RSV - P

Sorry, I've been on a bit of a hiatus from blogging. There were some crazy times around the extended Dr Jay family, and it's winter. Which makes pediatricians like me very busy. If this blog continues on for years and years, you will probably always see a slow down in the winter. Which brings me to my topic today, as it is the thing keeping me so busy right now: RSV.

Annoying call from emergency department or urgent care physicians (I know I disparage these poor folks, and most of them know better, but its the few that drive me crazy): I have a 2 year old kid here who has had several days of runny nose, cough, and fever. He looks great, but I tested him for RSV and it was positive, so we need to admit him.

Me: Doh! Where did you go to medical school?

There are many problems with what this ED/UC physician had to say, but its meant to illustrate that even many health professionals don't understand RSV all that well.

Lets have a little Q and A on the subject:

Q: What are the symptoms?

A: Most people who get RSV get a cold-like illness: runny nose, cough, fever, etc. This virus more than most other viruses produces TONS of snot. (I held back posting my snot pictures due to the reception they got last time). Some people, especially infants develop severe disease.

Q: What are the chances my baby will get RSV?

A: You should know that RSV is VERY common. Almost EVERY child will get it before they are two years old. VERY FEW of them are sick enough to need hospital admission.

Q: Which infants are a risk of getting severe disease?

A: The younger, the higher risk. Especially those who are premature (usually less than 35 weeks) or have significant congenital heart defects.

Q: How do you get it?

A: You mostly have to come in contact with the virus and then touch your eye/nose/etc. The virus can live on surfaces (doorknobs, shopping carts, etc) for many hours. There is some transmission by inhaling droplets, but you have to be within 3 feet of the sick one, and they basically have to cough in your face. Wash your hands!

Q: How long are you contagious?

A: The virus can be spread for a 3-4 weeks in nasal secretions after infection (but usually only for a week). Take home message #1 for this: if your child is in daycare they will get it. Take home message #2: Wash your hands!

Q: How can I prevent my kids from getting it?

A: Those high risk patients can get a very expensive vaccination once a month during RSV season, usually just premature babies and those with heart defects. If you think your baby may qualify, talk to your pediatrician. Wash your hands (and your kids')!

Q: I heard my child can only get this in the winter, is that true?

A: Kind of. It can happen at any time of the year, but for reasons not completely understood the VAST majority of cases happen within one month of the start of the outbreak. It seemed to hit here in California mid January, so we've got at least another week or so of the onslaught. If you child has had a cold the last few weeks or gets one the next few weeks, it is extremely likely that it is/was RSV.

Q: What do you feel is the most frustrating thing about RSV, Dr Jay?

A: Hmmm. This question doesn't sound spontaneous, a little forced. Almost as thought this conversation is scripted or something. RSV is one virus that DOES NOT confer lifelong immunity. So if you've had it once, congratulations, you can get it again. It is felt that we likely get RSV over and over again throughout life, but it isn't followed too much after childhood because it is usually mild disease from then on.

Q: My child was hospitalized for RSV, someone told me that it will give him asthma for the rest of his life, is that true doc?

A: Yes. I mean no. I mean I don't know. Babies that are hospitalized for RSV tend to develop asthma later in life. It really depends on if you are a fan of the chicken or the egg. I think I'm an egg fan, in that I think those kids who were going to get asthma anyway are likely the ones to get severe RSV, not that the RSV causes asthma. Or does that make me a chicken fan?

Q: What is the treatment?

A: You are going to love this: fluids, rest, etc - you know the old cold/flu/virus protocol. Infants only need hospitalization if they are having difficulty breathing, needing extra oxygen, or if they are so sick they are refusing to drink (and thus getting dehydrated).

Don't Look Back In Anger

Parent complaint: "Everytime I ask my three year old to do something he doesn't want to do he flips out. He seems to be full of rage. I'm worried he will turn out to be a serial killer or something. Please FIX HIM."

Diagnosis: Normal

While I can't promise that any given three year old won't turn out to be a serial killer, this behavior definitely doesn't guarantee it.

You may also be worried that they will turn out like this woman:



Again, I can't make any promises. I do have some advice, though. The answer is the same one you hear when you go to therapy for any relationship: communication. Your child still has limited vocabulary and it can be frustrating to want to say something, but not know how. Plus, ever since they were a baby, the way they got attention was by crying. Here's a few tips to help your toddler/preschooler with their 'rage' issues (actually most of these work at any age):

- Help them identify their feelings by pointing them out yourself. Example, "It looks like you are really disappointed that you can't have any more red hot Cheetos."
- It is important that you remain unemotional in your exchange. It shows your child that emotions don't have to heightened for every trivial matter. Plus, yelling at them only seems to fuel the fire at times. (My wife will readily admit that this is one area I have the hardest time with)
- Encourage them to 'use their words' instead of tantruming. Only give them what they want when they ask in a calm voice. Example, "It seems like you want these red hot Cheetos, but you can only have them if you uses your words in a calm voice." If you give them what they are 'raging' over without improving their behavior, you are just rewarding their rage, and it will be harder to overcome later.... which leads to my next point.
- Ignore. We've heard this one from when we were kids. "Why can't you just ignore your little brother, he's only doing it to get attention." Well you'll find its even harder as a parent to ignore it. There may be a component of attention-getting to their behavior. The less attention they get, the less reward they get. My parents always tell a story of a preschooler tantrum I threw at a movie theater once laying on the floor and kicking. They said they just left me there and walked away. I stopped my tantrum, jumped up and ran after them. Apparently that was my last tantrum.
- Work on your own feeling communication. Explain to your child why you are doing what you are doing. Don't say, "because I'm the daddy, that's why." Say, "I don't want you to have any more red hot Cheetos because you've already eaten a lot, and we are going to eat dinner soon."
- Positive reinforcement. When they respond in a 'grown up' way give them a reward. A sticker. A healthy treat. While they usually won't choose it over the other things, physical affection (a hug, etc) seems to work best of all. "I'm so proud of you that you were able to talk in a big boy voice instead of whining" (accompanied with a hug). Kids are suckers for that crap.

The good news is most people grow out of it (ignore the woman in the airport above). Through your excellent parenting skills you can help them get there sooner rather than later.

Fell free to add any comments of methods you have used to share...

Flu update

There have been many developments on the 'swine flu' front, so I thought I'd give my readers an update... I guess we are now calling it H1N1 to start off...


I'll be honest and admit that there was a much more significant outbreak this summer than I expected. It is still about equivalent to the regular flu for your average healthy individual. Here are some numbers you may be interested in: H1N1 deaths in the US = about 300. Number of deaths of regular flu per year in the US = 36,000.

We have learned a few things about this new strain of flu: It seems to be harder on pregnant women than previous strains of flu. There seem to be some concerns that it is easier to develop secondary infections (like pneumonia) from this strain than the average American strain. This risk seems to be increased in the teenage/20-something age group than 'regular' flu.

Things to do to protect yourself now, and during flu season
1) Get vaccinated (more on this later)
2) Be free with the hand sanitizer/hand washing especially before touching your eyes, nose or mouth (they both work!)
3) DO NOT wear a mask. There are very few masks (which are currently in low supply) that work for more than a few minutes against flu particles. In fact, wearing a mask in public may increase your risk of getting it, because it may make the flu particles get lodged between the mask and your face, increasing exposure time. You can wear a mask if you think you have swine flu to keep it from spreading to others, but do yourself and others a favor and just stay home (the CDC recommends staying home until your fever is gone for more than 24 hours).
4) Take antiviral medication. One of the antiviral medications appears to be more affective against this strain than others, but it is in short supply, so you may not be able to get it unless you are at high risk of developing severe disease. Ask your doctor if you are concerned.

5) Get plenty of rest, exercise and a healthy diet while you are well to keep your immune system up. Always good advice!

Should I vaccinate my family?
Unfortunately the regular flu shot isn't very affective against H1N1, and as of this year, the H1N1 strain is too new to be added to this year's flu shot. They are, however, feverishly working on developing an H1N1 flu shot. Which means this: you will have to get multiple shots to be protected from all strains of flu this year. It will likely be combined in the future, but not now.

Some people feel it isn't worthwhile to get vaccinated against something that probably won't kill you, since you are healthy. In fact, there's a good chance you won't even catch it. You may be right, unfortunately, your kids don't fit in that group. I highly recommend getting the flu shot (flu shot's' this year) if you are a kid or have kids. ESPECIALLY if you are pregnant or want to become pregnant. 6% of the swine flu deaths have been pregnant women. Here are the target groups the CDC gives for those who should be vaccinated this year:

- Pregnant women
- People who live with/provide care for infants besides being a pediatrician - and everyone knows pediatricians love to torture children with needles): kids are the vectors! Studies have shown that just vaccinating school age children signficantly decreases the load on ALL OTHER demographics. Kids spread germs. That's the reality. You decrease the germs amongst the kids, and everyone is better off.


For more info, see the CDC webpage on H1N1
http://www.cdc.gov/h1n1flu/

Senses working overtime

"Doctor, my 3 year old totally has ADHD. He cannot sit still. He has a hard time concentrating and staying on task. Can I get something to help with him? Please FIX HIM!"

Diagnosis: normal 3 year old.

ADD/ADHD (I'll just refer to it as ADHD from here on out because I'm lazy) seemed to be all the rage in the 90's. Seems to now to have taken a back seat to 'Autistic Spectrum Disorders'. It is still relevant, and while it doesn't get the press/publicity of autism, it is definitely more common.

First question: Does it really exist, or is it just a reflection of a generation of bad parents?
First answer: Yes, it does exist.

There are many kids that seem to very obviously have this diagnosis. The medication to treat is consists of a group of stimulants. If you give someone a stimulant and it CALMS THEM DOWN, I'd say that's pretty good evidence that they have some 'crossed wires' so to speak. It is a highly genetic situation, so kids with it are likely to have parents that suffered similarly as a child (and some continue to as adults).

Second question: Does my child with ADHD need medication?
Second answer: Maybe.

Parenting plays a large roll in ADHD. No, a bad parent cannot make a child get ADHD. There is something that genetically predisposes these children to behave they way they do, but poor parenting can really bring it out. Parent training has found to be so beneficial that many kids not longer need medication after their parents learn the right way to 'parent' them. Most of this training focuses on teaching the child organizational skills including making daily schedules/routines, simple and CONSISTENT house rules, close supervision, and a reward system that focuses on effort, not necessarily results. Sleep schedule is extremely important, as lack of sleep really exacerbates the symptoms. In fact, sometimes obstructive sleep apnea is misdiagnosed as ADHD. So if you have a hyper child that snores, get that checked out. After all that, though, there will still be a quite a few children that will need medication to function well.

Third question: Isn't it just easier to give them a pill to pop than to learn how to be a better parent?
Third answer: Yes.

Studies clearly show that even with medication, proper parenting techniques are invaluable. Do your kid a favor and get the training you need in order to give them the best chance to succeed. I will admit, though, I have had some parents that are so disorganized and ADHD themselves (its genetic, remember) that I don't even bring up parent training, because I don't believe in exercises in futility.

Fourth question: If I eliminate sugar from his diet, will he be normal?
Fourth answer: Probably not.

There are may people out there trying to sell their diet plans to help with ADHD. There is very little scientific basis for this. Most of the time, it is the case of a person who wants to prey upon someone else who is desperate for help (which describes pretty much any parent of an ADHD child). That doesn't mean they don't help at all. There may be a diet component, but I think these dietary needs can vary wildly between children. I don't see any problem trying different diet routines, as long as it doesn't but an undue financial (or other) stress upon your family. NONE of the diets work for every child. The parenting techniques described above help to some extent for EVERY child. Start with those, then consider diet therapy, but keep your expectations low and your wallet tightly closed.

Blister in the Sun

Alright, its summertime, and time to worship the sun god.

A very popular question we hear in the clinic is, "How much SPF do I need?" There's nothing America likes more than hysteria and overdoing it... Let me give you some data to chew on... the SPF of a 100% cotton shirt has been sited to have an SPF of somewhere in the range of 4-15. (Yes, don't you love the exact answers science likes to give us.) So if I'm being really honest with you, if you don't get a sunburn with a t-shirt on, you probably don't need anything more than SPF 15. But, doctor's aren't above the hysteria apparently, because I still recommend about SPF 30 for most kids. Anything over that really is overkill, so don't waste your money. Of course if the SPF 100 is on sale and cheaper, feel free, but I haven't heard of any real added benefit over SPF 30.

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The next question of course is: Can I put sunscreen on my infant less than 12 months of age?

My answer to this question is avoidant and simple: The best sunscreen for a baby is SHADE. Please, people, does your baby really need to lay out in the sun? If your family is enjoying a day out in the sun keep your baby covered! Especially if they are less than 6 months. A sunburn can be very severe in this age group, so don't mess around. Plus, they'll probably end up sucking the sunscreen off of their hands anyway, which are probably the most exposed part of the baby's body. Keep your kids in the shade until they are old enough to move around and play in the sun on their own, then hit them with the SPF 30. If you don't think you can keep your baby in the shade there are a million baby sunscreens you can try, and they are probably fine, but just be really safe and stick with the shade.

Let's Go To Bed

Just a quick post on a subject that bothers me because the danger of its practice still doesn't get universal acceptance in the pediatric community: co-sleeping. This is probably because a major pediatric celebrity (Dr Sears) still hold fast to the notion that it is alright, even beneficial. I will have to beg to differ on this subject. I spent a month in autopsy while in medical school. We would get about a baby a week, and most of the ones I had seen were victims of cosleeping. All of them were at least victims of being put to sleep in an adult bed.

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Just to be clear: co-sleeping is having your baby sleep in bed with you. Most other doctors (besides Dr Sears) believe that adult beds are death traps for babies with or without an adult in them. Even when Dr Sears went on Dr Phil, Dr Phil had to 'respectfully disagree' with him on the subject. And Dr Phil usually slurps his celebrity guests, so to make a stand, I was impressed. If you read Dr Sears website, he will make some convincing arguments and even state some evidence. But trust me, the evidence to avoid adult beds for babies far outweighs any studies he quotes.

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Since I've been at my current job, I've gone to 3 'codes' in which a baby arrived dead to the ER. Also, all three of these were in adult beds, some with other sleepers.

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Without the risk of death, I have to admit I have other concerns of the baby interfering with the parents' relationship. Sometimes bedtime is the only time parents get a chance to converse and touch base. Throw a baby in the middle, and you get no alone time for the two.

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Bottom line for me: leave the baby in the crib.

911 is a joke

It's my favorite thing... I'm on call overnight at the hospital and my pleasant slumber is interrupted by the ugly sound of my pager. I call down to the ER. They want me to consult on a patient who has been having a problem for two weeks. For some reason at 3 o'clock this morning was the time they had just HAD ENOUGH. Instead of waiting until the clinic opened the next morning, they needed answers NOW! So since the ER provider isn't used to dealing with such issues (they are EMERGENCY doctors), they get a 4AM personal pediatrics consult from me. Sure quick answers are great, until the bill comes in the mail.

If you have kids, you've been there... Its the middle of the night and something's not quite right with your little one. Is it an emergency? Should you wait until the morning? How about a compromise and just go to urgent care? I know, you try to get an appointment for your doctor and they don't have any openings for WEEKS. You can't wait that long.

There is a fairly new buzzword in the medical community called 'access'. Which just basically asks if your patients have access to your care in a reasonable amount of time. Most pediatrics clinics, as a result have put a high priority on getting same-day access to your physician. So hopefully the days of waiting days and weeks to get in to your child's doctor are over. In the busy winter months you may have to wait a day or so, but most clinics that are up to speed should be able accomodate.

I'll be honest. Most ER's and Urgent Cares don't have a guy like me (a pediatric guru/pediatrician)available to them, and when it comes to non-emergent cases, provide very poor care. Sure you may get your answer more quickly, but its likely to be the wrong one and you are going to pay more in copays,etc for it. Don't get me wrong, there are some excellent clinicians that work some of these late night places, but you, as a patient, aren't going to have any idea (see my first post ever). And, the numbers of good docs to bad docs in many of these places is pathetically low. To their credit, they are usually good in emergent situation, which is what they are trained for.

So I thought I'd give you a list of symptoms/situations your child may have and a breakdown of the severity in case one of these sneaks up on you in the middle of the night (this list is not exhaustive, but I tried to think of the most common - it may be a big mistake on my part to try it - remember disclaimer to the right):

Call 911:
Stops breathing/turns blue and stays blue
Seizure that doesn't stop
Passed out and not waking up
Difficulty breathing after contact with something they are allergic to
Concern that your child may have swine flu - PLEASE NOTE ITALICS HERE

ER:
Fever and stiff neck/baby's fontanelle(soft spot) is bulging
Persistant difficulty breathing (with asthma or otherwise) - this can be breathing fast that doesn't slow down, persistant skin sucking around the ribs, and/or difficulty getting out a few words
New or first seizure that stops on its own
Not very responsive, difficulty waking up.
Fever >105 (I might lower this to 104 for older kids >7-8 year old range)
A baby less than one month old with any fever (>100.4)
Your child is not acting like themself after having vomiting/diarrhea and being unable to take fluids
Fever and refusal to walk/excessive bone/joint pain
Lip/facial swelling after contact with something they are allergic to
Pain that is so intense it cannot wait for an appointment (wherever it is located)

Urgent care or ER:
Suspect a broken bone or may need stitches (actually these locations are probably better than your general pediatrician with these issues)
Head injury with loss of consciousness, but doing okay now
Persistant asthma that has difficulty breathing that comes back less than 3-4 hours after albuterol treatment.

**general note: Urgent Care facilities are good for injury-type complaints, but will otherwise usually give poor medical care for kids

Wait until the next day and see your pediatrician:
Almost anything else that is abnormal, but your child is eating, breathing, and acting normally otherwise
High fever, unless it gets above 105 or there are other symptoms you are concerned about
Anything that has been going or for days and didn't get suddenly much worse
Swollen lymph nodes
Persistant asthma but able to breath comfortably for several hours after breathing treatments
Baby is fussy and won't stop fussing (unless they really seem to be in great distress)
Your child is still acting like themself, but has been unable to keep and fluids down for >24 hours due to vomiting
Runny nose, cough, etc.

***If you have any additions/suggestions/questions feel free to comment, and I will try to update the list.

I am a big fan of mother's/woman's intuition, so if you REALLY think something is emergently wrong take your child to the ER, even if they don't fit a category above.

Hey man, nice shot

This will be my longest post, but it has to be. If I leave something out, I will be asked about it later. Before I get started on my opinions this is the bottom line: The parent is the boss and it is always their call on whether or not to administer vaccines. They (and their children) are the ones who have to live with their decision.

I am absolutely positive that I will offend someone with this post. Great. Sometimes the wicked taketh the truth to be hard. Sorry, I just have to call 'em as I see 'em and this blog is about the truth (or at least how I view the truth - which is obviously the right way). Remember I am trained in the art of pediatric medicine and work for a company where preventative medicine is a keystone, and vaccines are an important part of preventative medicine, so add your grain of salt as needed. And remember we are talking about vaccinations not your mom or your religion, so CALM DOWN.

Let me let you into the mind of a pediatrician and what is going on behind that cheesy grin...

You, the parent, say: "I've been doing some research..." That's all you have to say, your pediatrician knows what's coming next.

What the pediatrician hears: "My pride and/or insecurities and/or belief in misinformation is more important than my child's health." (whether this is fair or not, this is what they are thinking)

Then a discussion on vaccinations ensues. Usually it is either about how you want to avoid autism or how your read a book or website about how an 'alternative' vaccine schedule is more appropriate. Then your pediatrician says: "Well you are the parent, and you need to manage your child's health care according to your own conscience."

What your pediatrician is thinking: "You are an insane parent who has been manipulated or decieved by some outside influence and for some reason this information/influence is much more valuable than years and years and years of vaccine experience and vaccination of billions of children, and arguing with you is worthless since I have a waiting room full of patients and trying to convince you of your insanity would take more than the 15 minutes I have been allotted for you." I'm just being honest. That is really what they are thinking. All of them. Are they right? That is for you to decide.

Why do some parents want to avoid immunizations?

REASON 1: Scared of autism.
One study published about 10 years ago said there was a link between autism and the MMR. Since then study after study has shown this to be untrue. Some even show a protective benefit from autism by those who received vaccines. A HUGE study of the highest clinical power (a double blind placebo controlled trial) in Europe has shown no connection. Now the news has come out that the person who conducted the original study (that showed the connection) falsified information and is under investigation for misconduct (link). With all the evidence we have today, if you are not vaccinating your child for fear of autism you are putting your child at risk because you trust information that has been repeatedly found to be false and is now found to be one man's imagination from the start and no basis in reality.

REASON 2: Peer pressure

Unfortunately this is the most popular excuse these days, although there are few who are willing to admit it. **warning rascist comment follows**: I have never, ever, never had a mother decline vaccination who was not white. I've also never had a father (of any race) decline. These tend also to be part of the middle class. In my own experience, I've noticed as the family gets poorer and richer they are more open to vaccines. I have had a few mothers admit to me they had friends tell them, "I can't believe you are going to vaccinate your kids!" Then they go on to indoctrinate their friend with one of the other reasons listed. Just say no! I mean yes!

REASON 3: An 'alternative' schedule is better.
There are 101 theories on better ways to vaccinate your kids. Most of them are based upon the theory that an infant's immune system isn't ready to develop the maximal response at the age they are given. I may surprise you by my response to this one: this may be true. The one MAJOR problem with this thinking: several of the vaccinations protect infants (less than a year) from death. If you wait to vaccinate, the risk of death or severe illness has greatly declined. You are still preventing your child from an annoying illness, and the long term protection may be better, but I'd rather have slightly weaker protection from death than slightly stronger protection from an annoyance. Who needs vaccine protection more than an infant with an immature immune system? There are still MANY infants dying and getting serious illness each year due to illness that could have been prevented by vaccine (and the numbers are increasing due to decreasing immunization rates).

If you are choosing this reason for avoiding vaccines you are turning your child into one of these:

Calm down, Richard Gere, its a guinea pig, not a gerbal. The physicians/people who put forth these alternative schedules base their ideas on largely untested THEORIES. They all sound pretty good. They need to. They are trying to recruit unsuspecting parents (mothers, really - see above) to try their theories out for them without having to set up an actual study.

If the theorist is wrong, and their schedule increases infant death, they say, "Oh well, dang, I guess my theory was wrong." I'd imagine the mother of the child who died as a result of this schedule might be a little more disappointed. I'm not judging. I enrolled my son in a pharmaceutical study when he was less than 6 months old. Made some good money when we really needed it. But you are volunteering your guinea pig for free.

Another alternative is the 'spread the wealth' theory of only doing one or two vaccines at a time. This is another one that has no basis in scientific realilty. In my own personal opinion, I find this schedule as tantamount to child abuse. Instead of getting all the shots over in a span of about 60 seconds, a parents decides to spread the pain out over many months, mutiplying the number of traumatic days by up to 3-4 times for absolutely no medical benefit. You are a meanie and maybe a commie.

REASON 4: Various conspiracy theories, including pharmaceutical companies benefitting from this schedule

Dr Gregory House said it best when he was talking to a parent with the same concern. He basically said you can choose which company you want to support: the pharmaceutical company or the 'teeny tiny coffin' company.

Conspiracy theories are always a little off, and if you believe in one, you probably are a little off, too. Sorry to offend you, but if you do believe in the conspiracy, this post isn't going to change your mind anyway (because I'm obviously a part of it).

Take home messages: Is the current vaccine schedule perfect? Not likely.
Does someone have an alternative schedule that will work better? Maybe.
Did you pick the right person's thoery that will revolutionize vaccines? Not likely.

As for me and my house, we will participate in the most tried and true schedule available that protects babies when they really need it (when they are babies) - the one currently recommended by the American Academy of Pediatrics and the Centers for Disease Control. It will likely be changed many times over the years. This is good and healthy sign that we are striving for the best schedule availabe. I would be worried if it wasn't true.

Addendum: Are vaccines completely safe?
No. Usually just pain at the site of injection and fussiness and occasional fever are the only bad effects. Rarely there have been reports of seizure afterwards. Whether it is connected with fever (and thus the very benign febrile seizures of childhood) or purely from the vaccine, that remains to be seen. If you have had a child who had a seizure after a vaccine, it can be scary. The truth of the matter is, however, that seizures are typically benign despite how scary they look and are not life threatening. You still made the right decision, because you may have saved your childs life by protecting them through vaccination, even though they had a seizure.

More severe reactions? Vaccines have been blamed for all kinds of illnesses all the way to sudden unexplained death. Anyone with kids will tell you, they get shots every few months for the first couple of years. If something serious happens, there's always a recent round of shots that can be conveniently blamed for it. Did the vaccine cause it? Probably not. In the unfortunate event that a child suffers a severe illness, every parent asks the question "Why?" repeatedly. Sometimes its nice to have something to blame it on. Unfortunatley vaccines frequently take the scapegoat role.

I will try to fix you

Annoying complaint #2: Doctor, you have to help me. My son got a runny nose and cough three days ago, and he STILL HAS IT! What do I do?!?!? Please FIX HIM.

What the doctor hears: "I'm not leaving here until I have a prescription for antibiotics in my hot little hand." I have to admit, this type of response on the doctors part is annoying, too. Almost as annoying as the complainer. Education is much better than a reluctant antibiotic prescription.



News Flash: There is still no cure for the common cold. And no, antibiotics still don't work.

What can I give my child to make them better? Sorry. Turns out, lots of fluid and lots of rest work the best. I know THAT'S SOOOO BORING. Most studies of cold formulations show that these medications do absolutely nothing for children under the age of 6. Most studies also show they do nothing for children over 6, either, even 35 year old children. I know there is a place for sudafed in adult care, and I personally am a HUGE fan of Nyquil when I am sick. But most groups who have a statement on is (American Academy of Pediatrics, American College of Chest Physicians) say you should avoid cold medications in children under 6 (ACCP goes as far as to set the age at 14). I know what you are thinking.. these medications work great for me, why not my kids? The answer: Kids are different. Imagine that.

Okay, there's more to do than just fluids and rest, but those are the only 'cure' we have. Here's some other things that can help:



Mom: A ton of good old fashioned TLC helps anyone feel a little better when they are sick. I try to convince my wife this is what I need when I am sick, but she says she will never be my mom. Apparently, I already have on of those.

Saline water: Nose drops for the babies. Full-fledged lavages for older kids. It's uncomforable, but it works like a charm. Even better than sudafed. Your at home recipe for a nice salt water lavage: 1 tsp of salt and 1 tsp baking soda to 2 cups water. Some recommend pickling/canning salt over table salt and distilled water to tap, but if you aren't going to do it because you don't have those things, just do it with table salt and tap water. They sell bottles to (gently) shoot the stuff up your nose at the store, or you can just use a bulb syringe.

Cool mist: Cool mist humidifier in the room tends to improve symptoms and help with more restful sleep.

Honey: Yes, honey.

No, not THAT honey, this honey:

There's actually good evidence to show that honey helps coughs much more than cough syrup (which should be no surprise, since cough syrup does nothing). There are some good studies to back it up, also. 1/2 tsp for age 2-6yo, 1 tsp 6-11yo, 2 tsp 12yo and over. DO NOT give this to babies Unless the baby is a terrorist and/or poses immediate danger to the safety of all Americans (in other words: unless you want to kill them).

Cough drops: My favorite when I am sick. Only for older than 4 years due to choking danger.

Medicines: Yes, there are some medicines I recommend to my patients. Of course you can use tylenol/motrin for fevers. Also I'm a big fan of using Benadryl/diphenhydramine at night before bed, and maybe again in the day if your child is still taking naps. Remember, I said rest was very important to recovery, and while benadryl may produce very marginal results with the symptoms, they have the perfect side effect for this situation: sleepiness. I am pretty free with it (but do not endorse benadryl use to put annoying kids to sleep).

What should I expect?

Cold and the flu can last a long time. Usually the first few days are the worst and include runny nose, cough, sore throat, and fever. After that, its totally unpredictable. The fever typically subsides, but the runny nose and cough can go on for weeks! I am personally sporting a mild cough that's been with me for 4 weeks.

What about this green snot?

No it, in and of itself, does not mean there is an infection present. It is the natural course of a viral illness to produce thicker/darker mucous as the body fights the illness. Many times is it a sign that you are almost over your illness. But if the dark thick stuff persists for a long time or is accompanied with a new fever (remember your original one went away), I would see a doc to evaluate for infection. Actually, I think any new fever after the initial one has been gone for 2 or more days should probably be evaluated as it could signify an early pneumonia/sinusitis/ear infection.

I've been waiting FOREVER

Why do I have to wait soooo long when I get to the doctors office? The reasons are numerous. Many times you have a slow doctor that frequently gets behind. Many times (as is the usual problem with my personal clinics) the patients earlier in the day were late, thus putting the clinic behind for the rest of the day. I can't tell you how many times I've been twiddling my thumbs early, only to be totally slammed later. But probably the thing that backs up the clinic the most are lame complaints. (Is it still PC to use the word 'lame' or is is offensive to the weak and/or paralyzed members of the community?) Yes those complaints that really should have just stayed at home and saved the copay. Let me first say that I came from a family where you had to be dying to go to a doctor, and in fact I was once at home with a broken collar bone for a week before my parents took me to the doctor. I'll outline some of these complaints and we can all save some time together, starting today with:

My all time most annoying complaint:
Dr. Jay, my son woke up with a temp of 100.3 today, and I just wanted to bring him and make sure everything is okay. No he doesn't have any other symptoms. Can you please tell me what to expect?

Point 1 - The definition of a fever is 100.4 or higher. Some physicians are very strict about this and won't even listen to you unless it is measured rectally, as that is the most accurate way to measure. I for one, am not that picky (my wife will laugh because I used to be), and have never measured my childs temperature rectally, so wouldn't expect that to happen with my patients, either. The studies to compare rectal vs axillary (armpit) vs oral vs forehead/temple have all been done with pretty poor scientific reliability. So I don't usually subscribe to the add one degree here or 0.5 degrees there philosophy. Truthfully, the exact height of the temperature in kids doesn't really make that much difference until you get to the 106-107 range (unless you are dealing with a newborn - less than two months - in which case you want to let your pediatrician know about any fever over 100.3). Please don't use the kind of thermometer pictured below. It won't give you the desired results.

Point 2 - Lets assume the fever is for real (and not just due to overbundling a baby or running a mile); it just started. It is very difficult to determine where a fever is coming from on the first day, as it will most commonly just precede a cold. Just wait a day or two to see what happens. If cold symptoms develop, there you go... a cold. Some kids get a fever for a couple of days and nothing else and then a rash all over after the fever is gone. This is called roseola, and you definitely need to see the doctor for this right? Nope. The rash is the extent of the illness, and your baby doesn't notice it and it doesn't last long. I usually spend a significant amount of time preparing for the many things that could come up to save the next days annoying complaint: "Dr. Jay, my son has a runny nose, so now what do I do." We'll talk about annoying cold complaints in another post. I'll do it soon, as it is cold season and all.

Point 3 - Many times a parent says, "I just want to make sure the ears are okay," at this point. Ear infections typically come AFTER a cold or late in a cold, so this early of a check is usually completely worthless.

Point 4 - Coming in early in the course of a fever may result in more invasive evaluation that may not have been needed. If you bring a child that is less than 6 months with a fever and no other symptoms, many doctors will feel the need to find the source. This will include blood tests and urine tests. And since most 4 month olds aren't good at peeing in a cup it will buy him/her a catheterization of their bladder, which most people find uncomfortable. Two hours later they get a runny nose, and we say, "Now we know where the fever came from, too bad we did all those mean things to the baby." I personally won't usually chase a fever in a baby (unless less than 2 months old) on the first day unless it is high (>103) or the baby looks sick, but many doctors will. I won't ever chase it in a bigger child unless it is >105 or there is something else going on (but then I guess that takes away the fever with no other symptoms distinction).

This visit usually ends with me saying, "Your child looks perfectly fine. I can't tell you what's causing the fever, or if it is even a fever. I can't predict what's going to happen the next few days, but your child will likely be getting sick." This kind of answer is unsatisfying for the patient and the doctor, so please wait at least a couple of days before coming in (unless a newborn, but you already picked up on that). The only time I feel a fever, in and of itself, NEEDS to be seen is after 5 days with all other things being normal and the patient is >12 months old.

Bonus point: Q: At what temperature is it best to give tylenol/motrin? A: At the right temperature (or any other smart alec remark you want to insert). Stop getting hung up on numbers (this was actually hard for me personally to do). Give the medicine to your child, not to the temperature. If your kid's temp is 99.1 and they look miserable, give them the medicine. If your kid's temp is 102.5 and they are happy and running around like normal, don't give it to them. A fever is a good thing when you are sick and helps your body get better. There is no reason to bring it down unless your child is miserable.

Bonus bonus point: Tylenol/acetaminophen vs motrin/ibuprofen. Motrin works better for both pain and fevers, in my opinion, but comes with more side effects. These include stomach upset and, in rare cases, stomach bleeding. So if you give it to your child, give it with some food. I personally give my kids tylenol first and if it isn't cutting it, add the motrin. So, yes, you can give both. The most frequent you can give tylenol is every 4 hours, and motrin every 6 hours. Giving them both does not affect these frequencies. In other words, they don't interact, so you can still give tylenol every 4 hours counting from the last dose of tylenol, not the last dose of motrin. Some parents find it beneficial to alternate every 3 hours, so there is always new medicine coming in and each medicine is spaced from itself by 6 hours. I don't personally do this because, as above, I treat my child not the fever, and people who do this tend to be more obsessed with the actual the fever itself, rather than how their child looks/feels.