It's been a crazy couple weeks. I'm on vacation now, so I'm hoping to get a few of these cranked out so that I don't miss any for a while. Apologies for not keeping up with my self-imposed schedule!
I'm on my Emergency rotation this month, and after having only worked a handful of shifts, I've learned a ton. I've also seen a wide variety of anxious and worried patients and parents. However, I've also seen families who are frustrated by a perceived lack of help.
I encourage all parents, if they think there is a problem, to first call their pediatrician. This is not idle advice... half the things I see in the Emergency Department can be seen in a pediatrician's office, not only faster, but generally cheaper for both the family and the insurance company. I also recognize that there is a trend among primary care physicians in general to refer their patients to the Emergency Department if anything is concerning to them, rather than working it up themselves. This isn't necessarily a bad thing--it can just be very frustrating for the parents.
Let's go through some cases to see who is best treated in the Emergency Department (henceforth referred to as ED), and what expectations for them are.
Patient 1: 3 week old infant comes in with a fever to 101. Otherwise looks healthy.
Should the patient come to the ED? Yes, Absolutely. Infants are not good at localizing infection because their immune system--what helps them fight off disease--is not developed yet. Virtually all their protection comes from mom--either from that protection crossing the placenta prior to delivery, or in the breastmilk afterward. So, these babies are at risk of getting serious infections, and sometimes the only outward sign of those serious infections is fever.
What should you expect in bringing this child in? Because we cannot easily identify the source of the infection, we check the major areas where infections can hide: the urine, the blood, and the spinal fluid. This means collecting urine, drawing blood, and doing a procedure called a lumbar puncture to get the fluid from around the spinal cord. The child will then have to be admitted to the hospital to await the results of those tests.
Patient 2: 3 1/2 year old girl with a few red spots on her back. Otherwise looks and feels healthy. No fever.
Should the patient come to the ED? This one can probably be treated best at the pediatrician's office. If the child has a fever and it's after hours, it's reasonable to bring her in, but without a fever, the spots are either bug bites, hives, or maybe a viral rash. In any case, there isn't a whole lot that the ED is going to do for you other than reassure you that these things are not serious, and that might be better conveyed by your local pediatrician.
What should you expect if you do bring the child into the ED? Long wait times. We have kids that are legitimately sick, so they get priority. I will not fault you for bringing your child in if you are worried, but again, you're probably going to be seen faster and have a better relationship with your pediatrician in the office.
Patient 3: 14 year old who nearly passes out on the toilet, and has gained weight and been overly tired for a year.
Should the patient come to the ED? This is a soft call. Passing out is something that raises red flags for us in the pediatric population, but in this case, there was no actual passing out. So either we're going to say he's sick with some virus, dehydrated, or something along those lines, or we're going to say that maybe he was straining a little too hard on the toilet and that's why he suddenly felt lightheaded.
What should you expect if you do bring this child in? A lot of reassurance. Maybe a few tests if something in the history raises a red flag for us. However, you should NOT expect us to magically cure your child or figure out what is wrong with him, nor should you expect us to be able to expedite your wait to get in to see a specialist. We can rule out any life-threatening causes of the passing out, but we are not going to solve the mystery as to why he has been tired so long, especially if you've already been seen recently by a pediatrician. That is not the purpose of the ED.
Patient 4: 8 year old who has had headaches on and off for months at various times of day. They go away with ibuprofen/Motrin/Advil, but usually come back.
Should this patient come to the ED? This patient was a little complex, but as he only had a minor headache when he came in, there really wasn't anything we could do for him. Since it was a chronic problem, and the headaches were going away, this is really a patient that should be seen in a general pediatrician's office.
What should you expect if you do bring this child in? Again, a lot of reassurance. While there is some diagnostic testing we can do, unless the child is getting worse, vomiting with the headaches, or they do not resolve with medication, the testing really isn't needed on an urgent basis, so we're probably going to refer him back to his primary pediatrician. If you don't have a primary pediatrician, we will gladly give you some numbers for some.
The bottom line? I won't fault you for bringing in your kid to the ED if you are worried something is wrong. But please, if the problem has been going on for a while, and your child doesn't appear to be getting worse, please call your primary pediatrician and have your child be seen there. You will probably get in and out faster anyway (since waiting times in the ED for non-urgent problems can be several hours, even after you are initially seen).
Showing posts with label fever. Show all posts
Showing posts with label fever. Show all posts
Sunday, August 17, 2014
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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