part of the healthcare team.

But I do want to acknowledge that the training and background can vary widely, and I think it’s important to know the experience of your provider. It is not as regulated to become an NP or PA as it is to become a physician.

Many NPs have years of work experience before returning to school to get their advanced degree. But newer online programs do not require much clinical experience. At all.

If they then begin working independently without much supervision, they learn as they go and may or may not learn well. I’m not saying they’re not smart, but I also know how lost I felt those first months as a new physician after many supervised hours, and I know they have a small fraction of those supervised hours. I can’t imagine doing that as a new grad!

This is why I think that all new practitioners should work with others who have more experience, so they can learn from the experience of others. I worry when inexperienced people work alone in clinics, with no one to bounce questions off of.

Learn more about the training of healthcare providers in What kind of doctor is your doctor?

Patient experience and the 6th sense as a parent

Experience as a parent (and patient) matters too.

We can’t see what your child experienced last night if we’re seeing them in the morning and symptoms changed. Many symptoms are worse overnight, which makes it difficult to assess during the day. Of course if symptoms are urgent at night, go to a 24 hour facility that can adequately evaluate the situation.

If you are able to wait until regular business hours, you must describe it so we can understand it.

If you feel uncomfortable with the treatment plan, talk to the provider. List your concerns and let them address them. That’s not the same thing as demanding a prescription or further testing. It means asking for more information about why they feel the current plan is the correct one.

3. Surveys

Many hospitals, clinics and insurance companies are surveying patients to see if “good care” was provided. These surveys are used to place providers on insurance contracts and decide payment and salaries.

People are happier and think care is better if something was done. A lab, x-ray, or prescription (whether needed or not) is “something” people can identify.

People do not feel that information about viral illnesses and what treatments can be done at home is as worthwhile as a tangible treatment, even if it’s the correct treatment. They see the prescription as making the cost and time taken for the office visit “worth it” even if it is bad care. Leaving empty handed (but with proper treatment) doesn’t satisfy.

And the surveys reflect that.

Sadly, the pressure felt by physicians and other medical providers to perform well on surveys has been shown to have many negative side effects. Healthcare costs rise from unnecessary tests and treatments. Side effects of unnecessary treatments occur. Hospitalization rates and death are even higher with high patient satisfaction scores.

Don’t look for a quick fix. Look for the right fix.

Antibiotics certainly have their place. They are very beneficial when used properly. For a fun read about being responsible with antibiotics, visit RESPECT ANTIBIOTICS: USE THEM JUDICIOUSLY TO ENSURE WE CAN STILL WAGE THE WAR AGAINST BACTERIA from Dr. Michelle Ramírez.

If we use antibiotics inappropriately, they cause more problems.



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Flu Season Fears: What should you do?

Headlines are making everyone nervous about this year’s flu season. Schools are closing due to high flu numbers. Parents are worried that their child will be the next that dies.

Yes, the risk is real.

But there are things to do.

First: Prevent

Vaccinate

Vaccines are the one of the best inventions to prolong our lives. They really can help. I know the flu vaccine (or any vaccine) isn’t 100% effective, but it does help. Everyone over 6 months of age should get a flu shot.

I’ve heard from many pediatricians taking care of kids hospitalized with influenza, and none of the dying kids were vaccinated.

Kids who were vaccinated this season might get flu symptoms, but generally not as severe.

It does take 2 weeks for the vaccine to be effective, so get it ASAP. Kids under 9 years old who haven’t been vaccinated for flu previously will need 2 doses a month apart. Call around to see where you can get it.

If your kids (or you) are scared of shots, check out these tips.

Not convinced? Check out these 10 Reasons to Get the Flu Vaccine.

Wash hands

Wash hands often. This goes without saying. Whatever you touch stays on your hands. When you bring your hands to your face, the germs get into your body. Teach kids to wash hands well too!

Cover!

cough, cold, urgent care, primary care, medical home
Cover your cough!

Teach kids to cover their cough (and sneeze) with their elbow. This collects most of the germs in the elbow. Hands touch other things, so if you cover with your hands, you need to wash them before touching anything.

The only time I don’t recommend the elbow trick is if you’re holding a baby. Their head is in your elbow, so you should use your hands to cover and wash often!

You can get masks at the pharmacy to cover your nose and mouth to protect yourself from catching something and to prevent spreading an illness you have. We have masks available for anyone who comes to our office. We ask those who are sick to wear them, but those who are well can also put them on to prevent catching something!

In my office you’ll see that most of our nurses and clinicians have opted to wear masks when seeing sick kids even though we all have had our flu vaccine!

Avoid the T-zone

Avoid touching your face. It’s a horrible habit that most of us have. Be conscious of how often you wipe your mouth, eyes, or nose. Those are the portals to our body. Avoid touching them unless you can wash your hands before and after. Show kids how the eyes, nose and mouth make a “T” and teach them to not touch their T-zone.

Stay home when sick.

I’ve heard many angry complaints from parents about exposures. One mother was sick because she was exposed at work and then her illness spread to her family. She was especially upset because the exposure was from a child of a co-worker who brought the child to work because the child was sick and couldn’t go to school.

Keep sick kids home. If you’re sick: stay home.

If you’re sick with a flu-like illnesss, don’t
  • run to the store.
  • send your child to school with ibuprofen.
  • go to work.
  • go to your child’s game.

Stay home unless you need to seek medical attention.

Tamiflu and other anti-virals

My office is getting inundated with phone calls requesting us to call out Tamiflu. In some instances it’s appropriate for us to prescribe it for prophylaxis, but often we want to see your child first. If your child has flu-like symptoms, I do not want to prescribe a treatment without first evaluating your child. I don’t want to miss a more serious case that needs to be hospitalized. I don’t want to treat bronchiolitis or another condition as flu and miss the proper treatment. More on treatment with Tamiflu below.

Prophylactic uses

Tamiflu can be used for prophylaxis after exposure, but don’t rely on it. (If you follow my blog, you know I’m not a Tamiflu fan.)

Newborns

Some of the calls we are getting are from mothers with influenza who have newborns and their OB’s have recommended prophylaxis for the baby. If the baby is under 3 months of age, Tamiflu is not approved for prophylaxis. (See the chart and corresponding footnotes from the CDC below.) If you are sick, try these tips to prevent spreading illness to your kids.

Community exposures

Many calls are from parents worried about a classroom (or other) exposure in a child who is not high risk. Unfortunately we cannot and should not use Tamiflu for routine exposures. Tamiflu itself is not without risk and if overused it will not be available for people who might really need it.

Big event coming soon!

A big birthday party, a big test, a planned vacation, etc do not make your child high risk. We really shouldn’t use Tamiflu inappropriately just because flu will make life inconvenient. Remember that all treatments have potential side effects and if we use them indiscriminately they will not be available when really needed.

Tamiflu prophylaxis is recommended for high risk people who have known exposure.

High risk includes:

  • children under 2 years of age
  • adults over 65 years of age
  • persons with chronic lung (including asthma), heart (except hypertension alone), kidney, liver, hematologic (including sickle cell disease), metabolic disorders (including diabetes mellitus) or neurologic and neurodevelopment conditions (including disorders of the brain, spinal cord, peripheral nerve, and muscle, such as cerebral palsy, epilepsy [seizure disorders], stroke, intellectual disability, moderate to severe developmental delay, muscular dystrophy, or spinal cord injury)
  • persons with immunosuppression, including that caused by medications or by HIV infection
  • women who are pregnant or postpartum (within 2 weeks after delivery)
  • under 19 years of age receiving long-term aspirin therapy
  • American Indians/Alaska Natives
  • persons who are morbidly obese
  • residents of nursing homes and other chronic care facilities

Prophylactic and treatment options are summarized in this table from the CDC:

Antiviral Medications Recommended for Treatment and Chemoprophylaxis of Influenza
Antiviral Medications Recommended for Treatment and Chemoprophylaxis of Influenza

Finding Tamiflu

Right now it’s hard to find Tamiflu in many parts of the country, so you might not be able to get it after you’re exposed (or even if you’re sick with flu).

What’s better than Tamiflu?

Flu season can last through April, so taking it for 10 days now won’t help in 2 weeks when you’re exposed again. The flu vaccine protects more effectively and for a longer duration!

If sick: Treat

Most flu symptoms can be treated at home.
Fever and pain reducers

Use age and weight appropriate pain and fever reducers, such as acetaminophen and ibuprofen to keep kids comfortable. It is not necessary to bring the temperature to normal – the goal is to keep them comfortable. Don’t fear the fever – it is the immune system hard at work!

Offer plenty of fluids

Infants should continue their breastmilk or formula as tolerated. Older kids can drink water and it’s okay for them to eat. There is no need to avoid foods if a child wants to eat – I don’t know where the “feed a fever starve a cold” or other common myths started. Of course, appetite is usually down during illness, so don’t push foods. Push fluids.

Saline and suction

Saline and suction can go a long way to help relieve nasal congestion. Noisy breathing isn’t necessarily bad, but if the breathing is labored that’s another story. Check out the Sounds of Coughing to learn how to identify various breathing problems.

Cough medicine?

Pediatricians don’t recommend cough medicines due to high risk of side effects. Kids over a year of age can use honey. Some kids can get relief from menthol products. I’ve previously written all about cough medicines if you want to read more.

Natural treatments?

A lot of parents want to do natural treatments. Learn which have been shown to work and which haven’t.

For more…

For more on treating symptoms, visit my office website’s tips.

when not to go to the doctor

Not every person with influenza needs to be seen by a medical provider. I know we’re all scared, but in most cases there isn’t much doctors and other healthcare professionals can do to help.

Medical offices, urgent care clinics and ERs are overwhelmed with mildly sick people, which makes it harder for those who are really sick to be seen.

If your child is low risk (anyone who doesn’t meet the high risk criteria above) and is drinking well, overall comfortable with support measures, and doesn’t have any breathing distress, you can manage at home. Certainly if the situation changes, bring him in, but coming in before any signs of distress will not “ward off” the development of those symptoms.

When you should bring your child to be evaluated

If you think your child might have another illness, such as Strep throat, ear infection or wheezing, bring him in for evaluation and treatment.

When any signs of distress are noticed in your child: bring him in.

If your child is high risk (as described above) and has sick symptoms, he should be seen to determine if Tamiflu is appropriate. I do not recommend getting Tamiflu called in if a child is symptomatic. A child should have an exam to be sure there aren’t complications before just starting Tamiflu. I’ve seen several kids whose parents thought they had flu, but their exam and labs showed otherwise. They could be properly treated for Strep throat, ear infections, or pneumonias instead of taking Tamiflu inappropriately after an evaluation.

How can you tell if it’s the flu or another upper respiratory tract infection?

I have seen many kids who are brought in with a runny nose just to see if it’s early flu. No. No it’s not. Flu hits like a tsunami: fever/chills, cough, body aches, and fatigue. But the child was playing in the waiting room full of kids who do have flu, so you might recognize flu symptoms soon.

cold vs flu
From the CDC: How to tell if it’s a cold or the flu?

If your low-risk child had the flu vaccine, they may still get influenza disease. But if it’s mild, they can be treated at home. If symptoms worsen, they should be seen. Yes, there is a benefit to starting Tamiflu early, but we shouldn’t use it for low risk people who aren’t significantly sick. Even if you come in early, Tamiflu probably won’t be recommended if your child doesn’t meet criteria. Tamiflu has some significant side effects and is in short supply. We shouldn’t overuse it.

Flu testing

We currently have the ability to do a rapid flu test in the office, but there is a national shortage of the test supplies, so we might choose to not test your child if they don’t meet high risk criteria. I know at least one local hospital is out of rapid test kits and we probably won’t be able to get more this season if we run out.

Don’t come to the office or go to an urgent care or emergency room just to be tested.

Please don’t be upset if we do not test your child, especially if your child is not high risk and we wouldn’t recommend Tamiflu if they are positive.

If your child has classic flu symptoms, the guidelines don’t rely on test results for treatment, so if your child meets criteria for treatment, we can prescribe without a positive test.

Knowing test results doesn’t really help guide treatment when we have such high numbers of flu in the community. It does help early in the season to recognize when flu is coming to town, but we know it’s here. Pretty much everywhere in the US, it’s here.

Let’s work on stopping the spread.

Be healthy!


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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 weeks

I 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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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.

How 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.

Get your flu vaccine. #fluvaccine #vaccineswork
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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.

Help! I’m sick and I have a baby at home.

When we have newborns we don’t want them exposed to germs. We avoid large crowds, especially during the sick season. We won’t let anyone who hasn’t washed their hands hold our precious baby. We might even wash our hands until they crack and bleed.

infection precautionsBut what happens when Mom or Dad gets sick? What about older siblings? How can we prevent Baby from getting sick if there are germs in the house?

In most circumstances it is not possible for the primary caretaker to be completely isolated from a baby, but there are things you can do to help prevent Baby from getting sick.

Wash

Wash hands frequently, especially after touching your face, blowing your nose, eating, using common items (phone, money, etc) and toileting.

Wash Baby’s hands after diaper changes too. Make this a habit even when you’re not sick… you never know when you’re shedding those first germs!

Wipe down surfaces

Viruses that cause the common cold, flu, and vomiting and diarrhea can live on surfaces longer than many expect.

Clean the surfaces of commonly touched things such as doorknobs; handles to drawers, cabinets, and the refrigerator; phones; and money frequently when there is illness in the area.

Avoid touching your face

Avoid touching your eyes, nose and mouth – these are the “doors” germs use to get in and out of your body.

Pay attention to how often you do this. Most people touch their face many times a day. This contributes to getting sick.

Kiss the top of the head

Resist kissing Baby on the face, hands, and feet.

I know they’re cute and you love to give kisses, but putting germs around their eyes, nose, and mouth allows the germs to get in. They put their hands and feet in their mouth, so those need to stay clean too.

Cover your cough

I often recommend that people cover coughs and sneezes with their elbow to avoid getting germs on their hands and reduce the risk of spreading those germs.

When you’re responsible for a baby, the baby’s head is often in your elbow, so I don’t recommend this trick for caretakers of babies. Cover the cough or sneeze with your hands and then wash them with soap and water or use a hand sanitizer if soap and water aren’t available.

Vaccinate

If you’re vaccinated against influenza, whooping cough, and other vaccine preventable diseases, you’re less likely to bring those germs home. Encourage everyone around your baby to be vaccinated.

If you get your recommended Tdap and seasonal flu vaccine while pregnant, Baby benefits from passive immunity.

See Passive Immunity 101: Will Breast Milk Protect My Baby From Getting Sick? by Jody Segrave-Daly, RN, MS, IBCLC to better understand passive immunity.

Breastfeed

Breastfeed or give expressed breast milk if possible.

Mothers frequently fear that breastfeeding while sick isn’t good for Baby. The opposite is true – it’s very helpful to pass on fighter cells against the germs!

Again see Jody Segrave-Daly’s blog for wonderful explanation of how breast milk protects our babies.

Limit contact as much as possible

If possible, keep Baby in a separate area away from sick family members.

Wash hands after leaving the area of sick people.

If the primary caretaker is sick and there is no one available to help, wear a mask and wash hands after touching anything that might be contaminated.

Smoke-free

Insist on a smoke-free home and car.

Even if someone is smoking (or vaping) in another room or at another time, Baby can be exposed to the airborne particles that irritate airways and increase mucus production.

These toxic particles remain in a room or car long after smoking has stopped. If you must smoke or vape, go outdoors.

Change your shirt (or remove a coat) and wash your hands before holding Baby.

Final thoughts to avoid exposing Baby

It’s never easy being sick, and being a parent adds to the level of difficulty because you not only have to care for yourself, but someone else depends on you too.

As with everything, you must take care of yourself before you can help others.

Drink plenty of water and get rest!

Most of the time medicines don’t help us get better, since there aren’t great medicines for the common cold. Talk to your doctor to see if you might need anything.

Don’t be falsely reassured that you aren’t contagious if you’re on an antibiotic for a cough or cold. If you have a virus (which causes most cough and colds) the antibiotic does nothing.

You need to be vigilant against sharing the germs!
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