One abnormal lab we see in otherwise healthy kids is a low absolute neutrophil count (ANC). This is also called neutropenia. Know when you should worry.
It is recommended to screen for anemia (low red blood cell or hemoglobin levels) around one year of age. Our office orders a complete blood count (CBC), which checks for red blood cells, white blood cells, and platelets – the main components of our blood. Sometimes we find things that we weren’t looking for. In the winter months, neutropenia is one of those things.
What is neutropenia?
One relatively frequent abnormal lab we see is a low absolute neutrophil count (ANC). A low ANC is also called neutropenia.
What are neutrophils?
Neutrophils are a type of white blood cell that fights bacterial infections. When their numbers get too low, it can increase the risk of serious bacterial infections.
While some people have low ANCs that cause significant immune deficiencies and can lead to infection, the most commonly seen low ANC we see are brief dips after a viral infection.
What causes neutropenia?
Most causes of neutropenia are due to infection, drugs, severe malnutrition or immune disorders.
The most common cause of neutropenia we see in otherwise healthy kids is due to a recent infection. In most cases this type of neutropenia quickly resolves without any treatment.
Some viruses, such as hepatitis B, Epstein-Barr, and HIV, are associated with prolonged neutropenias.
The drugs that can cause neutropenia are not commonly used medications. Routine testing for neutropenia would be done when those medications are used because the risk is known. That’s one reason why people with cancer treatments often have regular blood counts checked.
Vitamin B12, folate, and copper deficiencies are very uncommon in children, but can lead to abnormal blood counts.
Three levels of neutropenia:
The large majority of kids with neutropenia have only mild drops in their ANC and are not at significant risk of illness. In general the more severe the drop, the more significant the infection risk.
Mild neutropenia: The ANC ranges between 1000-1500/μL
Moderate neutropenia: The ANC ranges between 500-1000/μL
Severe neutropenia: The ANC is less than 500/μL
What do you do if there’s neutropenia?
Since most mild cases of neutropenia self-resolve, it is not usually anything for parents to worry about.
I used to recheck all of these, but found that many kids needed several rechecks because they always had a mild viral infection so the levels stayed suppressed (low). Despite the low ANC, they never got significantly sick.
Of course if there is another clinical reason, such as a significant illness or growth problems, following up even a mild lab abnormality is recommended. If kids start getting sick, their blood counts should be rechecked because of the clinical concern.
When kids are otherwise healthy, I find that we end up chasing abnormal levels if we try to recheck, so I’ve stopped rechecking automatically.
When a child is overall healthy and growing well, the level is only mildly low (above 1000) I do not recheck the level unless there is a clinical concern. If your doctor wants to recheck it (or if you want it rechecked), that is appropriate to do.
When the level is in the mid-range (500-1000) or if the child has had problems with recurrent infections or growth, a confirmation (repeat test) and possible further evaluation is more likely to be recommended.
If the level is in the severe range (less than 500), it should be rechecked and the child should be closely monitored due to high risk of severe bacterial infections.
Some physicians recommend repeating a blood count with any fever for a year in kids who have had any degree of neutropenia, so you’ll have to talk to your child’s doctor for a plan.
What symptoms might happen if the ANC is low?
Most children with a temporarily and mildly low ANC will have no symptoms and need no treatment.
Children with chronically low ANCs may have more infections that require antibiotics, such as pneumonia, skin infections (abscesses, cellulitis) and lymph node infections. They might also have chronic gum disease, mouth sores, or vaginal or rectal ulcers.
Common colds often contribute to the temporary dip in the ANC, but are not caused by the low ANC. A different type of white blood cell fights off viral infections, so the low neutrophil count is specific to bacterial infection risk.
Common symptoms seen with neutropenia:
Frequent significant infections (not just the chronic runny nose of a daycare kid)
Serious respiratory infections, including pneumonia or sinus infections
Skin infections (e.g. cellulitis, abscesses)
Multiple serious infections (e.g. meningitis, bone infections)
Lymph node infections
Vaginal, urethral, or rectal ulcers
When should you worry?
The level of ANC as well as the cause both determine the risk level.
Lower levels of neutrophils increase the risk of an overwhelming infection. An example would be when people are immune suppressed from chemotherapy they are at very high risk of bacterial infections.
On the other hand, an otherwise healthy person with a mildly low ANC is not more likely to get a bacterial infection than another person with a normal ANC.
If the child has any of the symptoms noted above or a very low ANC level, we start to worry more. Each case must be evaluated by the person who ordered the test and who has recently seen your child.
What treatment is done for a low ANC?
Most children do not need any specific treatment. They are monitored for recurrent infections, especially infections that require antibiotics. They are also monitored for growth, since if a body is chronically sick, it often doesn’t grow well.
Each infection that requires antibiotics is treated and blood counts might be checked to see how low they are at the time.
In children who have a chronically low ANC or a significant illness with a low ANC, a hematologist (blood specialist) is often consulted. They help evaluate why the ANC is low and if it requires a special treatment that stimulates the bone marrow to make more neutrophils.
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?
Both 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:
body aches and pains
sensitivity to light
mental status changes
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.
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.)
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 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.
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.
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.
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.
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!
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.
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.
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.)
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.
I 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.
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 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:
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.
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.
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.
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.
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.
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!
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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?
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.
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.
Those of you who follow my blog or are my patients know that I’ve never been a fan of Tamiflu. I’ve written To Tamiflu or Not To Tamiflu and I’ve posted Tamiflu from guest blogger, Dr. Mark Helm. Despite the CDC’s recommendation to use Tamiflu frequently, I rarely prescribe it. And when I do, I often find that the whole course isn’t completed because the kids don’t tolerate it well – usually vomiting, but occasionally they’ve had scary hallucinations. I haven’t seen very much benefit, especially given the cost (and often the difficulty of finding it during peak flu season).
As I’ve said before, Tamiflu doesn’t seem to work as well as needed and it has significant side effects. Not all studies done on Tamiflu were published. Only studies showing a little benefit and minimal side effects were considered in making the recommendations to use it. If many studies show no benefit but aren’t published, it makes it seem better than it is. Most studies are done in adults, but studies in children for prevention of flu and treatment of flu also fail to show much benefit.
A 2013 review of all the studies done in adults found only a 20.7 hour reduction in symptoms (yes, less than one day). In the elderly and those with chronic diseases (among the highest risk adults) no reduction was found. They also found no evidence of decreasing the risks of pneumonia, hospital admission, or complications requiring an antibiotic. This same review also showed more side effects than commonly reported. Nausea, vomiting, and psychiatric side effects are common.
Will the CDC join in?
I hope that the CDC reviews its recommendations for antiviral use before the influenza season hits this year. Until then, plan on getting your family protected with the flu vaccine. It isn’t perfect, but it does help keep us from getting sick and it can help save lives!