Let me start by saying smoking is bad. You shouldn't do it. Period. I wouldn't be doing my due diligence as a physician if I didn't say that out front. Now that we've established that, let's talk about e-cigarettes.
Why does this matter for pediatrics? Simple. Second-hand smoke is a serious problem with kids, to the point where it can severely damage their overall health, especially if they have diseases like asthma. So, at every single well-check, we ask about smoke exposure. Most people I've dealt with seem to have gotten smart and are at least limiting smoking to outside and not in the car. This is a huge reason why there has been such an effort at eliminating smoking in the workplace.
Enter e-cigarettes. They were developed in the early 2000's as an alternative to smoking. Essentially, there's a liquid cartridge with nicotine and other staff that is heated by a coil and inhaled by the smoker.
Lots of concern about e-cigarettes has hit the news recently. So much that one blog post probably won't do it justice, but at least I can attempt to hit the high points. So, let's play a game of myth or fact?
1. E-cigarettes reduce smoking.
Myth.
One study done in September demonstrates a very small percentage of people were more likely to quit using e-cigarettes vs nicotine patches. The effect was very small, with only 1.5% more e-cigarette users quitting after 6 months. What's more, the confidence intervals (CI) crosses 0, which means the difference wasn't really a difference.
Another study in JAMA Internal Medicine shows a similar result: no difference in quitting between users of e-cigarettes and users of conventional cigarettes.
However, a study done in JAMA Pediatrics that hit the press earlier this month shows that e-cigarette use has doubled in teens in the past few years, and about half of current e-cigarette users also smoked conventional cigarettes. In fact, those who smoked conventional cigarettes were more likely to have tried e-cigarettes in the past. This goes against the claim that e-cigarettes are good for quitting smoking.
The increased usage might have something to do with the fact that while ads for cigarettes have been banned for 40 years, there is no ban in place for e-cigarettes, so an ad for such a device actually ran during the Super Bowl this year. It doesn't help that only about half states have bans against minors buying e-cigarettes, and there is relatively little attention to buying them online.
2. Second hand exposure from e-cigarettes is better than regular cigarettes.
True.
A review looking at several studies examined this question from the perspective of occupational health. That is, if an industrial worker was exposed to the same chemicals in the vapor of an e-cigarette, would this worker be at a higher risk of disease. They did negate the nicotine, since it is legal and the smoker is already voluntarily consuming more than the recommended exposure limit by using the device. It was the secondary exposures that they specifically wanted to look at.
The primary chemicals exposed to with e-cigarettes are propylene glycol and glycerin, which do not have known exposure thresholds, and volatile organic compounds. Polycyclic Aromatic Hydrocarbons are most of the cancer-causing chemicals in cigarettes; these were not found in most vapors.
I don't think anyone doubts that e-cigarettes produce fewer chemicals than regular cigarettes, thus reducing second-hand exposure. What seems to be the big debate right now, and the subject of e-cigarette bans in places like Los Angeles, is whether there is ANY risk for e-cigarette exposure, and the public health implications of encouraging e-cigarette smoking in public.
3. E-cigarettes are safer.
Generally true, as alluded to above, with a few exceptions.
Nicotine in cigarette form is relatively difficult to ingest. Smoking is the best way to do this. However, as I mentioned earlier, the nicotine for e-cigarettes is in liquid form. That makes it much easier to either drink or absorb through the skin, which could cause serious harm, especially to children. The number of calls to poison control centers related to the nicotine liquid went up 300% in 2013.
Why is it so dangerous? Well, nicotine is similar to a chemical naturally used by the body at the point where either two nerves meet or a nerve meets a muscle. That means it can cause any amount of damage to the brain, the spinal cord, and to muscles. Commonly, it affects the GI tract first, and the person gets vomiting, but if it is not caught early, it can result in seizures or other problems with the brain. In a small child, it doesn't take a lot of nicotine to have this effect.
Bottom line is that while e-cigarettes are safer than conventional cigarettes, we don't know the long-term effects of e-cigarettes because they are so new, and they do have unique safety concerns. It took a good 20-30 years before we saw lung cancer deaths spike from the cigarette usage in the 1960s, and it's very possible we'll see a similar rise 20-30 years down the line from e-cigarettes. But maybe not. As I'm pretty sure e-cigarettes are cheaper and generally less toxic, I'd encourage people who are smoking to switch to them, but that doesn't mean I'd encourage their blanket marketing.
Until then, I'll hold to my general recommendations: Don't smoke around kids. Don't smoke indoors or in the car. And when you do smoke, wear a jacket that can be removed when you are done, so you don't bring those chemicals inside with you.
Sunday, March 30, 2014
Sunday, March 23, 2014
Eating Right: The Moving Target of Good Nutrition
Between the various 'diets' (which should more accurately be called 'weight loss technique') and trends going around, it can be hard to get a good idea of what you should be eating. There are those who say meat is horrible (for one reason or another), others who say you should eat the way of the cave-man. There's the low-fat, the low-protein, and the low-carb fabs. But, really, what should you eat?
In elementary school, I was taught the food pyramid. You know, the one where sugar and salt were at the top, and meant to be used sparingly, and grains made up the heavy base at the bottom. In fact, in 1990, the US government recommended 2 servings of fruit, 3 servings of vegetables, and 6 servings of grain daily, along with a diet low in fats, and especially saturated fats.
Recently, the food pyramid has changed. The new pyramid, referred to as My Pyramid, changed the recommendations some. It placed a heavier emphasis on whole grains (at least 3 servings per day), oils for fats, and fewer meat and more of other sources of protein. It also placed heavier emphasis on physical activity with the stairs on the side of the pyramid.
Even more recently, the pyramid has been done away with completely, in favor of the My Plate method. Personally, this is my favorite way of showing portion sizes during meals, because it can be easily demonstrated with hands. You place your hands together. Your left palm represents the amount of meat or protein you should eat. For smaller kids, it's a smaller amount, and for adults, it's a larger amount. Your right palm represents the amount of grains, such as rice, bread, etc, you should have with each meal. Your fingers, then, represent the vegetables you should eat. You can spread your fingers to get more vegetables, but cannot expand your palms to get more protein or grains. Since most kids don't get enough vegetables on a day-to-day basis, this is a great way of encouraging them to eat more if they are still hungry.
For general child health, we make a few other recommendations. For instance, the dietary guidelines put out by the government only apply to those over age 2. Under that, we recommend whole milk because the children need the extra fat for brain development. Things like soda and koolaid are not recommended, because they provide no vitamins, minerals, or any other nutrients besides sugar. Even fruit juice, which provides some of the benefits of fruits and vegetables, aren't recommended in lieu of the actual vegetables, because you get the fiber and feel fuller when you actually eat the vegetables.
Milk is both good and bad. Kids all need calcium in order to develop strong bones, especially in adolescence. However, too much calcium can also work against you, and decrease the ability of the blood to carry oxygen, resulting in a very tired and potentially sickly kid. So, we recommend a total of 2-3 cups (or 16-24 oz) per day of milk or other dairy products. Another issue we see a lot is that kids who drink a lot of milk will get full, so won't eat as much solid foods, and it is still important once they are past 6 months to a year for them to get other nutrients. And please, no milk at bedtime--it does have sugar that can rot the teeth.
Fiber is also super important. Why? Because all kids are constipated. I've seen so many kids come in with abdominal pain, we get an x-ray, and see their intestines just filled to the brim with stool. I've seen one kid who was so constipated, that he had to get surgery to fix the problem. Fiber comes in all fruits and vegetables, but also whole grains. And when in doubt, Miralax is an amazing medicine.
So, a summary of our recommendations:
- A generally balanced diet, with sufficient protein, fat, and carbohydrates for growth. If they're gaining weight, they're getting enough calories.
- Lots of vegetables, and some fruits. In whole form.
- Limit juices, even fruit juices
- Lots of fiber
- Milk, but in limited amounts and not at bedtime
In elementary school, I was taught the food pyramid. You know, the one where sugar and salt were at the top, and meant to be used sparingly, and grains made up the heavy base at the bottom. In fact, in 1990, the US government recommended 2 servings of fruit, 3 servings of vegetables, and 6 servings of grain daily, along with a diet low in fats, and especially saturated fats.
Recently, the food pyramid has changed. The new pyramid, referred to as My Pyramid, changed the recommendations some. It placed a heavier emphasis on whole grains (at least 3 servings per day), oils for fats, and fewer meat and more of other sources of protein. It also placed heavier emphasis on physical activity with the stairs on the side of the pyramid.
Even more recently, the pyramid has been done away with completely, in favor of the My Plate method. Personally, this is my favorite way of showing portion sizes during meals, because it can be easily demonstrated with hands. You place your hands together. Your left palm represents the amount of meat or protein you should eat. For smaller kids, it's a smaller amount, and for adults, it's a larger amount. Your right palm represents the amount of grains, such as rice, bread, etc, you should have with each meal. Your fingers, then, represent the vegetables you should eat. You can spread your fingers to get more vegetables, but cannot expand your palms to get more protein or grains. Since most kids don't get enough vegetables on a day-to-day basis, this is a great way of encouraging them to eat more if they are still hungry.
For general child health, we make a few other recommendations. For instance, the dietary guidelines put out by the government only apply to those over age 2. Under that, we recommend whole milk because the children need the extra fat for brain development. Things like soda and koolaid are not recommended, because they provide no vitamins, minerals, or any other nutrients besides sugar. Even fruit juice, which provides some of the benefits of fruits and vegetables, aren't recommended in lieu of the actual vegetables, because you get the fiber and feel fuller when you actually eat the vegetables.
Milk is both good and bad. Kids all need calcium in order to develop strong bones, especially in adolescence. However, too much calcium can also work against you, and decrease the ability of the blood to carry oxygen, resulting in a very tired and potentially sickly kid. So, we recommend a total of 2-3 cups (or 16-24 oz) per day of milk or other dairy products. Another issue we see a lot is that kids who drink a lot of milk will get full, so won't eat as much solid foods, and it is still important once they are past 6 months to a year for them to get other nutrients. And please, no milk at bedtime--it does have sugar that can rot the teeth.
Fiber is also super important. Why? Because all kids are constipated. I've seen so many kids come in with abdominal pain, we get an x-ray, and see their intestines just filled to the brim with stool. I've seen one kid who was so constipated, that he had to get surgery to fix the problem. Fiber comes in all fruits and vegetables, but also whole grains. And when in doubt, Miralax is an amazing medicine.
So, a summary of our recommendations:
- A generally balanced diet, with sufficient protein, fat, and carbohydrates for growth. If they're gaining weight, they're getting enough calories.
- Lots of vegetables, and some fruits. In whole form.
- Limit juices, even fruit juices
- Lots of fiber
- Milk, but in limited amounts and not at bedtime
Sunday, March 16, 2014
Growing Big: The Issue of Childhood Obesity
Yes, it's time we talk about that sticky topic: obesity. It's a concern across all of American society, but we as pediatricians are specifically looking to curb childhood obesity, as it increases your chance of being obese as an adult and has its own health risks. Obese children are more likely to have early heart disease than those who are not obese. They are at risk of having bone and joint problems (due both to being obese and due to lack of exercise), and are much more likely to develop type 2 diabetes, a disease that used to be considered an adult-only disease. Obesity can also affect school performance, not only because of the psychological impacts of being obese (teasing, bullying, etc), but also because it can result in sleep apnea, a condition where you stop breathing periodically throughout the night, which can impact the ability to concentrate in school.
Clearly, there are many effects of obesity on health, which is why we care so much about it. But how bad of a problem is obesity, really?
First, let's start by defining obesity.
In adults, it's pretty straight-forward. We take a ratio of your height and your weight, a number referred to as your BMI, and compare it to what we've established as normals. Essentially, under 20 is considered 'underweight', between 20 and 25 is a healthy weight, between 25 and 30 is overweight, and greater than 30 is obese (with greater than 35 being considered morbidly obese). This tool is used because it allows a better comparison between a thin, short woman, to a heavy-set, tall man. However, it's not perfect. Muscle weighs more than fat, so someone could have a favorable body fat percentage, but have an elevated BMI. Still, it is one of the easiest measures we have of body fat, so it is the one used most frequently.
In children, though, the normals are understandably different. A baby is going to have a higher amount of body fat than a teenager should, because they use it for warmth. Also, when kids go through puberty, a lot of things about their body changes, often including their BMI. Kids also often grow taller faster than they grow fatter, so often have BMIs in what we would consider underweight in adults.
So, we use growth charts to help us out. If you've ever seen a pediatrician, you've probably seen these at least once. We have a chart for length (height in standing kids), one for weight, and one for length-vs-weight or BMI, depending on the age (BMI is used for children older than 2). There are growth charts available for children with different disorders, such as Turner's syndrome, Down Syndrome, PKU, etc, that allows us to track a child's growth compared to other children his age.
Thus, when we say a child is obese, we are using a slightly different set of criteria. We use these growth charts and define obesity as anything over the 95th percentile, meaning children who have a higher BMI than 95% of their peers are considered obese. Overweight is defined as a BMI between the 85th and 95th percentiles.
Back to how bad of a problem this really is. In 2011, approximately 8.1% of kids aged 0 to 2 are obese; the rate is higher among girls (11.4% vs 5%). We are, thankfully, seeing a decrease in obesity rates in children under age 2 compared to 2003, but that doesn't mean we are out of the woods yet. Approximately 31.8% of kids aged 2 to 19 were either overweight or obese. That means that 1 in 3 kids is bigger than they should be.
This is better than the adult numbers, where upwards of 60% of adults are overweight or obese, but realistically, I see it as only a matter of time before kids enter that trend, which is why it's so important to establish good habits early in life.
Clearly, there are many effects of obesity on health, which is why we care so much about it. But how bad of a problem is obesity, really?
First, let's start by defining obesity.
In adults, it's pretty straight-forward. We take a ratio of your height and your weight, a number referred to as your BMI, and compare it to what we've established as normals. Essentially, under 20 is considered 'underweight', between 20 and 25 is a healthy weight, between 25 and 30 is overweight, and greater than 30 is obese (with greater than 35 being considered morbidly obese). This tool is used because it allows a better comparison between a thin, short woman, to a heavy-set, tall man. However, it's not perfect. Muscle weighs more than fat, so someone could have a favorable body fat percentage, but have an elevated BMI. Still, it is one of the easiest measures we have of body fat, so it is the one used most frequently.
In children, though, the normals are understandably different. A baby is going to have a higher amount of body fat than a teenager should, because they use it for warmth. Also, when kids go through puberty, a lot of things about their body changes, often including their BMI. Kids also often grow taller faster than they grow fatter, so often have BMIs in what we would consider underweight in adults.
So, we use growth charts to help us out. If you've ever seen a pediatrician, you've probably seen these at least once. We have a chart for length (height in standing kids), one for weight, and one for length-vs-weight or BMI, depending on the age (BMI is used for children older than 2). There are growth charts available for children with different disorders, such as Turner's syndrome, Down Syndrome, PKU, etc, that allows us to track a child's growth compared to other children his age.
Thus, when we say a child is obese, we are using a slightly different set of criteria. We use these growth charts and define obesity as anything over the 95th percentile, meaning children who have a higher BMI than 95% of their peers are considered obese. Overweight is defined as a BMI between the 85th and 95th percentiles.
Back to how bad of a problem this really is. In 2011, approximately 8.1% of kids aged 0 to 2 are obese; the rate is higher among girls (11.4% vs 5%). We are, thankfully, seeing a decrease in obesity rates in children under age 2 compared to 2003, but that doesn't mean we are out of the woods yet. Approximately 31.8% of kids aged 2 to 19 were either overweight or obese. That means that 1 in 3 kids is bigger than they should be.
This is better than the adult numbers, where upwards of 60% of adults are overweight or obese, but realistically, I see it as only a matter of time before kids enter that trend, which is why it's so important to establish good habits early in life.
Sunday, March 9, 2014
Popping Pills: The Age of Antibiotics
Last week, we discussed how to take care of a sick child. Susie came in with a fever, cough, and runny nose, and we talked about the importance of treating the fever and keeping her hydrated. But gosh darnit, you want her illness to go away, for her to be able to go back to school or daycare, and so on. So, you demand a medication to make things go away. An antibiotic. Your pediatrician refuses, saying that it's not indicated.
Look, I understand why you want your child to feel better. You hate seeing them sick. I get it. Really, I do.
But antibiotic use with diseases like the one above is such an issue that the American Academy of Pediatrics has made it #1 on their list of 5 things pediatricians and parents need to discuss.
Let's take a step back a moment. As a kid, you certainly learned about germs. The germ theory of disease, that is, that germs cause disease, has been around since the mid-1800s. It is the reason that when you go into surgery now, any member of the staff touching your open wound is 'sterile', and the reason we wash our hands when going into and coming out of patient rooms. The reason you probably tell your children to wash their hands before dinner, and Lysol every surface in the house if you have a bad illness spread through.
There are four major types of 'germs': bacteria, viruses, parasites, and fungi. Bacteria causes diseases like strep throat (which is caused by a streptococcal bacteria), some pneumonias (infections of the lung), and some other, rarer infections of the brain, sinuses, and intestines. Parasites include malaria and pin worms. Fungi cause diseases like athlete's foot, yeast infections, and ringworm. Viruses can cause any number of different diseases, so many that we don't always know about them. The common cold is caused by a group of viruses called rhinoviruses. Herpes, chicken pox, the flu, cervical cancer, and any number of other respiratory or stomach bugs are also caused by viruses.
Statistically, you are more likely to come in with a disease caused by a virus than one caused by any of the other groups of germs. Antibiotics are not effective against viruses. We do have some medicines that are effective against some viruses; for instance, cold sores caused by the herpes virus can be treated with acyclovir to shorten the course of disease and the flu can be treated early on with Tamiflu (though it really doesn't help). But amoxicillin won't make your cold go away.
As with fevers, showing up to your doctor within the first few days of an upper respiratory infection (a cold) doesn't tell us a whole lot. It could be bacterial, but it is much more likely to be a virus. And if antibiotics aren't going to help you, then the risk of them doing harm outweighs the benefit. Any antibiotic, but particularly the penicillins, can cause life-threatening allergic reactions, or more mild side effects such as diarrhea and vomiting. Why chance it if you don't need it?
So when should you get antibiotics? The American Academy of Family Practitioners recommends antibiotic use for upper respiratory infections only if the symptoms have lasted 10 days. Viruses generally go away after 5-7 days (though the cough may last up to 2-3 weeks), but if you continue to have fevers, runny nose, etc after that period, or if you start to feel better and suddenly get worse, you're much more likely to have a bacterial infection. Note that the color of the snot or mucus has no bearing on whether or not it is bacterial or viral. Unless it's clear, then it's more likely to be allergic in nature, rather than infectious.
What about other things?
Ear infections should generally be treated, but the physician should see a bulging, red, and pus-filled ear-drum. An ear drum that just has fluid behind it is not a sign of a middle ear infection, and antibiotics should not be given in those cases. You can see some examples of what ear drums look like here.
Bronchitis (chest colds) should probably be evaluated by a physician, but generally follows the same concept as upper respiratory infections: no antibiotics until 10 days into the course, or if you get better and take a turn for the worse. There is one important exception: if a child has coughing spells so severe that he/she vomits at the end, or has a "whoop" trying to breathe during the spell, he or she should be seen, as these are indications of Pertussis, which can be life-threatening in very young children. There is an antibiotic treatment for it, but often once the coughing starts, the antibiotic is no longer effective.
There is some current debate over whether or not strep throat needs to be treated. Antibiotics do not shorten the course of strep throat. The reason we give them is to prevent the development of rheumatic fever, which can lead to permanent heart damage. It's a rare complication of strep throat, and studies have shown that treatment with antibiotics essentially eliminates the risk of rheumatic fever, but there has been some concern that the risk of complication from using antibiotics exceeds the risk of getting rheumatic fever in developed nations (David Newman, who is an awesome speaker, talks about this a bit in his book Hippocrates' Shadow). But, antibiotics should only be given in patients who have a positive strep test, or who have a high suspicion for strep throat, which is not the case in most instances of a sore throat.
Bottom line, those physicians who argue with you about the need for antibiotics are trying to help you. They are not trying to make your life more difficult. Instead, they are trying to eliminate the risk of a complication from taking an unnecessary medication. If they're doing their job right, they should provide you some information about how to treat your symptoms and get you back to your normal self, even without antibiotics.
If they aren't explaining to you why, ask. It's your right as a patient to know what your physician is thinking when deciding on treatment. And if you don't agree, talk about it. Don't get mad and run off to another physician who will just give you what you want--those aren't the type of physicians you want around when things get hairy because they truly don't have your best interests at heart.
Look, I understand why you want your child to feel better. You hate seeing them sick. I get it. Really, I do.
But antibiotic use with diseases like the one above is such an issue that the American Academy of Pediatrics has made it #1 on their list of 5 things pediatricians and parents need to discuss.
Let's take a step back a moment. As a kid, you certainly learned about germs. The germ theory of disease, that is, that germs cause disease, has been around since the mid-1800s. It is the reason that when you go into surgery now, any member of the staff touching your open wound is 'sterile', and the reason we wash our hands when going into and coming out of patient rooms. The reason you probably tell your children to wash their hands before dinner, and Lysol every surface in the house if you have a bad illness spread through.
There are four major types of 'germs': bacteria, viruses, parasites, and fungi. Bacteria causes diseases like strep throat (which is caused by a streptococcal bacteria), some pneumonias (infections of the lung), and some other, rarer infections of the brain, sinuses, and intestines. Parasites include malaria and pin worms. Fungi cause diseases like athlete's foot, yeast infections, and ringworm. Viruses can cause any number of different diseases, so many that we don't always know about them. The common cold is caused by a group of viruses called rhinoviruses. Herpes, chicken pox, the flu, cervical cancer, and any number of other respiratory or stomach bugs are also caused by viruses.
Statistically, you are more likely to come in with a disease caused by a virus than one caused by any of the other groups of germs. Antibiotics are not effective against viruses. We do have some medicines that are effective against some viruses; for instance, cold sores caused by the herpes virus can be treated with acyclovir to shorten the course of disease and the flu can be treated early on with Tamiflu (though it really doesn't help). But amoxicillin won't make your cold go away.
As with fevers, showing up to your doctor within the first few days of an upper respiratory infection (a cold) doesn't tell us a whole lot. It could be bacterial, but it is much more likely to be a virus. And if antibiotics aren't going to help you, then the risk of them doing harm outweighs the benefit. Any antibiotic, but particularly the penicillins, can cause life-threatening allergic reactions, or more mild side effects such as diarrhea and vomiting. Why chance it if you don't need it?
So when should you get antibiotics? The American Academy of Family Practitioners recommends antibiotic use for upper respiratory infections only if the symptoms have lasted 10 days. Viruses generally go away after 5-7 days (though the cough may last up to 2-3 weeks), but if you continue to have fevers, runny nose, etc after that period, or if you start to feel better and suddenly get worse, you're much more likely to have a bacterial infection. Note that the color of the snot or mucus has no bearing on whether or not it is bacterial or viral. Unless it's clear, then it's more likely to be allergic in nature, rather than infectious.
What about other things?
Ear infections should generally be treated, but the physician should see a bulging, red, and pus-filled ear-drum. An ear drum that just has fluid behind it is not a sign of a middle ear infection, and antibiotics should not be given in those cases. You can see some examples of what ear drums look like here.
Bronchitis (chest colds) should probably be evaluated by a physician, but generally follows the same concept as upper respiratory infections: no antibiotics until 10 days into the course, or if you get better and take a turn for the worse. There is one important exception: if a child has coughing spells so severe that he/she vomits at the end, or has a "whoop" trying to breathe during the spell, he or she should be seen, as these are indications of Pertussis, which can be life-threatening in very young children. There is an antibiotic treatment for it, but often once the coughing starts, the antibiotic is no longer effective.
There is some current debate over whether or not strep throat needs to be treated. Antibiotics do not shorten the course of strep throat. The reason we give them is to prevent the development of rheumatic fever, which can lead to permanent heart damage. It's a rare complication of strep throat, and studies have shown that treatment with antibiotics essentially eliminates the risk of rheumatic fever, but there has been some concern that the risk of complication from using antibiotics exceeds the risk of getting rheumatic fever in developed nations (David Newman, who is an awesome speaker, talks about this a bit in his book Hippocrates' Shadow). But, antibiotics should only be given in patients who have a positive strep test, or who have a high suspicion for strep throat, which is not the case in most instances of a sore throat.
Bottom line, those physicians who argue with you about the need for antibiotics are trying to help you. They are not trying to make your life more difficult. Instead, they are trying to eliminate the risk of a complication from taking an unnecessary medication. If they're doing their job right, they should provide you some information about how to treat your symptoms and get you back to your normal self, even without antibiotics.
If they aren't explaining to you why, ask. It's your right as a patient to know what your physician is thinking when deciding on treatment. And if you don't agree, talk about it. Don't get mad and run off to another physician who will just give you what you want--those aren't the type of physicians you want around when things get hairy because they truly don't have your best interests at heart.
Sunday, March 2, 2014
Sick Day: How to Manage Sick Kids
The scenario: Dad brings in little Susie to see the doctor because Susie has a fever, a cough, and a runny nose. She hasn't been acting herself today, not really interacting with people and not wanting to eat. Maybe Mom has a bit of a runny nose too, but she feels fine. Maybe little Susie goes to daycare or school and there are a half dozen other kids sick. She's been sick before, but it's never been quite this bad.
The three things I always want to know in this scenario are: 1) how high was the fever and how was it measured 2) have you given her any medicine for her fever (and if so, how much), and 3) is she still drinking and peeing?
A lot of parents will come in telling me their child just feels hot. And while that is an important measure of fevers, it doesn't really tell us much about the fever itself. And in many cases, there wasn't a fever at all. There really isn't such a thing as a 'low-grade fever'. A fever is defined as a core body temperature of 38.0C - 38.3C (100.4F - 101F), depending on who you ask. Emphasis on the 'core body temperature' part. That means, in really little kids (less than a year or so), you should take their temperature in their rectum (up their bottoms). In older kids, oral is a reasonable way to take a temperature (under the tongue), but can be flawed if they just ate or drank something cold. The thermometers that measure in the ears or across the forehead aren't really good measures of core body temperature.
In general, kids act weird when they have fevers. Sometimes, they'll just be listless and not want to play. Sometimes, it seems more serious, because they start shaking or seeing things that aren't there. One of my mentors has said repeatedly that he doesn't pay attention to anything strange a kid does when he/she has a fever, because fevers do weird things to the mind. And I'm not sure the last time you had a fever, but they aren't comfortable.
Giving medicines, such as Tylenol (acetaminophen) or Advil/Motrin (ibuprofen), in appropriate doses, can reduce fevers. I've seen Tylenol be given to a kid who was barely interacting with me in the Emergency Department (ED), and 15 minutes later, they're up and running around the room. Both acetaminophen and ibuprofen should be given in weight-based dosing, and ibuprofen should not be given to kids under 6 months of age. So you should check with your doctor to see how much medicine your kid should be getting. If they aren't getting enough, their fever might not come down and they still may look sick. Despite their best intentions, alternating between acetaminophen and ibuprofen every 4 hours doesn't really seem to help more than just sticking with one medication, and is more prone to errors that could lead to overdose. So, find one you like and stick with it.
At this point, I'd like to point out that fevers themselves do not harm kids. Even if your kid's fever is 104F*, if it comes down to normal with medicine, I'm less likely to be worried about it. Let me repeat that: fevers themselves do not cause harm. However, fevers are signs that something isn't quite right. Usually, in kids, it's a virus that they haven't been exposed to before, and their immune system is doing what it's supposed to and fighting it off. Every so often, though, it's something more insidious. It's that something else that results in fever that actually does the damage, not the fever itself. In fact, some would even suggest to allow a child to be febrile for a period of time to give them a chance of fight off their infection. I do agree that this is safe, so long as the child is comfortable. But if your child isn't comfortable, treat their fever. It'll make things easier for both of you.
When should you be concerned?
1) If you give the medication, and the fever does not come down. Call your pediatrician or go to an Urgent Care or Emergency Department.
2) If the child does not act normal after the medication is given and the fever has come down. As I said, most kids will bounce right back to their normal selves, but kids with bad infections will still look sick.
3) If the fever lasts more than 3-5 days, or if the child starts to get better and suddenly gets worse again. Both are signs of either another infection that is more worrisome, or a variety of disorders that are marked by prolonged fevers.
If you bring your child in to be seen on day 1 of the fever, there isn't going to be a whole lot your doctor can tell you. The illness hasn't had a chance to 'present itself,' and we can't really differentiate between the number of different diseases that cause fever.
And that brings me to the second thing I ask parents. If we've gotten past the fever part, and the child isn't staying hydrated, then we, as physicians, get a little more worried. See, kids become dehydrated much more quickly than adults. A really bad stomach bug that causes vomiting and diarrhea could dehydrate a kid and leave them looking really sickly. Fever itself can also cause dehydration, not only because kids don't feel like eating and drinking during that time, but it also increases how much they sweat, something we refer to as 'insensible losses'.
When kids are sick, they don't feel like eating. That is fine. Our bodies are used to using energy stores during times of infection. But, not drinking, or not having things like popsicles or other high-water 'foods' can quickly lead to dehydration. In little kids, particularly those in diapers, one of the easiest ways to determine whether they are taking enough in is to check how much they're putting out. If an infant goes from wetting a diaper every 2 hours (12 in a day) to wetting one every 12 hours, there's a problem, and they're not taking in enough liquids (or they have a problem with their kidneys, but that's another discussion).
Taking fluids by mouth is the best way to take them. It's non-traumatic, and the best way to prevent complications from a medical intervention. Kids who are throwing up everything they try to drink, or kids who are having difficulty breathing, are the hardest ones to get to drink. We generally recommend small volumes of fluids in those cases, 1-2 oz every half hour or so. Don't give the baby a full 8 oz bottle of milk if she's been vomiting all morning. Even things like popsicles, if given often enough, can keep kids hydrated. So, we do an oral challenge to see if they are willing and able to take the fluids by mouth.
If they aren't able, we consider admitting to the hospital for IV hydration. It's not preferred, because there's always the risk of injury or infection with placing things like IVs (a low risk, but still a risk), but the risk of dehydration is much greater than those risks, so we do it when it's necessary.
Now, if your child has a chronic disease, most especially something like Cystic Fibrosis or Diabetes, you should follow the instructions of the doctor regarding sick day rules.
Otherwise, managing their fever and making sure they stay hydrated are the two things you can do to get your child feeling well once again. And if you aren't sure, call your pediatrician. Most will have overnight people on call specifically to answer these questions for you and determine if your child needs to be seen right away. There's nothing wrong with getting in to see the doctor, but we can be much more helpful if you've tried a few simple things on your own first.
Next week, we'll talk more about the role of antibiotics in treating children.
*Note: Elevated body temperatures can cause damage, but they must be greater than 40-41C (104-105.8F) for a prolonged period of time for this to happen. This generally does not happen with infections, but more often in things like heat stroke or medication overdose resulting in hyperthermia. Note that at these times, it is not referred to as a 'fever', but 'hyperthermia'.
The three things I always want to know in this scenario are: 1) how high was the fever and how was it measured 2) have you given her any medicine for her fever (and if so, how much), and 3) is she still drinking and peeing?
A lot of parents will come in telling me their child just feels hot. And while that is an important measure of fevers, it doesn't really tell us much about the fever itself. And in many cases, there wasn't a fever at all. There really isn't such a thing as a 'low-grade fever'. A fever is defined as a core body temperature of 38.0C - 38.3C (100.4F - 101F), depending on who you ask. Emphasis on the 'core body temperature' part. That means, in really little kids (less than a year or so), you should take their temperature in their rectum (up their bottoms). In older kids, oral is a reasonable way to take a temperature (under the tongue), but can be flawed if they just ate or drank something cold. The thermometers that measure in the ears or across the forehead aren't really good measures of core body temperature.
In general, kids act weird when they have fevers. Sometimes, they'll just be listless and not want to play. Sometimes, it seems more serious, because they start shaking or seeing things that aren't there. One of my mentors has said repeatedly that he doesn't pay attention to anything strange a kid does when he/she has a fever, because fevers do weird things to the mind. And I'm not sure the last time you had a fever, but they aren't comfortable.
Giving medicines, such as Tylenol (acetaminophen) or Advil/Motrin (ibuprofen), in appropriate doses, can reduce fevers. I've seen Tylenol be given to a kid who was barely interacting with me in the Emergency Department (ED), and 15 minutes later, they're up and running around the room. Both acetaminophen and ibuprofen should be given in weight-based dosing, and ibuprofen should not be given to kids under 6 months of age. So you should check with your doctor to see how much medicine your kid should be getting. If they aren't getting enough, their fever might not come down and they still may look sick. Despite their best intentions, alternating between acetaminophen and ibuprofen every 4 hours doesn't really seem to help more than just sticking with one medication, and is more prone to errors that could lead to overdose. So, find one you like and stick with it.
At this point, I'd like to point out that fevers themselves do not harm kids. Even if your kid's fever is 104F*, if it comes down to normal with medicine, I'm less likely to be worried about it. Let me repeat that: fevers themselves do not cause harm. However, fevers are signs that something isn't quite right. Usually, in kids, it's a virus that they haven't been exposed to before, and their immune system is doing what it's supposed to and fighting it off. Every so often, though, it's something more insidious. It's that something else that results in fever that actually does the damage, not the fever itself. In fact, some would even suggest to allow a child to be febrile for a period of time to give them a chance of fight off their infection. I do agree that this is safe, so long as the child is comfortable. But if your child isn't comfortable, treat their fever. It'll make things easier for both of you.
When should you be concerned?
1) If you give the medication, and the fever does not come down. Call your pediatrician or go to an Urgent Care or Emergency Department.
2) If the child does not act normal after the medication is given and the fever has come down. As I said, most kids will bounce right back to their normal selves, but kids with bad infections will still look sick.
3) If the fever lasts more than 3-5 days, or if the child starts to get better and suddenly gets worse again. Both are signs of either another infection that is more worrisome, or a variety of disorders that are marked by prolonged fevers.
If you bring your child in to be seen on day 1 of the fever, there isn't going to be a whole lot your doctor can tell you. The illness hasn't had a chance to 'present itself,' and we can't really differentiate between the number of different diseases that cause fever.
And that brings me to the second thing I ask parents. If we've gotten past the fever part, and the child isn't staying hydrated, then we, as physicians, get a little more worried. See, kids become dehydrated much more quickly than adults. A really bad stomach bug that causes vomiting and diarrhea could dehydrate a kid and leave them looking really sickly. Fever itself can also cause dehydration, not only because kids don't feel like eating and drinking during that time, but it also increases how much they sweat, something we refer to as 'insensible losses'.
When kids are sick, they don't feel like eating. That is fine. Our bodies are used to using energy stores during times of infection. But, not drinking, or not having things like popsicles or other high-water 'foods' can quickly lead to dehydration. In little kids, particularly those in diapers, one of the easiest ways to determine whether they are taking enough in is to check how much they're putting out. If an infant goes from wetting a diaper every 2 hours (12 in a day) to wetting one every 12 hours, there's a problem, and they're not taking in enough liquids (or they have a problem with their kidneys, but that's another discussion).
Taking fluids by mouth is the best way to take them. It's non-traumatic, and the best way to prevent complications from a medical intervention. Kids who are throwing up everything they try to drink, or kids who are having difficulty breathing, are the hardest ones to get to drink. We generally recommend small volumes of fluids in those cases, 1-2 oz every half hour or so. Don't give the baby a full 8 oz bottle of milk if she's been vomiting all morning. Even things like popsicles, if given often enough, can keep kids hydrated. So, we do an oral challenge to see if they are willing and able to take the fluids by mouth.
If they aren't able, we consider admitting to the hospital for IV hydration. It's not preferred, because there's always the risk of injury or infection with placing things like IVs (a low risk, but still a risk), but the risk of dehydration is much greater than those risks, so we do it when it's necessary.
Now, if your child has a chronic disease, most especially something like Cystic Fibrosis or Diabetes, you should follow the instructions of the doctor regarding sick day rules.
Otherwise, managing their fever and making sure they stay hydrated are the two things you can do to get your child feeling well once again. And if you aren't sure, call your pediatrician. Most will have overnight people on call specifically to answer these questions for you and determine if your child needs to be seen right away. There's nothing wrong with getting in to see the doctor, but we can be much more helpful if you've tried a few simple things on your own first.
Next week, we'll talk more about the role of antibiotics in treating children.
*Note: Elevated body temperatures can cause damage, but they must be greater than 40-41C (104-105.8F) for a prolonged period of time for this to happen. This generally does not happen with infections, but more often in things like heat stroke or medication overdose resulting in hyperthermia. Note that at these times, it is not referred to as a 'fever', but 'hyperthermia'.
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