Fever, Infections and Medicine – PediaCast 446

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Show Notes

Description

• Our Pediatrics in Plain Language Panel returns to the studio as we consider fever, infections and medicine. We explore best ways to take a child’s temperature and explain the cause and treatment of fever. We’ll let you know when to worry and share tips for fighting infections at home. We hope you can join us!

Topics

• Fever
• Infections
• Medicine

Guests

• Dr Mary Ann Abrams
  Primary Care Pediatrics
  Nationwide Children’s Hospital

• Dr Alex Rakowsky
  Primary Care Pediatrics
  Nationwide Children’s Hospital

Links

• Primary Care Pediatrics at Nationwide Children’s
  Find a Provider: 614-722-KIDS (5437)

• What To Do When Your Child Gets Sick
  IHA 40% Discount Code: POD719

• Pediatrics in Plain Language Survey
• Pediatrics in Plain Language Playlist – SoundCloud

Transcription

Announcer 1: This is PediaCast.

[Music]

Announcer 1: Welcome to PediaCast, a pediatric podcast for parents. And now, direct from the campus of Nationwide Children's, here is your host, Dr. Mike.

Dr. Mike Patrick: Hello, everyone. And welcome once again to PediaCast. It is a pediatric podcast for moms and dads. This is Dr. Mike, coming to you from the campus of Nationwide Children's Hospital. We're in Columbus, Ohio. 

It is Episode 446 for December 5th, 2019. I want to welcome all of you to the program. 

We have another Pediatrics in Plain Language episode for you this week, as we consider fever, infections, and medicine. And it's a good time to cover these topics because we are getting knee deep into the winter viral season with lots of infections, most of them caused by viruses including the cold virus that I have right now.

0:01:14

My voice may be a little rough this episode but it happens every winter. And it's just one of those things, when you are a pediatrician and you are around sick kids day in and day out, you get sick yourself. And so, it just goes along with the job. So please bear with me as I battle my own virus. 

I will say this, though. We've not really seen much of the flu yet, and things can get really ugly when flu comes to town, which is why we recommend your entire family gets a flu vaccine to protect yourself each and every year from this potentially deadly illness. And no, it is not too late to get one. 

You just don't know what you're going to get with each flu year. Sometimes, they start up early. Sometimes, they start up late. Sometimes, they're really not so bad in terms of hospitalization and deaths. And sometimes, they're just horrendous, with the numbers of people who get sick and die from the flu. 

0:02:10

And last couple of years had been pretty bad flu years. So my hope is that this year, maybe we'll get lucky and it won't be quite as bad. 

But still, I would definitely get a flu shot though, each and every year, whether we're going to have sort of an easy flu year or a bad flu year. Regardless, there will be some folks who get very sick each and every year with the flu and people who die. And your best protection is a flu shot. So please do get one of those. 

We're also seeing an uptake of bacterial infections which are often complications of the viral infections. So you get a bad cold and then, few days later, ear infection or pneumonia, sinus infection. And all of these things, both the viral and the bacterial infections can cause fever. 

And medicine of one sort or another is often recommended to help you get through the virus and the bacterial infection and the fever. There are also medicines you want to avoid when fever and infections strike. 

0:03:09

So our plan today is to cover everything you need to know about fevers, infections, and medicine. To help me out with today's conversation, we have our Pediatrics in Plain Language Panel back in the house, Dr. Mary Ann Abrams and Dr. Alex Rakowsky.  Both are primary pediatricians here at Nationwide Children's Hospital.

And as you recall when they join us, we try really hard to speak with plain language, no medical jargon to get in the way of your understanding. That's our plan anyway. 

And when uncommon words are the only option, we do our best to explain exactly what we mean as we go. And we also have a friendly competition to try not to use medical jargon and to let each other know when the other has done so and then explain what we mean.  

And we also ask you to hold us accountable to the task by giving you access to our Plain Language survey so you can tell us how we are doing and suggest future topics for our Plain Language episodes. I'll put a link to that survey in the show notes for this episode, 446, over at pediacast.org.

0:04:15

Now, I realized that many of you are doing something else right now. You're busy doing something while you're listening. And so, it's a little difficult to get to the survey and then you forget. But please add visiting our survey to your computer time to-do-list. 

Or if you can't pause the program, visit pediacast.org right now on your mobile device and click on the Survey tab. It's a really quick survey. And we just really want your feedback on these episodes. Or I guess, okay, if we want your feedback on today's episode, don't pause it now. Listen to the episode and then when we get to the outro, pause it then and please take the survey. 

All right, fever, infections, and medicines today. Next week, we're going to a couple of specific infections in much more detail, ones that are very common in this time of the year, croup and bronchiolitis. For each of these, we'll cover the cause, how they make little ones sick, symptoms, treatment, prevention, everything you need to know. 

0:05:15

Then, we're going to break for the holidays and come back with the show on colds and flu, a lot of details on the common cold and influenza after the new year. 

So a trio of episodes coming your way over the next few weeks as we consider the many things that make kids sick in the winter. 

All right, couple of housekeeping items before we bring in our panel. Don't forget, you can find PediaCast in all sorts of places. We are in the Apple Podcast app, iTunes, Google Play, iHeart Radio, Spotify, SoundCloud and most mobile podcast app for iOS and Android.

Reviews are helpful wherever you listen to PediaCast. We always appreciate when you take a moment to share your thoughts about the show. And we love connecting with you on social media. You'll find us on Twitter, LinkedIn and Instagram. Simply search for PediaCast. 

Also, I want to remind you the information presented in every episode of our program is for general educational purposes only. We do not diagnose medical conditions or formulate treatment plans for specific individuals. If you have a concern about your child's health, be sure to call your doctor and arrange a face-to-face interview and hands-on physical examination.

0:06:16

Also, your use of this audio program is subject to the PediaCast Terms of Use Agreement which you can find at pediacast.org.

So, let's take a quick break. We'll get our Plain Language Panel settled into the studio and then we will be back to talk about fever, infections, and medicine. That's all coming up, right after this.

[Music]
 
0:07:05

Dr. Mike Patrick: Our Pediatrics in Plain Language panel joins us again this week. You will recall that Dr. Mary Ann Abrams is an assistant professor of pediatrics at the Ohio State University College of Medicine and a pediatrician with the Hilltop Primary Care Center at Nationwide Children's Hospital. 

And Dr. Alex Rakowsky, also an assistant professor of pediatrics at Ohio State and a pediatrician with Olentangy Primary Care at Nationwide Children's. Really appreciate both of you joining us again. 

Dr. Alex Rakowsky: Thanks for having us again.

Dr. Mary Ann Abrams: Great to be here. 

Dr. Mike Patrick: So Dr. Abrams, why don't you remind us about this whole Plain Language thing? What is exactly is it and why is it important? 

Dr. Mary Ann Abrams: Well, we've talked about this often. Well, every time we get together, we talk about it. And I'd like to try to bring something new to each of these times you'll give me the chance to talk about plain language. The bottom-line is it's important for us to speak in a way that make sure the people that we're giving advice and recommendations to have that key information and know what to do and understand and feel comfortable with what we've told them. 

0:08:06

An example I thought we would share is something that I saw in the paper over the last week or so. On one of those advice columns where someone -- this was an adult -- wrote in to Dr. So and So, and was a very healthy older person that had been told by their doctor they had an extra heartbeat. And they were very, very worried that they might have a rhythm problem or need surgery. And suddenly, they're having a decline in their health. 

Dr. So and So responded that probably this was just a little extra heartbeat that jumps in there every so often that doesn't cause any problem and we all have them. And that doctor pointed out the importance of making sure when we tell people these things that we are clear. 

So a little extra heartbeat to us sounds like no big deal. If I were not a cardiologist or a health professional and you said I had an extra heartbeat, I could see where that could be very concerning. 

Dr. Mike Patrick: And if you called it a pre-ventricular... 

Dr. Mary Ann Abrams: That would even be worse.

Dr. Mike Patrick: Yeah, yeah, contraction. 

0:09:06

Dr. Mary Ann Abrams: But they were worried their heart was going to overwork and maybe run out sooner. So that's another great example of a very simple word and yet we aren't sure that they truly understand. 

So plain language and making sure our patients and families understand is the bottom-line.

Dr. Mike Patrick: Yeah, premature ventricular contraction, that's what I was trying to say. But my words are all going together. See, when we try to use big language, we don't use it properly.

Dr. Mary Ann Abrams: And often, plain language is easier. You don't have to work so hard to say it.

Dr. Mike Patrick: Yeah, yeah, absolutely. In doing this Pediatrics in Plain Language Panel episodes right now, we are kind of loosely following a book called What To Do When Your Child Gets Sick from the Institute for Healthcare Advancement. And we'll have a link to that book in the show notes for this episode, 446, over at pediacast.org. 

We also have a discount code. It's already really low price, like $12.95 to begin with and with the discount at $7.77. But it's also available in Amazon, Barnes & Noble, It's such a good book written in plain language. It's really easy to understand but still has some great information. 

0:10:14

And then, I also want to mention that for all of these Plain Language episodes of PediaCast, we have a survey that we would encourage all of our listeners to take. And as I mentioned in the intro, I know folks are busy doing things when you listen to podcast, whether you're driving or doing dishes or walking around the house, talking a walk, exercising. And so, it's not always convenient to click on the link and take a survey. 

But if you can remember to try to do that, you can even take it on your mobile device after you listen to this episode. Really easy quick survey. And we will just appreciate so much your feedback in terms of what we could do better or what we're doing well, what topics we ought to cover in the future as we think about plain language. 

And then, also, over on SoundCloud, we have all of our Pediatrics in Plain Language episodes with the playlist there for you. So you can find them and listen to them easily.

0:11:00

All right, so let's move forward, Dr. Rakowsky, we're going to start with fever. So what exactly is a fever? 

Dr. Alex Rakowsky: So I'm going to give one a formal definition, and that's when you have an elevated body temperature. And most of us have a body temperature that runs between, using Fahrenheit, 97.5 and around 99. So it really varies depending on who you are. 

And if you have an elevated body temperature to a certain level, then it's considered to be a fever. And most people use 100.3 or 38 degrees Celsius as a definition of fever. 

Dr. Mike Patrick: Okay, then what is a low-grade fever? What would you call that? 

Dr. Alex Rakowsky: So it's sort of like... And that's a loaded question because there really is no good...

[Laughter]

Dr. Alex Rakowsky: From like research, so there is really no good research definition of a low-grade fever, but it's sort of like this, "Doctor, my child is above her normal body temperature but doesn't have fever level." And I think a lot of us will get low grade fever with I think Mike and I both have bronchiolitis currently. 

0:12:04

Dr. Mike Patrick: Yeah, yeah.

Dr. Alex Rakowsky: I have a low-grade fever, so it was just something where your body's responding to the infection, but you will have a full blast, sort of temperature response.

Dr. Mike Patrick: So it's not really a medical term. For our standpoint here, 38 degrees Celsius or 100.4 degrees Fahrenheit is really like definition of fever, correct?

Dr. Alex Rakowsky: Yes, I should have said greater than 100.3, yes.

Dr. Mike Patrick: Oh yeah, yeah,  so 100.4...

Dr. Alex Rakowsky: And higher.

Dr. Mike Patrick: Or higher is the definition of a fever. So when folks come in and say, "Oh, my child had a fever and it was 99." I mean, from a strict definition standpoint, that's not a fever. 

And, you know, I love that you say there's this range because some people do "Well, my kid usually runs hot or my kid usually runs a little bit cooler." We're still going to use the 100.4 or more as a definition of a fever, but it is true that some kids, your natural thermostat may be a little higher or a little lower than 98.6. Which is kind of if you Google what's a natural body temperature, you're going to see 98.6. But maybe yes.

0:13:05

Dr. Mary Ann Abrams: Then, are you guys talking about oral temperature in your mouth or rectal temperature in your bottom? Not your bottom.

Dr. Mike Patrick: Yeah, I think we still use the same numbers regardless of how we take the temperature but we want to take into account how we take the temperature. And we're going to get to that as we move on.

Dr. Mary Ann Abrams: It's a question that comes up a lot.

Dr. Mike Patrick: It does, yeah. Like do I a degree, do I subtract a degree? We will have the answer coming up.

So then, the next question then will become why do we get fevers? What causes fever? 

Dr. Alex Rakowsky: So I like to break it into three sort of main causes of fever. Number one is your body sees something infecting it which doesn't belong. And then, your body as part of that sort of response -- I'm going to call it an inflammatory response or sort of like a swelling response to the infection -- will then produce chemicals to kill off the bacteria or kill off the virus.

And are the chemicals designed to give a fever or is it a side effect of the chemicals? Who knows? But regardless as to response of the infection, then that gives you that fever response. 

0:14:11

The number two cause is there are some bacteria that actually will give you a fever. So they produce some called pyrotoxins or fever toxins. And there are some viruses that do similar, that actually produce the toxin, then your body goes all wild about you getting a fever. So it's not really your body responding. It's your body responding plus this toxin that's kind of giving you the fever.

And then the third thing -- and it's probably not going to be discussed at all after this -- is if you're doing two-day football in a 105 degree weather, your body can overheat. So you can get a fever just from pure overheating and not cooling enough. 

I think we tend to forget that. I bring this up because both of us do urgent care where infants come in with a fever and they come in all bundled up. I'm like, well, is it because they're bundled up or is it because they actually have a true fever? 

And it becomes difficult. So sometimes, the body just can't regulate because they're so overheated. 

0:15:02

Dr. Mike Patrick: I love that you pointed out, does the fever have an actual function in our body fighting illness or infections? Or is it a by-product of our immune system in action? And, of course, we'll never really know for sure what the answer to that question is. 

But we do know that kids are pretty uncomfortable when they have a fever. As an adult, you get a fever, you just feel miserable. Like, you would lie on the couch and, "Everybody, just leave me alone." And you feel achy and you might have a headache and kids feel the same way.

And you lower that fever with some medicine and, suddenly, they're like a different kid and they're playful. You want your kid to be comfortable. But, on the other hand, you don't want to do something that decreases your body's ability to fight infection if you think the fever is having a contributing cause or it's helping you to fight that infection. 

But there's really no evidence that treating a fever is going to be a bad thing in terms of your body not able to fight the infection right. There's not anything shown that I know of.

0:16:02

Dr. Alex Rakowsky: Yeah, we actually had a journal club article last night, which I missed because had bronchiolitis. 

Dr. Mike Patrick: I did not set you up for this question. I did not know. 

Dr. Alex Rakowsky: No, no, no. And there's one article out there, it's a bunch of articles together. So it's called the meta mini-analysis. And they looked at world's literature on this exact question and they found all of five articles. 

And three of them were in children with malaria and then two of them were in just children with regular colds. I think one in Britain, one in the States. 

And they essentially showed that your time to clearing your infection based on sort of like certain behavior markers didn't vary if the parents gave every six hours Tylenol, every eight hour Tylenol, or no Tylenol. 

So in the US study, actually, the ER docs actually randomized to don't get rid of fever versus do get rid of the fever. So that's one study, the one metanalysis out there. So it's a great question with no data, and that's for people listening, it'd be a great study to do -- hello, residents -- to kind of work on this. We just don't know.

0:17:08

Dr. Mike Patrick: Yeah, very interesting. 

Dr. Mary Ann Abrams: I do think it's important to point out that, technically, when you're body's overheated like from working out in the football field for 10 hours on a 100-degree day in August, the technical term could be hyperthermia which means your temperature is really high. And that's a different... It's not good for you and it actually could be very very dangerous versus fever itself which it's not the fever -- and we'll talk about this more, too -- it's the underlying cause of the fever that could perhaps be dangerous. 

And we treat them differently. We have to go to the bottom of it immediately when we first see the kiddos or adults with that situation.

Dr. Alex Rakowsky: And I brought it up because we're in the middle of viral season here in the mid-west. And you'll see kids and the parents will come in, they have a 100.3, 100.4, right on the border, overly bundled kid in the house that's at 75 degrees. And you really struggle, am I dealing with the true fever?

0:18:10

And I use a football example, just to kind of give an example, but infants don't thermal regulate their temperature really well. And you really struggle sometimes. And I've had a few in the last couple of shifts where I was like I don't know what to do. 

Dr. Mike Patrick: Yeah, because at the same time, we have some pretty firm rules in place especially for very, very young infants based on that rectal temperature. And you don't want to overdo things but you don't want to under do things. And yeah, that's one of the difficulties of being a physician and making those kind of decisions for families. 

I kind of mention other symptoms that go along with fever. Fever can increase your heart rate, increase your respiratory rate, and make your skin flush and then those other things, headaches and achiness and just generalized feeling tired. Whether those are caused by the fever or whatever your immune system is doing from a chemical standpoint, it's giving you that fever, maybe also causing some of those symptoms.

0:19:05

Dr. Alex Rakowsky: I think the chills may be your body trying to raise temperature. So that one actually may be related to the fever production but other one's just may be side effects of your body sort of fighting something off. 

Dr. Mike Patrick: It's one of those things we just don't really know for sure. 

Dr. Alex Rakowsky: You're in the war zone. 

Dr. Mike Patrick: Yeah. And so, now, we're just going to get just a little bit more complicated here. But there's a part of the brain called the hypothalamus that acts kind of like a thermostat. So you got the thermostat in your house and you set the temperature. And so, the hypothalamus kind of sets that temperature. And we know when it changes the thermostat, you may do some behaviors to help increase your temperature. 

If you change that thermostat to a higher level, then you get those chills. You may feel cold and put a blanket on. There's even some behavioral aspects to our body helping us to get a fever when I guess when the thermostat goes off. 

0:20:02

Did I do okay with that, Mary Ann, from a plain language standpoint?

Dr. Mary Ann Abrams: You did. 

[Laughter]

Dr. Mike Patrick: That's a complicated...

Dr. Mary Ann Abrams: And if you disagree with us, fill up that survey and let us know. 

Dr. Mike Patrick: Yes, absolutely. So Mary Ann, so I hear this a lot where families will come in and say, "My kid has a fever," and you ask, "Well, what was it?" And they just say, "No, it just feels hot." How accurate can a parent determine if a child has a fever or not by touching their skin?

Dr. Mary Ann Abrams: I think there's two answers to that. There is the technical answer which is you can't take a temperature by putting your hand on somebody's forehead. But as a mom, you can tell the difference, especially with your own kids, you kind of know. And you know if your child is usually kind of cool or whatever and it feels really warm. Plus, they're not acting well or they have other symptoms, you can put two and two together and come up with, "Yes, my child has a fever." 

I also, I almost, I'd take that as part of the information they share with me and then I really want to measure the temperature. 

0:21:09

I take it the same way people report their child has a fever. And one of the things the book talks about is it's hard sometimes even though how to talk about a fever. "He's a 100 and 2." Well, was he a 100.2 or a 102? "Well, I don't know, it's 100 and 2." Or that way you take the temperature, we're going to talk about that in just in a minute.
  
So I think it's part of the history, we call the history, the story that the parents and patients tell us about the history of their illness. 

Dr. Mike Patrick: I guess the good news is that -- except for like little babies where we are making some really important decisions on how we're going to treat based on what the number is -- for the most part, in most other kids, it just doesn't really matter what the actual number was. 

0:22:04

And so, if your kid felt warm and they were achy and not playful, then that does make you think they have something going on whether they met the criteria of a technical fever or not, probably doesn't necessarily make a difference. And the longer I've been a doctor, the less that that answer to that question had bothered me.

When I was a young doctor, it was like you can't tell because how their skin feels, there's a difference between what their body temperature is and what your body temperature is. And you really need to buy a thermometer and do this the right way. But I don't know, I think the longer your doctor, the more relaxed with some things you get. I don't know if you found that your... 

Dr. Mary Ann Abrams: I think that's why I answered the way I answered. 

Dr. Alex Rakowsky: I agree. I agree.

Dr. Mary Ann Abrams: Yeah, very much so.

Dr. Mike Patrick: So then, you mentioned you'd take it by mouth or rectally, and there's ear thermometers and skin ones and under the arm. Does it matter the way that we take the temperature? 

Dr. Mary Ann Abrams: The three main ways that I always think about are the mouth or oral, in the bottom, rectal and under the arm which can be called axillary. 

0:23:10

I think the one under the arm is pretty unreliable. Some people may think it's easiest but, actually, you have to get that thermometer under their arm and keep their arm flat so it doesn't fall out. 

So oral, a child has to be big enough to be cooperative and keep it in their mouth and under their tongue. And most people I think use the electric, the little battery-operated thermometer. So it will beep when it's ready. And I've noticed with my own family that wow, when it beeps really quickly, I know my child has a fever because it's heated up right away. And if it's still in their mouth after three minutes, chances are that temperature's not going to be very high. 

And then, with babies especially, rectal temperature helps us feel like it's the most accurate. And I know that that can be kind of scary to people to take a rectal temperature if they're not comfortable because they're not quite sure where that thermometer's going. But the American Academy of Pediatrics has a couple of handouts on how to take a rectal temperature and there's some illustrations in the book as well.

0:24:17

Also, the biggest concern is just keeping your hand on the child so that if they wiggle, you're stabilizing the thermometer and that doesn't cause any problem.

So I think it's most important and I know you want to get to this but I'm just going to go there. You don't have to act or subtract a degree. Just say how you took the temperature. So tell us whatever the number is and how it was taken.

Dr. Alex Rakowsky: If I can also throw in, a lot of parents now are using either an ear scanner or a forehead scanner, which are becoming really popular. The one I don't like are the therma dots on the forehead. There had been some nice studies with the ear and the forehead scanner, like you kind of swipe it. But the dots just don't have sort of a good database behind it. You'll see a lot use those because those are cheap.

Dr. Mary Ann Abrams: They're easy. 

Dr. Alex Rakowsky: They're easy to do, yeah. 

Dr. Mary Ann Abrams: But if they don't give good information, then they're not cheap and they're not easy. So it's sort of the list. 

0:25:18

Dr. Mike Patrick: Yeah,  absolutely. So I love what you said, just take the temperature, tell us what you got, and how you took it. And then, those are two different data points and let the medical provider determine what that all means.

Dr. Alex Rakowsky: Again, for infants, I really stress to get a rectal for parents. That's the one you really have to worry about. 

Dr. Mike Patrick: And I said it doesn't really matter what it is but there's another exception to that other than young babies. And that's if you have a fever that's present for several days in a row, there kind of is a difference between really high fevers and sort of more like between 100.4 and 101. 

And we've covered Kawasaki disease before on this program. But those really high-spiking fevers for several days in a row make you concern about that. So there is more nuance than just me saying, "Oh, it doesn't really matter." But for a lot of kids, it doesn't really matter. But there are times that it does.

0:26:10

Dr. Mary Ann Abrams: And if a child has another illness, an underlying health problem that makes their immune system not work as well, even a low-grade fever can be a sign of something more serious though. 

Dr. Mike Patrick: Yeah, for brain injury where the hypothalamus that thermostat doesn't work correctly. 

Dr. Mary Ann Abrams: The fever doesn't cause that problem. If the child has had a head trauma for some other reasons, then their thermostat in their brain may not be working and you can't count on it.

Dr. Mike Patrick: And that walks us right into the next question perfectly and that is for Alex. Is fever dangerous?

Dr. Alex Rakowsky: Again, another loaded question. So let me answer it first by is there any data to show that if you have a certain fever, you're going to have brain damage? So sort of like the worst case scenario. 

And unless you go over 106, I don't even know what that is in Celsius, like 42 or something. I'm not sure. 

Dr. Mike Patrick: Yeah, yeah. 

0:27:07

Dr. Alex Rakowsky: You don't seem to have any damage to your brain. So regardless of old Helen Keller movies where she gone blind because of a fever, virus infection that did it. But I think a lot of our parents told us, "You get a high fever, you're going to have brain damage." And that's never been shown, unless it go really, really high. 

But then it probably gone really really high because there's something wrong with either your brain to begin with, like the hypothalamic issue, or something is going on. 

Dr. Mary Ann Abrams: Or it's that outside temperature and the heat thing, which is a high temperature but not a fever. 

Dr. Alex Rakowsky: So a fever by itself in the vast majority of cases will not cause direct harm. However, if you have a high fever and the child's not eating, not sleeping, breathing quicker, has a quick heart rate, yes, they can get worse quicker. 

So if you have somebody with the flu running 105 fever and they're not eating or drinking or sleeping because of it, and they're breathing quicker because of the fever response, and their heart's beating quicker because of fever response, they can quickly sort of have their body crashing just because they're using a lot energy to kind of keep up with it. 

0:28:16

So yes, the fever production and infection are related to, it can give you problems. But it's not like it's a direct "I'm going to fry my brain or have a problem with my liver or kidneys because of this." 

Dr. Mike Patrick: Yeah. So it's the whole process, not the number itself. But then, you'd had folks say, "Well, my child had a fever and then they had a seizure. Isn't that evidence that the fever cause a brain problem?"

Dr. Alex Rakowsky: It's just kind of go back to last question a little bit. So you can actually have a viral illness, like we just went through adenovirus here in Columbus. And that classically give you a fever of 104, 105, in some small kids. And that just passes on its own. And then, you see kids in clinic or urgent care with a low-grade fever, not a real fever but on the lower end can have a referring urinary tract infection and needs to be treated.

0:29:03

So the fever by itself and the level of fever by itself doesn't really correlate with or show that you have a seriousness of infection. It really depends on what's infecting you. So that kind of goes back to the febrile seizures or fever seizures. When we were all training, it was assumed that it was because of the spike in fever. 

So if you had a child who's after a baseline of say 99, to make it easy, quickly rose up to 102, that thermostat in the brain irritated the brain and the brain essentially had sort of like a twitch and you had the seizure. That's kind of the old theory. 

There's a lot of debate now. In fact, the debate now seems to say that it doesn't really matter on the spike, it matters on the person genetically. Are you more prone to have seizures? Are you more prone to having a fever response and how high do that fever get? So it's a lot more complicated, kind of like the old way of thinking "I'll just give you Tylenol to prevent you from having a fever spike." But that doesn't seem to work, at least in some of the US studies.

0:30:11

So fever responses can lead to seizures in smaller kids. 

Dr. Mike Patrick: But there's still no lasting brain damage from that. It's still just a brief seizure that happens associated with fever and it tends to run in families. 

Dr. Alex Rakowsky: Yeah, again, a little bit of a nuance here. So six months to six years, if you have a fever that led to a seizure, it's short, it's sort of predictable, it's probably going to be what you call febrile seizure. If you have somebody who has a seizure disorder or has something chronically wrong, a form of premature infant who has a bleed who's more prone to a seizure, if they get a fever causing a seizure that can lead to a non-febrile seizure but a true generalized seizure. And that can lead to problems. 

So again, the caveat tends to be that if you have a parent that witnesses a febrile seizure, watch your child. If it's more than five minutes, consider getting help. 

0:31:08

Dr. Mike Patrick: Yeah, absolutely. You raised a good point and this goes a little beyond what we kind of planned on talking about today. But there are certain things that if you have epilepsy, which is seizure disorder where you have seizures from time to time, there are things that can make you more likely to have seizures and having a fever is one of those. 

So if you had a young child who has a fever, that then has a seizure, most likely it's a febrile seizure that just is not worrisome. But there are going to be a small number of folks who have epilepsy or seizure disorder and they just happen to have their first seizure when they had a fever. And so time kind of tells the difference between those two things, right?

Dr. Mary Ann Abrams: I do think it's really important though that people don't take away the... I think there's a lot of fear about what we call febrile seizures, seizures with fever. And most of the time, they are very frightening to people who aren't used to seeing children have a seizure, but they're also not going to be a problem or serious or a sign of things to come. 

0:32:16

And often, they occur in very healthy children and they never have another one. And it has nothing to do with the underlying cause of the fever. You can have a horrible illness and not have a seizure, horrible illness with the fever and not have any seizures. And you can just be a healthy kid who got a little bug, infection of some sort with, kind of like you said, not a really high fever but not a serious lingering illness and have a seizure. 

So I always try to really acknowledge to parents, "Yes, that was very frightening, but let me give you the good news," and help them to not be terrified and worried. 

Dr. Alex Rakowsky: And that's well said. I mean, 10% of all kids will have febrile seizure so I think that helps kind of make things more reassuring to parents to know that hundreds of thousands of kids will have febrile seizures in any given year. And the vast, vast majority are going to do fine. It's our job to figure out if it really was febrile seizure. 

0:33:16

Dr. Mike Patrick: But we don't want to minimize the fact that they are scary and it is absolutely fine to get your kid checked out when they have one. 

Dr. Mary Ann Abrams: Absolutely.

Dr. Mike Patrick: I was a resident physician and I was home alone with my daughter. She was 18 months old and she had a brief febrile seizure and it was scary. It was very scary. And here I am, I was a doctor. And so, I totally get that. But at the same time, most of them are... It's not really a dangerous thing for the vast majority of kids. 

Dr. Mary Ann Abrams: It's sort of one of those rewarding moments in medicine when you can really help the parent who's very very scared and helped them feel okay. I really enjoy being able to do that.

Dr. Mike Patrick: Yeah. And then it becomes when do we worry about fever?

[Laughter]

Dr. Mary Ann Abrams: I like to say don't worry about the fever but worry about what's causing the fever. Because at the end of the day, that's what's going to cause further health problem or help you just realize "It will take a few days and my child will be fine." 

0:34:18

So it's the things that are going on. And a lot of these things, people heard about before. So to kind of jump ahead a little bit, that's one of the reasons that sometimes even we as health professionals treat the fever. Because you really do want to tease apart, are they behaving and looking really sick because they're miserable from the fever? Or are they looking really sick because of the infection going on?

So if we can get that temperature down and the child still has a really runny nose but they're running around the room and asking for lunch, that is very reassuring. You can check them for ear infections and things like that. 

0:35:05

But if you kind of get that fever down and they're still looking really sick -- and we'll talk about what that means -- that helps us know we need do some lab tests or look further for the underlying cause of that fever. 

So what are we worried about? Are really worried about just a cough and a runny nose? We're more worried about a child who is very, very weak, or flappy or dehydrated. When you pinch their skin and their skin kind of sticks together. Their mouth is really dry because they're not drinking. 

And it may be that they've lost a lot of liquid from vomiting or diarrhea, but it could be that they're just so miserable that they're not drinking enough. And that can make them dehydrated, which can be dangerous if they don't get those fluids back in to them.  

If they are complaining of severe, severe pain like a horrible headache or a stiff neck or a really terrible sore throat, that is another thing to look for. 

Dr. Mike Patrick: Abdominal pain.

0:36:10

Dr. Mary Ann Abrams: Yeah, and we're going to be talking a little bit more detail about some of those things. Severe belly pain, pain in their arms and legs, and also rashes. Rashes can tell us a lot. And depending on what kind of a rash, it can be a be a very reassuring rash or it can be a very life-threatening rash. 

So again, I think the takeaway from your question, Mike, is it's not fever, it's what's causing the fever. 

Dr. Mike Patrick: Yeah, and what other symptoms are kind of going along with that. 

Dr. Mary Ann Abrams: Yeah, what are the symptoms that are showing is what is causing the fever.

Dr. Mike Patrick: And I think also if they just have a fever and not a lot of other concerning symptoms and it's a previously healthy kid, there's nothing wrong with -- and we'll talk here in a minute about treating fever -- there's nothing wrong, if you're not really worried, of kind of waiting a day or two and just seeing where things go. 

But if your child's having a fever that's lasting more than a couple of days, it probably ought to be seen even if there are any other concerning symptoms. Would you agree with that? 

0:37:10

Dr. Mary Ann Abrams: It is good to definitely give us a call. And depending on the age and whether they're healthy to start with, we may want to see them. Or it's always on a Thursday or Friday and the weekend's coming up, a lot of people really do want to get them checked up before then because then, it's harder to access healthcare. So totally legitimate reasons.

Dr. Mike Patrick: And a lot of these kids we're going to end up saying, "Oh it's virus." And I think from a parent's standpoint, like "I wasted this time going in and it was just a virus." But there's some comfort in knowing it's just a virus and kind of getting some reassurance. And that's a part of our job. 

Dr. Mary Ann Abrams: And it's getting a second opinion. The parent may have a feeling about it and now, the doctor agrees. So that's reassuring, just like I'd say, "Alex, come in and take a look at these kids. See what you think, can you agree? Well, good, we both think the same."

Dr. Mike Patrick: Yeah, absolutely. Okay, so let's talk about treating a fever. How do we go about doing that?

0:38:04

Dr. Mary Ann Abrams: So there's two main medicines that we use in pediatrics. There's one medicine that we never use in pediatrics...

Dr. Mike Patrick: For fever. 

Dr. Mary Ann Abrams: For fever, yeah. For treating fever. And the one we never use is aspirin. And I think I hear a surprising number of people who talk about giving their child aspirin. Now, I think sometimes, they mean they use aspirin as are a very general term for any kind fever medicine. But sometimes, I think people are giving children aspirin.

And for those who didn't live through the Reye Syndrome epidemics, we know that aspirin can have a devastating impact, can lead to a condition that has devastating impact on children. And it was particularly associated with chicken pox as well. But the bottom-line is, unless there's a very, very specific reason, don't give your children aspirin. 

Dr. Mike Patrick: Just under direction of a... If a doctor's telling you to do it, then there's some other reason. 

0:39:06

Dr. Mary Ann Abrams: Right. 

Dr. Mike Patrick: Okay. 

Dr. Mary Ann Abrams: There are several diseases that actually require aspirin as the main medicine. But don't just pull a bottle out of the cupboard somewhere and say, "Here, take an aspirin." 

But what can you give? The two main medicines again are acetaminophen. The brand name's that's most common for that is Tylenol. And then, the other one is ibuprofen. And that has a lot of brand names, but Advil and Motrin are two of the main ones. And we'll probably slip in to that, into using those terms here.

Acetaminophen, we usually can use for babies maybe starting at three months. And six months is sort of the cut-off for ibuprofen. And the takeaway is they both work to help lower fever and they both help people feel more comfortable. Ibuprofen sometimes helps decrease what we call inflammation, when there's more redness or swelling or just deeper pain perhaps.

0:40:11

Dr. Mike Patrick: Yeah, like an ear infection, for example. 

Dr. Mary Ann Abrams: Yeah, I think so there's a little nuance difference there. Sometimes, people talk about alternating them. The studies there go back, they haven't really shown that they make a big difference. They can create more opportunities for mixing up medicines and wrong dosing and giving too much or too often. 

So I would initially recommend just starting with one. And again, you don't have to treat the fever but if you choose to treat the fever, you can start with acetaminophen or ibuprofen. 

Dr. Mike Patrick: And at least start with following the directions on the bottle. 

Dr. Mary Ann Abrams: Absolutely. 

Dr. Mike Patrick: Like, you know how, the acetaminophen you can do over four hours. Ibuprofen, every six hours. But we don't expect you to memorize all that, just follow the directions on the bottle that you're using.

Dr. Mary Ann Abrams: And that's important because a lot of this come in so many different concentrations. And they come in liquids and drops and tablets and liquids and capsules and chewables. So definitely read the directions and don't switch bottles and don't put them back in a different box. Follow those directions because that's really critical to not accidentally giving too much.

0:41:21

Dr. Alex Rakowsky: I'm glad you brought that up because it seems like it's gotten better as far as having different formulations out there. But it's really ten different kinds of formulations. 

Dr. Mike Patrick: I love acetaminophen or Tylenol, the difference now between infants and children is where they a syringe or a cup in it, but it's all 160 milligrams and 5 milliliters. I think, I'm pretty sure it's all that now. 

Dr. Alex Rakowsky: I mean, the Dollar Store may still have, yeah. I think a quick rule of thumb is...

Dr. Mike Patrick: Good point, yeah. 

Dr. Alex Rakowsky: I think a quick rule of thumb is if it's your regular ibuprofen or acetaminophen, it's usually 1 ml for every 2 kilos, oh, for every kilo. So it's 1 ml for every 2 pounds. And it doesn't matter if you give them the Tylenol or the Motrin. So a 10-kilo kid is going to get 5mls of Motrin or 5 mls of acetaminophen. 

0:42:10

Dr. Mike Patrick: This is a lost skill. Because every time I see a resident in the emergency room, I'm like, "Do you know how to quickly figure out a Tylenol or an ibuprofen dose?" They don't teach it anymore. 

[Laughter]

Dr. Alex Rakowsky: Yes, so I mean, people kind of got away from it because there's so many different formulations out there. 

Dr. Mike Patrick: Yeah, and the EMR figures it out. 

Dr. Alex Rakowsky: A lot of the parents will go on and says... 

Dr. Mary Ann Abrams: EMR meaning the electronic medical record that we use now. 

Dr. Mike Patrick: Yes, thank you. 

Dr. Alex Rakowsky: Bang, bang, bang. But when urgent care people come in and say "I wasn't sure if I can't give acetaminophen to my infant because the bottle says "Call a doctor." So I'm now here." 

But if it's like Mary Ann said, over three months for acetaminophen, over six months for ibuprofen. A basic rule of thumb is 1 ml for every 2 pounds of the child's weight. Make sure it's the right bottle, yeah. 

Dr. Mary Ann Abrams: Yeah. And the other piece is make sure you're using the right dosing instrument. If there's a dropper in the bottle, use the dropper. If there's a cup, use the cup. If it says 3 mls, find a way to get that measuring cup or the dosing spoon that let you measure 3 mls. Don't use teaspoons or... 

0:43:22

Dr. Alex Rakowsky: Or soup spoons in the house because, yeah, it doesn't work.

Dr. Mike Patrick: Oh yeah, yeah, because that's what's going on exactly.

Dr. Mary Ann Abrams: Everybody's teaspoon is different and that has led to some overdoses. 

Dr. Mike Patrick: So milliliter is the unit that we want to use. 

I don't hear this from families quite as much as I used to but people will talk about when their child had a fever, giving them a cold bath or lukewarm room temperature bath or alcohol rubs. You just want your kid to be comfortable, right? And that doesn't sound very comfortable if you have a fever, like dipping in cold water, I don't know.

Dr. Mary Ann Abrams: I think, well, first  of all, we strongly discourage don't do an alcohol bath because the alcohol can actually get absorbed through the skin and cause...

Dr. Mike Patrick: Yeah, just not a good thing.

Dr. Mary Ann Abrams: Very serious health problems. And I don't actually relish the idea of getting plunged into a cold bath or a cold shower. So I don't know why a sick child would either. 

0:44:14

If you feel like you want to do something, a lukewarm bath will be okay. And Alex talked earlier about sometimes people bundle people who are sick up, take off the extra blankets and take off the little sweater and loosen up whatever their clothing is to give their body a chance to let that heat just radiate off of their body.

Dr. Mike Patrick: Yeah, and it is. It's really comfort care. It's supportive care is kind of the medical term. But we just want kids to be comfortable and one of the ways to help him do that is getting that fever down but in a comfortable way and a safe way.

Dr. Mary Ann Abrams: And keeping in mind that the fever in and of itself is not going to hurt them. And assuming that they're acting relatively okay, you don't have to do these things. But if you want to do something, that's the first to do. 

0:45:08

Dr. Mike Patrick: So we really have this focus on plain language, and I kind of put the word infection in there because from a doctor's standpoint, like "Of course, I know what an infection is. But then, there's also the word illness or I'm sick. Infection, what specific connotation... Connotation, that's a terrible word. 

Dr. Alex Rakowsky: Pa-pa-pa.

Dr. Mike Patrick: Yeah, yeah. What do we mean when we say infection?

Dr. Mary Ann Abrams: As you just pointed out, it's a more complex question then that you  might think. An infection, I would say, it means that something in my body, either a virus or a bacteria or maybe a fungus, has sort of set up housekeeping or taken hold and is kind of living in the cells of my body. 

0:46:00

An illness can be diabetes or arthritis, those are illnesses or conditions. But an infection means some other sort of living thing -- probably very small, I guess a parasite is bigger and that would be an infection as well -- is living in my body. 

The other thing is that you can be infected with something and not be sick. That happens a lot.  A lot of children because they always are putting their hands in their mouth and crawling around and putting everything in their mouth. They'd be infected with a lot of different viruses and even some bacteria in the environment, but never really show that they've been sick, acted sick. 

And then, say they get their blood drawn when they're 10 or 12, or 15 years old, and if you did a whole bunch of tests, you find out, "Oh, they are immune, their body shows that they've had this and this and this." And you're like, "Why, I didn't even know my child ever had those things."

Dr. Mike Patrick: Yeah, yeah. Like mono.

Dr. Mary Ann Abrams: Mono is the most common, yeah.

Dr. Mike Patrick: We think of mono as being like this big bad illness but a lot of people don't even know they ever had it. 

0:47:06

Dr. Mary Ann Abrams: And hepatitis A was another one back in the day. Especially a lot of the youngsters got hepatitis A. And maybe they just were sick for a couple of days with what people thought was a little flu bug. But by the time they were adults, they didn't even realize they have it.  

Dr. Mike Patrick: Is that a concern then? Should parents worry, like "Oh, my child may have mono and I don't even know it." 

Dr. Mary Ann Abrams: I would say look at your child and see how they are behaving and acting. 

Dr. Alex Rakowsky: They'll have the symptoms again. 

Dr. Mike Patrick: Yeah, absolutely. And then, what are some of those symptoms? It really depends on where the infection is, right, what kind of symptoms that you see? But what are some of the worrisome ones that you would, "Yeah, we need to get this checked out?"

Dr. Mary Ann Abrams: Yeah, you can kind of categorize this in different ways. Alex is always does a good job of it. I like to think of things in threes or whatever. 

[Laughter]

Dr. Mary Ann Abrams: But I was trying to think about terms of parts of the body.               

So when we look at the head, we look at the eyes. Do they have real eyelids and stuff draining out of their eyes? Obviously, do they have really runny nose? Do they have little spots in their mouth? People always think about always looking at their throat, is that red or got a lot of pus draining down there? 

0:48:15

But don't forget to look at the sides of the mouth and the tongue because a lot of little kids in particular can get like a hand foot and mouth disease and have a really sore mouth and that can cause a fever. 

And obviously, the ears. What do we worry more about? If they've got a fever, if they've got a bad headache, or if they're neck is really stiff. 

A lot of times, we'll look for swollen glands in the neck and that's pretty common with most. Every time you get a cold, you could probably feel your own neck and start to get a sense of this little swollen glands or swollen lymph nodes. 

Moving down to the chest or abdomen, we're thinking about hard trouble breathing, what's going on with the lungs? Is it just wheezing like bronchiolitis or is it pneumonia? Things like that. 

And are there infections in the belly. The most common ones are what we call gastroenteritis, vomiting, and diarrhea, but there can be some other infections as well. 

0:49:17

And then, I'll see and look at the kidneys. So is there a urinary tract infection somewhere between the kidneys and the bladder.

Dr. Mike Patrick: Yeah, something like pain when they're urinating or abdominal pain, vomiting. 

Dr. Mary Ann Abrams: Yep. And then, I thought about arms and legs, so do we look at sore joints? Again, back before some of the vaccines, we used to see kids with red swollen joints that had a septic joint or an infected bone. So we've always wanted to feel those arms and legs to see if there's any tenderness that we didn't realize.

And then, the skin itself -- is there a rash, is it red? Is it warm? Is it swollen? And is there a rash that disappears when you push on it? Or is there a rash that stays? 

And where are those rashes? Are they starting at the top of the body and moving down? Are they on the palms and soles? There's all these fascinating details that we dig deeper when we start to examine a patient. 

0:50:21

Dr. Mike Patrick: And the bottom-line if there's any symptoms that you're worried about, that you have not come across before, that you're not sure, if you even have to think like "Shall be worried about this or not worried about it?" just have someone take a look. That's what we're here for, to distinguish whether this is worrisome or not worrisome. At least, make that phone call. 

Dr. Alex Rakowsky: Also, just going to add to pure symptoms, kids are active in general. There's some who are little less active just by nature. But if your child is active usually, and they're just lying around and not eating, that's worrisome. If they're not walking because it hurts, that's worrisome. If they are just sort of staring at you and not even responding to you properly, that's worrisome. 

And then, infants who breathe very quickly. And there's some nice videos for parents to watch what a bad RSV bronchiolitis can look like. If your child's really huffing and puffing using their lungs a lot, their ribs a lot, then definitely get seen. 

0:51:15

Dr. Mary Ann Abrams: Or breathing so fast that they can't drink. Or they can't take their bottle or they can't breastfeed because they get out of breath. 

Dr. Mike Patrick: One of the first things that we teach pediatric residents when they're interns is differentiating the difference between sick and not sick. And I think parents really have that feeling, too. 

Like, "My mom radar is going off. I don't like this. I can't exactly explain why I don't like it but it bothers me." And you got to listen to that, right?

Dr. Mary Ann Abrams: They'll say I know my child and that's...

Dr. Mike Patrick: That gets my radar up when a parent says that.  

Dr. Alex Rakowsky: I agree, I agree.

Dr. Mary Ann Abrams: We need to listen when they say it. 

Dr. Mike Patrick: Yeah. And then, in terms of treating infection, it really, gosh, depends on where the infection is located, what sort of infection that we're talking about, right? 

0:52:07

Dr. Alex Rakowsky: Unfortunately, the vast majority of things we're going to see in clinic or urgent care or emergency rooms is going to viral. And there are some antivirals out there, so there are medicines against the flu if you catch it early enough. But the vast majority of viruses just kind of run their own course.

Dr. Mike Patrick: Herpes being another one that will, if you catch it soon.

Dr. Alex Rakowsky: If you catch it soon, yes. So the classic bacteria that we see in pediatrics are ear infections, antibiotic, strep throat antibiotic, pneumonic antibiotic, urinary tract infections, and then some of the skin and joint infections antibiotics. 

But I think parent should be aware of the fact that nine out of ten times of a child who has a completely normal development till that time, when they get sick, they probably not going to get an antibiotic because it's probably viral in nature. 

It may lead to bacterial infection and then you need the antibiotic but it's not like you have to get an antibiotic for every head cold the child had. 

0:53:05

Dr. Mike Patrick: And that's something to pay attention to with regard to fever. That if you have a child with a fever that's there for a couple of days at the beginning of the illness and the fever goes away but now, they get a new fever, then that could be sign that there's bacterial complication of their viral infection, like an ear infection or pneumonia or sinus infection. 

Dr. Alex Rakowsky: Yeah, I agree. 

Dr. Mike Patrick: So something to kind of pay attention to. Or they just got a second virus.

Dr. Alex Rakowsky: And the second thing, it's not really treating it like killing, but if you have a stomach virus, we can give you a medicine called Zofran to help with some of the nausea. So it's not really knocking out the virus but it helps the symptoms, keeps some fluid there. 

Dr. Mike Patrick: Yeah, absolutely. And then, just that what we call again supportive care, just rest, and fluids, and stay home from school, lay on the couch, eat some Jell-o, just the comfort stuff.

Dr. Alex Rakowsky: If I can just add, in pediatrics, we tend not to stop diarrhea. I think a lot and I've seen this a few times recently because we had a mild stomach virus go through here. And people are given Motrin and Imodium. Again, using just a trade name here. I mean, in kids, you just want the stuff to run out and I feel horrible not stopping the diarrhea. But in pediatrics, we tend not to stop it. 

0:54:19

I mean, there are some circumstances where you would, but the vast majority of times, if it's diarrhea, I really can't do it and I don't want you doing all for, just feed through it. 

Dr. Mike Patrick: It's one of the ways we get rid of the microorganism, by getting it out of the intestine. But if there's blood in the stool, that's one of those differentiating things. This is something you want to get checked out sooner, not later, if there's blood noted. 

Dr. Alex Rakowsky: Or really mucousy.

Dr. Mary Ann Abrams: And I think what you are saying too, the other reason is we're not wanting to stop it is it can mask that the child is still sick. You're like, "Oh, the diarrhea's gone," but instead, maybe something else is going on inside the child. And because they're little, they can't talk about that the way an older person might. So that is very true.

Dr. Mike Patrick: In terms of preventing the spread of infections, Mary Ann, what are the best ways to prevent spreading infections from one person to another? 

0:55:13

Dr. Alex Rakowsky: Be a hermit, live in a plastic bubble, and never go outside. There we go, there's my list of three. So yeah. 

[Laughter] 

Dr. Mike Patrick: Dr. Alex's list of three ways to avoid getting an infection. 

Dr. Mary Ann Abrams: And if you can't do those, then wash your hands. Wash your hands before you eat. Wash your hands before you prepare food. Wash your hands after you go to the bathroom, after you change a diaper, after you've worked out in the yard. Wash your kids' hands before they start to eat, if they've been playing and running around. Handwashing is really, really important. 

And don't be afraid to say to your healthcare provider, please wash your hands, if we come in to the room to examine you and don't wash our hands. We want to be reminded. I think we are very conscientious about that, but every once in awhile there's a slip. Don't be afraid to ask us to do that. 

0:56:05

Dr. Alex Rakowsky: If I can empower parents, because again we all have kids, but the sleepover or the birthday party or whatever events going on, and one of the parents calls in says, "Joey has diarrhea. Is it okay if I come?" Or, "Do you still want to come?" The answer should be no. 

So it's fine to say to somebody, "If your child is sick, one, let your child rest. And two, to prevent your child from getting sick, you really shouldn't be exposing him to anything else beyond what he's going to get exposed to in a normal setting."  

So if there's somebody really sick in a birthday party, I think it's fine to say "I'm sorry, but you know..." I've seen so many parents say, "I was in a birthday party where people were sick, and we still stayed." I was like, "You don't have to, because you're just asking for trouble." 

Dr. Mary Ann Abrams: That's a good point.

Dr. Mike Patrick: So people always want to know, "When can I go back to school?" We say that when you've been fever fee for 24 hours, but there's no formula, right?

0:57:06

Dr. Mary Ann Abrams: The short answer to that is yes, there is no formula. There are state laws and rules and regulations for child care centers and schools, et cetera. But first of all, they can go back A, when they feel better. They shouldn't be going back if they're still having diarrhea or they can't manage, if they've got a runny nose and they can't manage their secretions. The word secretion's for all the stuff coming out of your body. 

So a little bit of common sense, the fever should be gone. The symptoms should be pretty much resolved. They should be able to eat and drink okay. And for many of these illnesses, they got it at school and it's still out there. So common sense, along with kind of having a sense of most of these viral illnesses, you probably, the technical word is kind of shed the virus. Or the virus is still around in your saliva or in your runny nose for three to five days afterwards.

0:58:14

So I don't think that a child needs to stay out of school for a full week after their cold is getting better, but I think the second thing I was going to bring up is good hygiene. We talked about cough etiquette which I think is a wacky, non-plain language term. Teach your cough to be polite.

[Laughter]

Dr. Mary Ann Abrams: But basically, don't cough into your hand. Cough into your sleeve or your elbow and then don't put your elbow around somebody else's face and cover any open sores or things like that.

And then, the third thing I want to talk about is get your child vaccinated. That is one of the absolute best ways to prevent infections, especially life-threatening infections.

Dr. Mike Patrick: And one in particular I think that has made a huge difference in pediatrics that kind of doesn't get talked about as much as things as pertussis and chicken pox and mumps and measles, obviously, is the -- it's a really complicated word -- but Haemophilus influenzae type b. 

0:59:16

There were a lot of kids who got meningitis and, of course, bad ear infections and something called epiglottitis where you had swelling that was life-threatening in the back of the throat and interfered with breathing. And there were lots and lots of kids who had very serious infections from these back as recently as like early 1980s. But it's completely gone now. 

Dr. Alex Rakowsky: I trained in the early 90s and I remember seeing a Haemophilus influenzae epiglottitis and it was devastating. And I think I was an intern. So it was like the year that it became mandatory in most states. I trained in Pennsylvania and it had just become mandatory.

And this kid, I remember being an intern in the ER, trying to intubate this child with epiglottitis. And the senior couldn't get anesthesia. To this day, I just remember this case vividly. And they were bad players. So yes, I don't think Hib, the Hib vaccine or the pneumococcal vaccine...

Dr. Mike Patrick: Yeah, don't skip that one. Don't skip any of them, but you know, that's what... 

Dr. Mary Ann Abrams: Well, we all live...

Dr. Alex Rakowsky: Those are good ones.

1:00:15

Dr. Mary Ann Abrams: We all live in fear of that. And we thought tons of it because it just love to set up in whatever little soft tissue there was. So that's the cheeks, the big tender cheeks, the septic joints, and osteo or bone infection. It's a bad actor. 

Dr. Mike Patrick: I also want to mention, so of course, not everyone's going to keep their sick kids out of school. And so, we definitely want that hand washing and soap water, at least 20 seconds. So kind of teach your kids to sing the ABC song. If you sing it kind of slowly, that's a good amount of time to wash your hands with soap and water. 

And alcohol-based hand sanitizers are fine, but keep in mind, they don't kill everything. And especially, there's some hardy viruses that cause gastroenteritis or vomiting and diarrhea like a stomach virus. And those aren't always killed as well with the alcohol-based hand sanitizers. So if you can, soap and water is your best bet. 

1:01:13

Of course, if we do that too much, it dries your skin out and there are problems with that.

Dr. Alex Rakowsky: I think parents can always talk to the school. I think the vast majority of daycares and schools would like some input from parents. And it creeps up on you every year, when winters hits and all of a sudden, every kid in school's getting sick. I think it's perfectly fine if you're part of like a parent-teacher organization, or even just talking to your school, to your teacher, "What's your plan if ten kids in the class get a head cold?"

And most schools are really open to, will have hand sanitizers available. In between classes, we're going to run all to the bathroom to wash your hands. 

You see schools come up with some very ingenious things, but just empower them because they don't want the kids missing either. We have two years ago, some school districts here I think closed for a week because there's so many sick kids. And that's the last thing they want to do.

1:02:04

Dr. Mike Patrick: Yeah, very good point. So we've covered in terms of medication that we would use for infections. Of course, antibiotics depending on the infection. We talked about acetaminophen and ibuprofen.

Another one that comes up a lot especially this time of the year with lots of nasal congestion and runny nose, cough are cough medicines, cough and cold medications. What's the current thinking in terms of kids and cough medicine?

Dr. Alex Rakowsky: Let me start off as a parent and then also as somebody who gets frustrated not being able to help out more parents. So you wait in the lobby for two to three hours for somebody to come to your room to say it's a virus and I can't do anything for it. So I see what parents want to do. You see your child struggling, it is a parental love thing that you want to essentially do something for your child. So it's hard to get these people not to use these medicines to begin with.

1:03:04

Unfortunately, the data for decongestants in almost all ages, but definitely kids less seven, eight, six, depending who you read, just don't seem to work. And if they do work, they work for very short period of time. What I tell my parents is that if you do decongest them, it may thicken things up which makes them more prone to ear infections or pneumonia potentially. That's not proven but potentially. Plus, it gives them some side effects.

And then, cough suppressant can definitely lead to pneumonia. So even though your child may feel better with these medications, they just in the long run don't seem to do a lot of good. But I can see where parents are coming from. 

Then, it boils down to what can you do for your child? Cool mist humidifiers, nasal suctions. This NoseFrida, I'm not sure, there's a generic name for NoseFrida. 

Dr. Mike Patrick: Human-powered suction. 

Dr. Alex Rakowsky: Human aspirator, that was called, yeah. We actually have the parents, it looks really gross. I tried this, it's not as bad as people say it is. 

1:04:04

Dr. Mike Patrick: It's like slurping snot out of your kid's nose with a straw. 

Dr. Mary Ann Abrams: But there's a filter. 

Dr. Mike Patrick: But there's a filter.

[Laughter]

Dr. Alex Rakowsky: There's a  filter, yes. And a fairly big filter, leave it at that. 

Dr. Mary Ann Abrams: Yeah, it's very big.

Dr. Mike Patrick: They're great. They're really great. I wish they had one when my kids were little.

Dr. Alex Rakowsky: Yeah, but they're out there. For older kids, more than a year old, honey. Honey actually helps soothe the throat, helps you cough less. And then, just the realization that coughing is a protective mechanism. You're coughing so as to get stuff out of your lung so you don't get a pneumonia. 

And yes, the child's miserable because of it but there's a reason that cough exist. And the runny nose, you can help the best you can, but again the medicines that we use as adults in kids, one, don't seem to work really, and two, can give side effects.

Dr. Mike Patrick: And one of the side effects is sedation. So they make you sleepy, which of course for a parent, yeah, well, my kid get to sleep. But if you're really sleeping deeply and not coughing, you're more likely that mucous and mouth bacteria to get that down into the lungs. Because you're not coughing, you don't have that protective mechanism. 

1:05:04

And then, when you're really sleeping deeply and especially if you're not dosing it correctly or double dosing or using medicines that shouldn't be used together, there'd been kids who have died from lack of breathing because they were so sedated from this. 

Dr. Alex Rakowsky: And for older kids, a hot bath that you can let ...

Dr. Mary Ann Abrams: Shower steam.

Dr. Alex Rakowsky: I mean, I'm not a huge aromatherapy fan, but there's a lot to be served, like a nice lavender bath just lying in the bathtub for an hour, assuming get in an hour in the bathtub. Some hot tea, honey if you're older, more than a year. 

There's a lot of different things that you can try. Popsicles for a sore throat, it makes your throat feel better. But unfortunately, a lot of them, you just have to kind of ride out and try the best you can. But I see where parents are coming from. It's so hard as a parent to watch your child sick and you say, "I'm going to give you a popsicle." 

Dr. Mike Patrick: And especially with getting so many viral illnesses in the winter. It's where our body's immune system works, we have to get sick in order to build immunity against that particular strain of virus. And every new virus that comes along is going to make your kids sick. 

1:06:09

And you got a classroom of 26, there's going to be five different viruses at any one time. And so, it is just common to, I hear a lot, "Oh, my kid's sick all the time." So all the other kids are, too.

Not to minimize that, but it's just that it's a common experience. 

Dr. Mary Ann Abrams: They're close together and sometimes, depending on the age, the hygiene is not as good. So they're just exposed to more.

Dr. Alex Rakowsky: I tell parents that the expected number of colds for a child in daycare is going to be six to ten in the winter. And the government defines the essentially as five months. So if you're getting six colds, that's at least one a month. If you're getting ten, that's two a month. 

It takes about a week to run over, get rid of the cold. You have three days where you're feeling healthy and then you get your next one. So it looks like the child has an immune problem. 

So then you look for things like poor weight gain, pneumonia, ear infections, severe diarrhea over and over again. I think parents are worried. So if you just let him know that six to ten infections for a child in daycare the first year is the norm, then I think it's really reassuring. 

1:07:13

Dr. Mike Patrick: Yeah, I think so, too. 

Dr. Mary Ann Abrams: I think, too, emphasizing again, I totally agree with Alex. I just feel for those who, they've waited forever, their child is sick, they waited and then we don't give antibiotics and we don't give cold or cough medicines. But trying to frame that as this is actually better for your child, that antibiotics have side effects and can set them up for not being able to be effective when they really need them later. 

The dosing can be kind of dangerous on those cough and cold medicines. It can lead to the things that you just talked about. So framing it as this is a good positive thing. 

Dr. Alex Rakowsky: And I think it's important also...

Dr. Mary Ann Abrams: And we ruled out the scary bad things that are dangerous. 

Dr. Alex Rakowsky: But I think it's important to sit down and to -- this is to speaking to the providers out there -- spend 30 seconds to a minute talking about, "But this is when I need you to worry." In other words, this looks like a cold. But if your daughter is pulling on her ears, they'll need the child to come back. If she or he is reading a lot faster, and worried about a pneumonia. 

1:08:19

In other words, empower the parents to kind of know, this is what I'm really supposed to worry about. Because otherwise, they get frustrated by the fact, "It's just a cold." "That's only a cold." And then, also, they'll come in one day and it's an ear infection and it looked like a cold. 

But I think just the gentle education, 30 seconds per visit, after awhile the parents kind of get used to, "This is what I look for." 

Dr. Mary Ann Abrams: And taking that a step further, I think we often say if he's not better in a week, if he's not better, come back. And we need to take that 35 seconds to say what does not better mean? It doesn't mean the cold and even the fever are going to be gone tomorrow or the next day. 

It means, it's going to -- and especially if they brought them in early -- they might even get a little sicker for the next couple of days. He's got a runny nose today, he's going to get a little bit more. He's going to cough some more. He's going to turn green. But he should be turning the corner by a week, and it should be totally gone by 10 days. 

So give them the time frame, and tell them what to look for -- if he's really having trouble breathing, if he's breathing so hard he can't eat or drink, or some fever doesn't go away. 

1:09:26

Dr. Mike Patrick: Yeah, a lot of repeat visits. I'm not saying they didn't need to be done because we definitely want to see kids when parents are concerned. But by spending a little more time explaining that may help prevent future visits or off to an urgent care, seeing another provider and then you don't have the continuation of care that we really like to have in the medical home. 

Dr. Mary Ann Abrams: And parents have to take off work. And there's a lot of implications, they want to bring back child if they need to. But if they don't need to, that's important for them as well. 

Dr. Alex Rakowsky: And just to kind of like go back to close loop on febrile seizures. One of the most common viruses for febrile seizure is actually when the fever breaks, you get a rash.

1:10:06

So the parents already freaked out, like you were freaked out by daughter having febrile seizure. You go to the ER and then some guy like me says febrile seizure, you do the best you can to explain it. They go home. Twenty-four hours later, they break out in a rash. 

Now, one, they think I'm an idiot because they didn't mention the fact that this could happen. And two, now, the parents are really freaked out. They definitely missed something because "My child seized and now has a rash." And rashes really freak parents out. 

So do the parents a favor and just you know, if you have a febrile seizure, a good chunk of those viruses actually give you a rash. And just warn them that a child looks better and looks great and develops a rash, it's cool. 

Dr. Mike Patrick: Yeah, good points. We could go on literally talk about all of this for another hour, easily, right?

Dr. Alex Rakowsky: Or more. It's a great topic.

Dr. Mike Patrick: But it is time to wrap things up. I really want to thank as always, Dr. Mary Ann Abrams and Alex Rakowsky , both with primary care pediatrics at Nationwide Children's. We have a fantastic primary care pediatric group here at our hospital, with many locations all around town.

1:11:11

If you are in Central Ohio and looking for a pediatrician, 614-722-KIDS. That's 614-722-5437 is our phone number to find the provider in your area. And they are a fantastic group, really highly recommended. And I'll put a link to primary care pediatrics at Nationwide Children's in the show notes for this episode, 446, over at pediacast.org.

We'll also going to have a link to the book that we're kind of roughly following along as we do these special episodes of Pediatrics in Plain Language called What To Do When Your Child Gets Sick. And I have a discount code for you at the website, 40% off the price of the book, which is already a non-profit organization, pretty low price to begin with. 

And then, please remember to take time to fill out our Pediatrics in Plain Language survey. We just want to know what you think of these episodes. Are we doing a good job? What could we do better? What do you like? What works, what doesn't work? What topics would you like hear us talk about in the future? 

1:12:06

And I know it's not always convenient, while you're listening to a podcast, to take a survey but it really means a lot to us. We took a lot of time to put this together and we just really value your feedback on these episodes in the link. 

If you head over to pediacast.org, click on the survey tab. You'll find a link to it there. It's also in the show notes for all of our episodes on Pediatrics in Plain Language. And then, we have that playlist in SoundCloud with all of these special episodes.

All right, so again, thank to both of you for stopping by today. 

Dr. Alex Rakowsky: Thanks as always. 

Dr. Mary Ann Abrams: Great to be here. Thanks, Mike. 

[Music]

1:13:08

Dr. Mike Patrick: We are back with just enough time to  say thanks once again to all of you for taking time out  of your day and making PediaCast a part of it. Really appreciate that. 

Thanks also to our Pediatrics in Plain Language Panel, Dr. Mary Ann Abrams and Dr. Alex Rakowsky, both from Nationwide Children's Hospital Primary Care. So we covered fever, infections, and medicine today. 

Again, next week, we're going to explore a couple of specific infections with lots of details, ones that are very common this time of the year. Croup, that's the one that gives you that barky cough. And bronchiolitis, little babies who wheeze and their nose are just so full of mucous, what can you do about it? We're going to talk through that.

We'll cover symptoms, treatment, prevention, really everything you need to know about croup and bronchiolitis next week. And then, we're going to break for the holidays, come back with the show on colds and flu after the new year. 

So a trio of episodes here today and then in the next couple of episodes on the many things that make kids sick in the winter. 

1:14:07

Don't forget, you can find us in all sorts of places. PediaCast is in the Apple Podcasts app, iTunes, Google Play, iHeart Radio, Spotify, SoundCloud and most mobile podcast app for iOS and Android.

We're also a proud member of the Parents on Demand Network which you can find at parentsondemand.com. 

We also have a landing site with all of our past shows, all 446 of them, our entire archives there on the landing site, also show notes, transcripts for many of the episodes, our terms of use agreement and handy contact page if you would like to suggest a topic for an upcoming program. 

Also, don't forget about that Pediatrics in Plain Language survey that I mentioned at the beginning. So now, you've listened to the podcast, please pause and go to pediacast.org, click on Surveys and consider taking that Pediatrics in Plain Language survey for us. Tell us what you think about the show, how can we make it better and what did we do well, and what would you like to hear about in the future. It's really a quick survey, shouldn't take you much time at all. 

1:15:11

Also, reviews are helpful wherever you listen to PediaCast. We always appreciate it when you take a moment to share your thoughts about the show. 

We love connecting with you on social media. We're on Facebook, Twitter, LinkedIn and Instagram. Simply search for PediaCast.

And of course, as you are holidaying it up this season and you're at parties and gatherings, get-togethers, family, co-workers, friends, neighbors, please let them know about PediaCast if they have kids or take care of kids.

Also, let your child's pediatric healthcare provider know. And while you have their ear, tell them we have a podcast for them as well. It's called PediaCast CME. That stands for Continuing Medical Education. 

Very similar to this program, we do turn up the science a couple notches. Not as much plain language in that one. And we offer free Category I Continuing Medical Education Credit for those who listen. Shows and details available at the landing site of that program, pediacastcme.org.

1:16:08

It's also in all the places you can find podcasts, so Apple Podcasts, iHeart Radio, Spotify, mobile podcast apps, all that stuff. Simply search for PediaCast CME.

Thanks again for stopping by. And until next time, this is Dr. Mike saying stay safe, stay healthy, and stay involved with your kids. So long, everybody.

[Music]

Announcer 1: This program is a production of Nationwide Children's. Thanks for listening. We'll see you next time on PediaCast.