Cold and Flu Season is Upon Us!

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

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

Illness doesn’t work that way.

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

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

Urgent cares are popular because they’re convenient.

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

Can it hurt?

Extra tests = Extra costs

Some kids will get unnecessary tests, x-rays, and treatments at urgent cares and emergency rooms that don’t have a reliable means of follow up. They attempt to decrease risk often by erring with over treating.

The primary care office does have the ability to follow up with you in the near future, so we don’t have to over treat.

No history

Urgent cares outside of your primary care office don’t have a child’s history available.

They might choose an inappropriate antibiotic due to allergy or recent use (making that antibiotic more likely less effective).

It’s easy to fail to recognize if your child doesn’t have certain immunizations or if they do have a chronic condition, therefore leaving your child open to illnesses not expected at their age.

We know that parents can and should tell all providers these things, but the new patient information sheets in my office are often erroneous when compared to the transferred records from the previous physician. Parents don’t think about the wheezing history or the surgery 5 years ago every visit.

It’s so important to have old records!

Records in one place

Receiving care at multiple locations makes it difficult for the medical home to keep track of how often your child is sick.

Is it time for further evaluation of immune issues?

When should you consider ear tubes or a tonsillectomy?

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

Not all locations are good with kids

Urgent cares and ERs are not always designed for kids.

I’m not talking about cute pictures or smaller exam tables.

I’m talking about the experience of the provider. If they are trained mostly to treat adults, they might be less comfortable with kids.

They might order extra labs or x-rays that a pediatric trained physician would not feel are necessary.

This increases cost as well as risk to your child.

Drug choice and dosing can be complicated for clinicians not familiar with pediatric care.

We have been fortunate in my area to have many urgent cares available after hours that are designed specifically for kids, which does help. But this is sometimes for convenience, not for the best medical care.

Cost

As previously mentioned, cost is a factor.

I hate to bring money into the equation when it comes to the health of your child, but it is important, especially with the increasing rates of high deductible health insurance – you will feel the burden of cost.

Healthcare spending is spiraling out of control.

Urgent cares and ERs usually charge more.

This cost is increasingly being passed on to consumers. Your copay is probably higher outside the medical home. The percentage of the visit you must pay is often higher. If you pay out of pocket until your deductible is met, this can be a substantial difference in cost. (Not to mention they tend to order more tests and treatments, each with additional costs.)

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

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

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

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

Telehealth

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

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

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

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

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

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

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

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

Issues better addressed with an Appointment in the Medical Home:

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

telehealth

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

Fever Is…

Fever is scary to parents.

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

Fever is uncomfortable.

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

Fever is often feared as something bad.

Parents often fear the worst with a fever:

Is it pneumonia? Leukemia? Ear infection?

Fever is good in most cases. 

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

Fever is often associated with decreased appetite.

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

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

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

Fever is inconvenient.

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

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

Fever is a normal response to illness in most cases.

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

Fever is most common at night.

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

Fever is a time that illnesses are considered most contagious.

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

Fever is an elevation of normal temperature.

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

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

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

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

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

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

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

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

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

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

But should we use it?

Cough drops

Menthol is a mild anesthetic that provides a cooling sensation when used as a cough drop. It is basically a local anesthetic which can temporarily numb the nerves in the throat that are irritated by the cold symptoms and provide some relief.

Interestingly, menthol is added to cigarettes in part to numb the throat so new smokers can tolerate the smoke irritation better. Hmmm…

Menthol cough drops must be used as a lozenge and not chewed or swallowed because the menthol must slowly be exposed to the throat for the numbing effect. They are not recommended for young children due to risk of choking.

Science lacks strong evidence, but the risk to most school aged children is low and it is safer than most other cough medicines. For these reasons, I use the “if it seems to help, use it” rule for children not at risk of choking.

Do not let any child go to sleep with one in his mouth. First, he might choke if he falls asleep with it in his mouth. Second, we all need to brush teeth before sleeping to avoid cavities!

Vaporized into the air

When it is put into a vaporized solution, menthol can decrease the feeling of need to cough.

Vaporized menthol should never be used for children under 2 years of age. They have smaller airways, and the menthol can cause increased mucus production, which plugs their narrow airways and may lead to respiratory distress.

Infants can safely use vaporizers (and humidifiers) that put water into the air without any added medications.

The rubs for the skin

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

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

Putting menthol rubs directly under the nose may actually increase mucus production according to a study published in Chest. In children under age 2, this could result in an increase in more plugging of their more narrow airways.

There might be a concern with putting any petrolatum based product in or near the nose. There is a more recent study that does show children ages 2-11 years with cough sleep better with a menthol rub on the chest.

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

Cautions

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

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

Camphor is another ingredient along with menthol in the rubs. It can be deadly if swallowed.

It has been known to cause seizures in children under 36 months when absorbed or ingested in high concentrations.

Menthol rubs in the US contain camphor in a concentration that’s felt to be safe if applied to intact skin in those over 2 years old.

Mucus membranes absorb medicines more readily than intact skin. Do not apply to nostrils, lips, or broken skin.

Do not allow children to handle these rubs. Apply only below their necks to intact skin.

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