Fever (3)

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     I have written previous articles on fever in children, but, because fever is the most common reason that parents contact physicians, it always deserves more mention. The American Academy of Pediatrics recently released an updated clinical report on fever authored by Janice Sullivan M.D. and Henry Farrar M.D.  This is a review of that article.

     The article repeats the facts that fever is not an illness, does not worsen an illness and does not cause brain damage. The only goal in treating fever with anti-fever medications is to make the child more comfortable.  Anti-fever medications don’t necessarily lower the temperature and certainly do not prevent fever seizures.  There is never a reason to wake a child at night to give these medications.

     The fever that comes with an infection is not the same as a fever that comes with hyperthermia.  Hyperthermia (the problem that causes heat stroke) is a condition in which the body loses its ability to control temperature and can result in death. It does not occur as part of the body’s reaction to illness. However, studies show that most health care workers, including physicians, wrongly believe that temperatures above 104 can be dangerous in a child with illness-created fever. This contributes to the irrational fear of fever called “fever phobia”.

     Either acetaminophen or ibuprofen makes the child with fever more comfortable. Acetaminophen can cause liver damage if it is over-dosed. Because it comes in so many different forms and dosages, parents need to only give it according to directions and to adjust the dosage according to weight rather than age. It is not recommended to give ibuprofen to children under 6 months of age because of the possibility of kidney damage.  It seems that alternating acetaminophen and ibuprofen is slightly more effective in lower temperature than either agent alone, but alternating increases the risk of over-dosage of either medication and is not recommended.

     When giving either medication, parents need to check any other cold or cough medications they give the child. Many of these medications contain acetaminophen or ibuprofen and giving them also increases the risk of over-dosage.

     Finally, fever, although it is not dangerous, still means that the child has an infection and the infection itself might be dangerous. In the first three days of the fever when it is up and down day and night, I recommend giving anti-fever medication because the child’s response to the medication helps me to decide how serious the illness is. If an hour after giving the medication, the child is a little more active, has a little better appetite or drinks a little more, and, in general, is acting less sick, then I am less worried about the child. A child who seems more weak or sick an hour after a dose of acetaminophen should give the parents concern and should be watched closely. As I have said in other articles, the fever might still be present in the evening on the fourth and fifth days but then resolves and does not return. If the fever does not follow that pattern, the child should be seen by his caregiver.

Should a CT Scan Be Done After Head Trauma?

     A previous article discussed the risk of radiation in children. Doctors have always been concerned about exposing their pediatric patients to X-rays and that concern is growing as we become more aware of the increased risk of cancer caused by even one CT scan of the head. As with all dilemmas in medicine, doctors and parents must choose between the risk of the procedure (cancer) and the risk of not doing the procedure – in this case, it is the risk of missing a significant brain injury.

     There are a number of factors that doctors and parents can look at to determine whether a child with a head trauma needs to have a CT scan of the head. If the mechanism of the trauma is more violent or severe, such as a motor vehicle accident in which another passenger was killed or ejected or the vehicle rolled over, the risk of brain injury is higher. If a pedestrian or bicyclist is struck by a motor vehicle, or the patient’s head was struck by a high-impact object, the patient is also at higher risk. Falls from higher than 3 feet for children under 2 years old or 5 feet for children under 5 years are more dangerous. If there is visible swelling and bruising of the scalp that is in an area other than the forehead, the trauma is potentially severe. If the child was unconscious immediately after the accident or if there is any confusion or change of consciousness after the accident, the child is at greater risk. Finally, if there is severe headache or vomiting after head trauma, there is increased risk that the child has brain injury.

     If a child with head trauma did not lose consciousness and has none of the factors mentioned above, the risk that he has significant brain trauma is lower than the risk involved with a CT scan. He should be closely observed to see if any of the more serious symptoms develop.

     As we strive to protect our children from unnecessary X-ray exposure, it is important for parents to keep a good record of any procedure done on their child. An imaging record for parents is available on-line at: www.imagegently.org .

Tonsillectomy

     Tonsillectomy has gone through many phases. In the 1950’s it was almost done routinely. It then fell out of favor and was rarely done. Now there are new reasons to do it and it is being done more often.

     There have always been good reasons not to do tonsillectomy. First, the anesthesia needs to be very deep to overcome the gag reflex. This can lead to more post-operative problems in the recovery room. The area around the tonsils has lots of blood vessels and there is danger of serious bleeding during and immediately after the surgery along with a risk of bleeding seven to ten days later. Finally, the throat is very sore immediately after the procedure and can remain sore for 2 weeks. The pain is bad enough that a child may simply refuse to eat or drink after the operation and need to get IV rehydration.

     Tonsillectomy has always been used to decrease the number of sore throats in children who have frequent, recurring sore throats, especially strep throat infections. If the child has a deep infection in the tonsils that never gets totally resolved and continues to reoccur, tonsillectomy will certainly help. However, for routine sore throats or strep throats, the evidence is less clear that it helps.The child certainly won’t get a tonsil infection (they are gone!) but the rest of the child’s throat can get infected. With or without tonsils, if a child shares a sucker with a child who has strep throat, that first child will probably get strep throat.

     The reason tonsillectomy is being done more frequently is to correct sleep apnea. Some children have tonsils so large that they cause obstruction to the child’s breathing while the child is asleep. This is more than just snoring. The child may have periods where he stops moving air in and out even though his chest is moving and he is trying to breathe. Children who are obese have even more problems with sleep obstruction. Having large tonsils is common between the ages of 3 and 6. Tonsils normally shrink in size as a child gets older, so the sleep problem may go away by itself.  But severe blockage can cause a child to be sleep deprived and start to fail in school. It can also cause poor growth and contribute to behavior problems. When the sleep disturbance is causing other problems, it is time to consider tonsillectomy. There are centers that study children’s breathing patterns when they are sleeping and can give parents the information they need to help them make the decision about whether to do surgery.

Whooping Cough Vaccine

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     In the 1920’s and 30’s, whooping cough (pertussis) caused from 125,000 to over 250,000 deaths every year. An epidemic could devastate an entire community. After the introduction of pertussis vaccine in the 1940’s the number of cases of pertussis decreased dramatically and deaths from whooping cough dropped to around 5,000 a year. However, since 2001, the number of cases of pertussis has increased, especially in older children. Before 2005, less than 10% of pertussis cases nationwide occurred in children ages 7 to 10. This year, nearly 40% of the cases are in this older age group. One of the factors may be that in the 1990's a weaker vaccine was introduced to decrease swelling and redness at the injection site and post-vaccine fever. The effectiveness of this vaccine has been found to decrease each year after it is given so that older children and adults lose protection without booster shots.

     In Washington state, 2,500 cases of pertussis were reported from January 2012 to June 2012. This is 3 times the rate of whooping cough reported for that time period last year. Experts are investigating reasons for this increase. The effectiveness of the vaccine if definitely a factor, but it needs to be considered that the Pacific Northwest has a strong anti-vaccine culture. Vaccinations are delayed, given on alternative schedules or simply not given at all. This results in a decrease in the general immunity of the community. When there are more cases of pertussis in a community – even mild cases – there is more exposure to pertussis for the people who are vulnerable to severe disease. Infants should receive their first pertussis vaccine at 2 months of age but don’t develop strong immunity until they have received boosters. What protects these infants is the pertussis immunity of the people around them – parents, siblings and caretakers.  With poor community immunity, very young, unvaccinated infants are 8 times more likely to become infected with pertussis and these infants are the ones who have the greatest risk of death from pertussis.
     Almost every medical procedure and medication involves some degree of risk. For any child who experiences a complication from a vaccine, it is a disaster. However, the small risk of complications from vaccines is greatly overshadowed by the complications and deaths that would return if vaccines were not given. Time has erased the painful cries of the parents who watched their children die during pertussis, diphtheria and polio epidemics.
     

Intussuseption - Every Parent Should Know About It

     Intussusception is not a word most parents are familiar with, but every parent needs to know the symptoms of intussusception. It is a condition in which a portion of the bowel pulls into nearby bowel and collapses the bowel segment like a telescope. It results in bowel blockage and, if not diagnosed and corrected, can result in bowel infection, obstruction and death.

     Itntussuseption occurs between 3 months and 6 years of age.  80% of the cases occur under two years of age. It is difficult to diagnose because the symptoms can be confused with other problems.

     The symptoms begin suddenly. The child begins having bouts of severe, colicky abdominal pain that occur at frequent intervals. During these episodes of pain, the child may cry, bring his legs up and seem like he is straining. He may seem normal between episodes. The diagnosis can be difficult because a child with constipation can have the same kind of cramping.  However, a constipated child usually has a history of recurrent cramps and the cramps usually are associated with meals.

     The child with intussuseption begins vomiting and might develop fever. Finally, the child becomes profoundly weak and lethargic. It is clear that the child is very ill, but the child may be diagnosed as having flu, dehydration or some other infection. One of the key symptoms that points to the diagnosis of intussuseption is that the weakness and lethargy are out of proportion to the diagnosis of flu or dehydration. The vomiting in intussuseption is not accompanied by diarrhea, which also goes against the diagnosis of stomach flu. A child with intussuseption has stools that are small and contain mucous. Finally, 60% of the children have stools that become bloody and are described as looking like currant jelly. These bloody stools give the definite diagnosis of intussuseption, but the child might not have them until late in the disease or not at all.

     What makes the diagnosis even more confusing is that intussuseption can occur when a child has stomach flu or another viral illness. Parents need to watch for intermittant cramping abdominal pain, severe weakness and bloody stools. The diagnosis can be easily confirmed by ultrasound, but delay in diagnosis makes treatment more difficult and increases the risk of serious complictions.

Skin Problems In Young Athletes

     Young athletes can have a variety of skin problems caused by covering, rubbing or scraping the skin. The most common problems are infections. We all have bacteria and fungal spores on our skin and our best protection against infection from these agents is healthy, intact skin. Trauma caused by sports equipment rubbing against the skin can create open areas that can get infected. If a student complains that equipment doesn’t fit or hurts, the area involved should be closely inspected and if it is irritated, the parent should clean it gently, put a sterile, dry covering on it and pad the equipment to eliminate the irritation.

     If the area is open, weeping, crusting or red, it may be infected with a bacteria and needs an over-the-counter antibiotic ointment applied on it. If there is not immediate improvement or if there is an abnormal amount of pain, the child should be seen by his caregiver to get an oral antibiotic.

     Sweating under equipment or sports shoes creates a warm, moist environment that is perfect for the growth of a fungal infection. Athlete’s foot is a fungal infection that creates moist, red, itchy areas between the toes and can be treated with over-the-counter creams, sprays and powders. Fungal infections elsewhere on the skin can be raised, red, round, scaling lesions that slowly expand. They itch but don’t usually hurt. They can also be treated with the same antifungal creams unless the fungal infection is on the scalp, which needs an oral antifungal medication. Fungal infections take longer to heal than bacterial infections and frequently reoccur. Participants in sports with close physical contact like football and wrestling frequently get both bacterial and fungal infections.

     In close contact sports, herpes infection is also common. Herpes is a virus that causes painful, itching, red areas with blisters and open sores. Herpes needs to be treated with an oral antiviral medication that needs a prescription.

     With bacterial infections, the athlete should not return until the lesions have been cleared for at least two days. Skin fungal infections need to be treated for at least three days and scalp fungal infections for fourteen days. Antiviral treatment is for five days and the athlete should not return until the lesions have been dry without new blisters for three days.

Bicycle Helmets - Pro And Con

     Many communities are currently debating whether to make the use of bike helmets mandatory. The American Academy of Pediatrics recommends the use of bike helmets for all children.

     If you are involved in a serious biking accident, the statistics clearly show that your head is likely to sustain injury. 75% of deaths from bicycle accidents are the result of head trauma. But what has to be taken into account is the risk of having a serious accident. If adults are riding at slow speeds on a designated bike trail, a loss-of-balance accident would probably only result in scrapes and bruises. It could easily be argued that helmets wouldn’t be necessary in this circumstance. If one is riding a bike on a city street or at higher speeds, the risk of head injury and death goes up dramatically. Children have little fear of accidents, don’t observe their surroundings carefully and usually ride at speeds that exceed their ability, so they also have a high risk for serious injury .

     Few people would argue against wearing a life jacket when waterskiing. We all know that, if an accident occurred, the skier could go under water and not surface again. If a parent saw their child getting ready to water ski without a life jacket, there is no question that the child wouldn’t be allowed to do it. However, that same parent might watch the child go out of the driveway on his bike and, with a frustrated smile, say, “ I just can’t get him to wear his helmet.” If you can insist that the child uses the life jacket, you can insist that he wears the helmet.

     On a controlled bike path with little or no fast bikers, the adult might choose not to wear the helmet. If you are biking with your child, don’t worry about being inconsistent – grown-ups do lots of things that children are not allowed to do. It is all right for the parent to say, “When you are grown up, you can decide whether you want to ride a bike without a helmet. Now you are a child. You can still decide whether you want to wear a helmet or not, but not wearing a helmet means not riding the bike.” But it might be better to just wear your helmet, skip the discussion and enjoy the day with your child.

Physical Punishment - Spanking

There has always been a segment of our population who adhered to the “spare the rod, spoil the child” philosophy.  They contend that physical punishment teaches respect and obedience. I’m not talking about child abuse, I’m talking about spanking, slapping, shoving and grabbing as a means of punishing a child’s behavior. 32 nations have banned this kind of punishment, but it is legal in the United States and Canada. A study done in 2006 found that 48% of adults questioned reported a history of being subjected to some form of physical punishment without having been more seriously abused.

     Previous studies have found that children who receive physical punishment have higher levels of aggression, delinquency, poor emotional development, depression and alcohol abuse. In the latest issue of Pediatrics, the journal of the American Academy of Pediatrics, the leading article is about a study of information on 34,653 adults that was collected between 2004 and 2005. The researchers took pains to exclude any behavior that would be considered child abuse and tried to only include what people would consider harsh physical punishment. They found that this physical punishment was associated with increased odds of mood disorders, anxiety disorders, substance abuse and personality disorders in the adults who had received the punishment as children.

     I’ve written a number of articles about how to discipline children and no one has ever felt I was “soft” on discipline. However, it is clear that there is never a reason for an adult to strike a child and that doing so can injure the child’s emotional well being for life. Using the rod spoils the child.

Rabies In Children or Do You Want To Build A Bat House?

     Rabies is a viral disease that almost always results in death. There is no treatment for rabies once a person has an active infection, so the only way to prevent death is to prevent the rabies by giving vaccines after a bite occurs.

     The most common animals in the United States that are infected with rabies are raccoons, skunks, foxes, coyotes and bats. From 2000 to 2004, 15 human cases of rabies were reported in the United States and 10 of those cases came from contact with bats. Rabbits, squirrels, chipmunks and mice do not seem to shed the virus in their saliva, but any carnivorous mammal can have rabies. Now that skunks and coyotes have become city-living animals, any out-door mammal is at-risk. Pet dogs, cats and ferrets need routine rabies vaccination.

     If a child is bitten by a domestic animal, the animal can be observed for ten days. If a child is bitten by a wild animal and the animal was killed or captured, the animal’s brain can be examined for signs of rabies. If the animal cannot be observed or examined, the child should receive immunization to prevent rabies. Prevention of rabies after a bite involves two medications – one for short-term protection and one for long-term protection. The first is given in one dose injected at the site of the bite (or split into two shots if the area that was bitten is too small). The long-term prevention is given in four shots – the first on the day of the bite and the others on days 3, 7 and 14 after the bite. The shots of the second vaccine alone cost almost one thousand dollars apiece.

     The reason for concern with bats is that bat teeth are very small and a bat bite might give no pain and no visible mark. Anyone who has had physical contact with a bat or is in a confined area with a bat when the person is not fully awake (like waking up to find a bat in the room or finding a bat in the nursery with the baby) needs to have the rabies prevention shot series.

     Which brings me back to wondering why there seems to be a “bats are your friends” movement in the nature groups. Building a bat house in your yard may decrease the mosquito population but four thousand dollars buys a lot of mosquito repellent.

You Can Lower Your Child's Risk Of Heart Disease

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     It is now very clear that elevated cholesterol, elevated triglycerides and obesity in childhood all create a significant increased risk for heart disease later in life. It is also clear that having normal cholesterol, avoidance of smoke exposure, and not being obese protects children from developing atherosclerosis in young adulthood. As parents, we have the opportunity to teach our children the behaviors that can help them have better health throughout their lives.

     Habits are hard to break once they are established, but parents can decide what habits their children learn.  From the time an infant starts solid foods at six months of age, parents determine what foods the child will eat and consider “normal”. We also teach eating habits and, in the fight against obesity, the way we eat is often as important as what we eat.

     There are many ways to decrease the extra calories that lead to obesity. Don’t give your child juices and sugar-sweetened drinks. From the very beginning, give the child real fruit rather than fruit juice and start right way putting water in the bottles when the child isn’t drinking formula. Don’t give prepared foods or foods with extra sugar added. Give fresh, frozen or canned fruits and vegetables and serve them at every meal. Limit high-calorie sauces such as cream and cheese sauce. Serve lean meats, limit red meat, take the skin off poultry after cooking it and eat broiled or baked fish as often as possible. Buy whole–grain breads and cereals rather than the high salt, added sugar, processed breads and cereal. Read the labels, but you don’t have to spend extra money for “natural” or “organic” foods that are often just marketing ploys. Limit eating out, especially at fast-food places where the serving sizes are huge and the calories are high. Limit the size of servings at home and don’t force the “clean plate” philosophy. After two years of age, give nonfat or low-fat milk. Use vegetable oil in cooking and avoid saturated fats and trans fatty acids. Finally, only eat in the kitchen. The habit of constantly snacking creates obesity and starts with popping a fruit snack or goldfish into an eighteen month-old’s mouth every time you’d like to quiet him down.

     Finally, there is the issue of exercise.  Getting the kids out of the house and away from the electronic games is difficult unless the child has grown up with the concept that the whole family takes a walk together after dinner – rain, shine or snow. Children want to do what their parents do and if they get used to walking, biking, jogging, or swimming with their parents, they’ll be looking forward to it – you won’t have to force them.

     The added benefit is that by teaching your child these habits, you’ll be doing them yourself and giving yourself and your child a head start in the fight against obesity and heart disease.
     Current recommendations are that all children should have lipid screening between ages 9 to 11 but earlier if a child has diabetes, exposure to tobacco or a family history of high cholesterol or triglycerides.