Measles 2025

 You may have heard the term herd immunity.

This is my best way to describe what we are talking about.

Imagine a forest. After a rainstorm, the trees are moist. A spark is unlikely to cause much damage. If the trees are dry and brittle, that same spark can cause a raging inferno quickly.

People who are unvaccinated are like dry trees. The more of them there are, the more danger there is of more damage to the surrounding area. If the fire is strong enough, even some wet trees don’t stand a chance. Some people (such as babies, and people with cancer or other immune compromise) can’t be vaccinated, and can’t help but be a ‘dry tree’.

Herd immunity is when at least 95% of people have the vaccine-induced protection.

We shouldn't need to be writing this post! Measles was eliminated in the US in 2000. It is horrible to see the news about the current rise in cases.

Measles, also known as rubeola, is very contagious

This virus is so virulent that ninety percent of unvaccinated people will catch this virus once they are exposed. What is even more alarming is that it can remain on surfaces or even in the air for 2 hours after someone has sneezed or coughed! If someone travels on a plane while they are contagious...that is a potential nightmare. One of the reasons that it spreads so easily is that people are contagious as early as 2-4 days prior to showing any signs of the virus and may remain contagious until the rash is gone, or 4 days after the symptoms are all clear.

How the measles rash spreads on the body

The measles rash follows a characteristic head-to-toe spread.

1. Incubation Period (7–14 days after exposure)

• The measles virus enters through the respiratory tract and replicates in the local lymph nodes.

• It then spreads through the bloodstream to various organs, including the skin.

• No symptoms appear during this phase.

2. Prodromal Phase (Days 1–4)

• Before the rash appears, the child develops high fever (up to 104°F), cough, runny nose, and red eyes.

• “Koplik spots” (tiny white spots on the inner cheeks) sometimes appear 1–2 days before the rash.

3. Rash Stage (Days 4–10)

The rash appears as red, blotchy spots that spread in a predictable pattern.

Day 1: Face and Neck

• The first spots appear around the hairline, forehead, and behind the ears.

• The rash spreads downward to the neck and upper chest.

Day 2: Torso and Arms

• The rash extends to the trunk, upper arms, and thighs.

• Individual spots start merging, forming confluent patches.

Day 3: Lower Body and Extremities

• The rash spreads to the lower legs and feet.

• By this point, most of the body is covered.

4. Recovery (Days 6–10)

• The rash starts to fade in the same order it appeared (face first, then torso, then legs).

• As it resolves, it leaves behind a brownish discoloration and fine skin peeling.

If you have a happy child with a rash, our guess would be that it isn’t measles. People with measles will look sick and likely have a high fever. The rash will not be one of the first symptoms.

Complications are frequent

They range from ear infections to pneumonia, encephalitis and/or seizures. 1 in 5 people are hospitalized after infection (roughly 1 in 4 when just looking at kids), often with pneumonia or brain swelling. 1-3 out of every 1,000 cases are fatal. Take a moment and reflect on what that means. This is a serious illness. This is not one of those illnesses to wish your child would catch in order to get natural immunity.

Vaccination

The routine measles vaccine is combined with mumps and rubella and is referred to as the MMR. The individual components have not been available separately for many years. The first MMR shot is routinely given to patients between 12-15 months and again between 4-6 years.

Why do we wait so long before giving that first MMR protection to babies?

Assuming that the birth mom has been fully vaccinated (or less likely has had the actual measles) infants are born with passive immunity to the disease. This immunity starts to wane and is considered mostly gone by the time the babies are between 12 and 15 months. If a child is vaccinated when they are younger than a year old and still have some maternal protection, the vaccine does not seem to be as effective for long term protection.

For the second dose there is the option of combining it with the chickenpox vaccine called Varivax. That combo vaccine is called Proquad or MMRV.

Just one dose of the MMR vaccine is thought to be 93% effective. The second dose is given just to catch the occasional person who didn't get effective immunity from one dose and bumps the effectiveness up to 97%. It can be given earlier than 4 years, but I am not too concerned about the timing of the second dose as long as patients have gotten the first one.

If you are traveling to a high risk area, the CDC will suggest getting the second shot early. The 2 shots simply need to be given at least 28 days apart and after the age of 1 year.

The MMR is a live vaccine and it is true that in some rare cases the reaction can be a little rough. Interestingly, most kids are just fine the day of the immunization. Typically the reaction comes along between 7-21 days after the shot. This reaction may include high fever and rash. This is not thought to be contagious. It usually lasts only a day or so.

Kids with severe egg allergies don’t need to worry about the MMR vaccine. Even though the vaccine is made using chick embryo cell cultures, it doesn’t actually contain significant egg protein. Studies have shown that even kids with a history of anaphylaxis to eggs can get the MMR safely without any extra precautions. The only vaccines where egg allergy is a concern are some flu vaccines and the yellow fever vaccine (which isn't routine anyway).

Before routine use of the measles vaccine, there were about 500,000 cases of measles in the United States each year, and about 500 deaths. Measles also led to about 48,000 people being hospitalized and another 1,000 people being left with chronic disability from measles encephalitis. Study after study has shown that there is no link between the MMR and autism, but there are still some folks reluctant to give their children the vaccination.

In July 2016, SB277 was signed into law. It is now a requirement that all children attending schools in California have the measles vaccine unless they have a medical contraindication. Since the law passed, I have seen a steep increase in vaccination rates. This law probably has saved lives.

Most schools just require 2 doses after the age of a year and don't care a bit about the timing.

Outbreaks

The CDC defines an outbreak as “a chain of transmission that includes 3 or more cases linked in time and space.” As this post is written, in February of 2025, the numbers are increasing. We are seeing an outbreak in a rural pocket of unvaccinated children in Texas. The CDC is currently updating its page monthly, so it is challenging for us to give you exact numbers. If you’re traveling to the South, check the local news sources before you go.

Travel considerations

Unfortunately, measles remains a common disease in many parts of the world. Each year, an estimated 128,000 people die from measles. Take a moment to recognize what a huge number that is! Quite a few countries and popular travel destinations have experienced measles outbreaks in recent years, including countries in Europe, Israel, India, Thailand, Vietnam, Japan, Ukraine, and the Philippines. This is only a partial list. Before your next trip, check your destination and CDC’s global travel notices.

If you do travel, pay attention to your health for 3 weeks after you return to make sure you didn’t bring this home.

Infants can get the vaccine early for travel or exposures

If you are traveling to a high risk area or there has been a possible measles exposure, the vaccine can be given as early as 6 months. You need to be aware that this early shot can’t be counted on for lasting protection. Your child will still require two shots after the first birthday. Your insurance company also might refuse payment if the shot is given outside of the routine schedule, but this is less likely if your doctor “codes” for the shot to be given due to travel or exposure.

If your child is over a year and has had only one MMR so far, go ahead and see about getting them their second shot early if you are going to one of the higher risk countries (or Texas).

It takes about 10-14 days to get any significant protection from the first MMR. Hence planning is important.

Hepatitis A is one more vaccine that can be given early for travelers.

Several years ago when I was working on my very first measles post, one of my adult friends said to me, "We all got measles and survived, what is the big deal?" My response was, "It is true enough that the vast majority of folks who get measles will recover intact and have lifelong immunity. However, one to three kids out of 1,000 will die; many more than that will be permanently harmed. That is too many when we are talking about something that can be prevented. That 1 child out of 1,000 matters."

Remember, that babies are vulnerable “dry trees.” We all need to do our part to keep them safe.

Extra note for adults - depending on when you were born, your original vaccination may or may not be still providing protection. You may have been given only 1 shot, a one time common practice; you may have been given an inactivated virus shot, which was also a long ago common practice; or if you were inoculated in the 1960s, you may have been given a relatively ineffective vaccine because of now-known manufacturing problems. The best way to make sure is to have your titers measured, or you can do what I just did since we will be traveling internationally later this year, and simply get a booster. Talk to your doctor about the best option for you.

Do you know your love language?

 I may have many positive traits, but being romantic is not one of them.

As is often the case, one half of a couple is more romantic than the other. It is rarely 50/50.

My husband Sandy clearly carries the lion's share of the romance in our marriage.

The poor guy is actually one of the most romantic men I know. How he got saddled with me is a question for the ages.

We often joke that February 14th is the one day of the year when he is grateful for the fact that my romance gene is apparently missing.

On Valentine’s Day, when flowers and chocolates have doubled in price, there is no expectation that he needs to partake in this made-up Hallmark occasion.

But, it seems as good a time as any to update my old post about love language. Are you familiar with this?

This idea comes from a book by Gary Chapman, written back in the 1990’s.

I first learned of it from my daughter Alana who refers to this concept in her work as a therapist.

The 5 love languages that Chapman identifies are as follows:

• Words of affirmation

• Physical touch

• Gift giving

• Quality time

• Acts of service.

Most people have one or two that resonate the most for them.

The first step is figuring out how you tick. What works for you?

Then think about your partner? How do you each need to receive love? How do you like to show it?

Here is a quiz that can help you figure it out!!

Are you able to have a conversation about this and actually spend some time pondering this? If you don’t have insight to your own needs, your partner doesn’t have a chance.

This is basic relationship building stuff.

I consider this valuable because anything that can be done to help couples have positive and loving interactions is going to directly impact their children in more ways than I can count.

Having a foundational conversation and understanding about what makes you feel loved is an excellent first step.

This isn’t just about your partner. Try to understand where other people in your life, including your children fall on this list. Everyone is different.

In her practice, my daughter Alana tells her clients that all love languages are valid, even if they do not resonate with you personally.

The list is also not set in stone, it is just a basic guide. You may come up with something that isn’t considered one of the standard five main categories.

In the ideal and healthy relationship, we show love to our partners, friends and family members in the way they understand, and receive love back in the ‘love language’ that charges our battery.

There is nothing automatic about this; as with most things in relationships, it takes a little bit of work.

I know that many people (women in particular) would prefer to have their partner be a mind reader, but alas, that isn’t usually the way it happens.

Consider this example: Your birthday is coming up. Your wish is that your partner would get you flowers.

But if you need to tell them that, the actual receiving of the flowers somehow is not quite as special as if they had thought about it on their own.

Having your partner know what you want and then be thoughtful enough to follow through is often more valuable than the actual bouquet.

In the partner’s defense, they would be delighted to get you flowers, just ask. They would like it if you communicated your desires. Your point is that you don’t want to have to ask. Round and round and round we go.

In another example, one person bestows flamboyant gifts, which are nice, but the recipient would have been much happier with a back-rub.

With a little intel, you can direct your energy to where it will be most appreciated.

Don’t make assumptions. My sister-in-law Barbara, a therapist and the author of Love in the Time of Chronic illness adds that to really make this work, you need to be deliberate and instructive about what you need from your partner.

Because people often regress during times of stress, it would be great to have these discussions in advance and revisit them periodically.

Keep in mind that your love language can change as often as your hair color. Circumstances change. The love language that you most relate to as a young single person can completely shift when you become a parent.

Physical touch may not be what you are craving when you are breastfeeding and exhausted.

Here is a bonus quiz about what kind of apology works best for you. (Thanks Alana)

I took it and found that restitution and accepting responsibility count much more for me than asking for forgiveness or expressing regret.

Final message for all the single folk who read this to the end. Sometimes you may need a reminder that it is so much better being on your own than being in a toxic relationship. Give yourself some self love and try not to let all the Valentine Day marketing make you nuts

Head Injuries/ When to worry/ How to manage

 Kids fall. When I was working as the advice nurse at Noe Valley Pediatrics, not a week went by when I didn't get the ‘call’. The mom or dad would be in tears as they recounted in horror that their baby fell. With young babies, this can happen if you leave them on an unprotected surface for even a moment. More often than not, the caregiver was close by, watching it happen, but couldn't move fast enough. That thud is an awful sound.

Of course it isn't only babies who fall. Children and adults have accidents and sports injuries all the time.

If your child falls or you are the first responder at any kind of accident, take a deep breath. The most important thing is to remain calm. You can give yourself some great self care, later. (glass of wine, bubble bath, hug)

Medical personnel will want to know:

• How far do you think they fell? The rule of thumb is, that if they fall from a height that is higher than they are tall, then they need to be evaluated. (Tripping from standing doesn’t count)

• Were they in a moving vehicle where the airbags were deployed?

• What kind of surface did they fall onto?

• What was the immediate reaction?

• How long did it take until they stopped crying?

Of course, if there is a loss of consciousness, or any possible neck injury, don’t move them, CALL 911!

A moment of stunned silence is common. If the fall is soon followed by crying it is unlikely that there was any loss of consciousness.

Do a quick head to toe assessment. Is there any obvious bleeding, bruising, sprains or fractures?

Put immediate pressure on any bleeding wounds.

Try to get a cold pack on any bruises. If you are out of the house, a cold drink from a vending machine is a good option. If you are near a freezer, a bag of frozen veggies makes a nice ice pack.

Kids might comply more easily if they know the routine. For toddlers and preschoolers, playing doctor before anything happens can be very useful. “Uh oh, we have a boo boo, quick, let’s put the cold pack on there to help make it feel better.”

There are also plenty of cute pediatric ice packs that might elicit cooperation.

I also recommend Arnica. I imagine that some of you are asking, “what on earth is that?” Arnica is a homeopathic remedy. It comes as a topical ointment or little oral pellets. Many parents swear that it significantly decreases bruises. Roll your eyes if you must, but I have seen it work. It is worth having some around. I would keep it handy in your diaper bag or backpack. Kids often like to have ‘cream’ applied to a little ‘owie’. Arnica is perfect for that.

Check the mouth and make sure there are no loose teeth. While you are thinking about it, I suggest that you have an established relationship with a pediatric dentist. In the case of a mouth injury this will be very useful.

Before you completely flip out, it is important to know that head wounds can create a huge amount of blood if there is even a tiny little break in the skin. If the skin remains intact, all that blood (that didn’t come out) can collect into an enormous goose egg. These can look alarming. Just to be on the safe side, a significant goose egg should be checked out to make sure there is no fracture.

Mild bruises and bumps by themselves are not a concern if the child is acting fine otherwise. The affected areas can turn all sorts of lovely colors as they resolve. Expect greens, purples and yellows.

Noticeable bruising around the eyes is worth reporting.

Simple bleeding doesn’t worry me as long as it stops within a reasonable amount of time. Hold pressure for at least 10 minutes. If it is still oozing at that point, you might need to go in to get the wound sutured or glued.

The potential bleeding that may be taking place internally is a different story. Any accumulation of fluid or swelling within the hard shell of the skull can cause pressure on the brain. A slow bleed might not show symptoms immediately, so I would be alert for at least a week or two after a significant impact. If there is anything going on in there, your child's behavior will not be normal.

Here is a gentle reminder that this post is NOT meant to freak you out. By far, most of the time kids are fine after a mild fall, but it is always wise to be on the lookout to make sure there isn’t a concussion.

Most of us have heard the term concussion, but might not actually know what it actually is. A concussion is a type of traumatic brain injury that stems from an impact that causes the head and the brain to move quickly back and forth. The brain may bounce or twist in the skull from this sudden movement. This in turn can cause stretching and damage to the brain cells as well as chemical changes in the brain.

If there is a TBI ( traumatic brain injury) you are going to have clues that something is not right. Physical symptoms would include

• dizziness

• balance problems,

• headaches,

• vision problems

• light sensitivity

• sleepiness

• nausea and vomiting

I actually give the kids "one free vomit". Often they have cried hard enough that they might spit up a little. Let's not worry about that first emesis. If they vomit a second time, it’s time to call your doctor.

Murphy's Law comes into play here. With children, vomiting could simply be a sign that they are coming down with a tummy bug. Nonetheless, if they whacked their heads and are now vomiting, they need to be checked out.

Regardless of symptoms, after any fall or accident, if you are worried, it is always appropriate to call the doctor's office to let them know what happened. It is reasonable to need a bit of reassurance! But more often than not, if your child is acting fine most of the time they will tell you to keep a close eye on your child at home.

What about sleep?

Assuming they are not showing any obvious worrisome symptoms, keeping someone awake after a head injury is not necessary:

If it is during the day, experts agree that once your child has calmed down it is fine to let them take their normal nap.

An overtired baby will be cranky and may be near impossible to assess. If they are nodding off, it is likely because they are tired, and not from the head injury. That being said, do not let them take a nap that is longer than the typical nap time.

If they are old enough that they no longer take naps, excessive sleepiness would be something to report.

Nights might feel a bit trickier. Research shows that if it has been more than 3 or 4 hours since the fall and there is no vomiting, you don’t actually need to wake them up.

Depending on how far and hard they fell, I would suggest checking on your child every couple of hours to make sure they haven’t thrown up and they seem to be peacefully sleeping. You can set an alarm to make sure you get up to do this.

The key is to monitor any status changes.

Traumatic Brain Injury symptoms are not only physical. We need to keep an eye out for social or emotional changes as well. If the head injury patient is having any of the following issues, bring that up with your medical team.

• anxiety

• nervousness

• irritability

• trouble with memory

• New onset insomnia

There is no downside to getting your child evaluated if you are even the least bit concerned. Most pediatric emergency rooms will do a thorough assessment.

They may order a Cat scan if there is:

• loss of consciousness

• suspicion for a skull fracture

• the patient is under the age of two and is showing any symptoms

Doctors will use their clinical judgement and make a case by case decision. A basic neurological exam might include the following

• Can they answer simple questions?

• Is there any complaint of blurry vision?

• Do the pupils react to light at the same speed? (some people have pupils that are not quite equal and that is their norm. It is a good idea to check your kids pupils before an accident so that you have a baseline)

• Can they touch their finger to their nose? Do this with each hand.

• Is there any clear drainage from the nose or ears? (Of course, what toddler doesn't have a runny nose?)

These little tests are obviously age dependent.

Newer protocols for concussion care are not as restrictive as they used to be.

Screen time has a big impact. Patients who abstained from it for the first 48 hours had a quicker recovery

• Rest right after the injury

• Take it easy the first few days when symptoms are more severe.

• Avoid any activities that seem to be making symptoms worsen.

• Anything that can cause eye strain is not a good idea. This includes screen time and reading

• Find activities that are quiet and relaxing and don’t need a lot of mental stimulation.

• It is okay for you to read to them.

Your child can return to non strenuous activities as soon as they start to feel better.

• Return to school gradually.

• If symptoms do not worsen during an activity, then this activity is OK for your child.

• If symptoms worsen, cut back on that activity until it is tolerated.

• Encourage outside time, such as taking short walks if the weather cooperates.

• Make sure they are getting a good night's sleep.

• It is especially important to avoid screen time and loud music before bed.

After the first 48 hours it is appropriate to try to get back to normal. Let the teachers know what is going on so they can get a little leniency if needed

Remember, after a solid knock to the head you are not out of the woods right away. Pay attention to any dizziness or headaches. This is especially important within the first couple of weeks. Get immediate attention for any vomiting or confusion.

Discuss return to sports with your medical team. The research is constantly evolving

The large majority (70-80%) of people with Traumatic Brain Injuries recover within 3 months. Every child’s recovery period is unique.

There have been some new findings that females across all the age spans recover more slowly from a TBI than males. Studies are being done to look more closely into that.

Nurse Judy adds that a trusted and gentle chiropractor might help with healing

Prevention

• Keep in mind that it is very unlikely that simply falling (toddlers learning to walk) will cause any actual damage.

• Accidents happen on the watch of even the most vigilant care giver.

• Sometimes a parent falls when holding the baby and they both get injured. Beware of trying to manage a baby along with armloads of groceries.

• I have seen “selfie” accidents. No photo op is worth it if your baby's head gets whacked in the process.

• Never leave your baby on a surface that they can fall from; they will!

• Watch out for wet squirmy babies right out of the tub. Using a towel or terry cloth robe can help give you traction. Skin to skin is especially slippery.

• Make sure your kids wear helmets when using bikes, scooters or skates. Model good behavior!

• Make sure your child is in the appropriate car seat.

• Make sure your house is child-proofed with necessary safety gates.

• Make sure that stairs are free from clutter.

• If your child is sitting in a shopping cart, make sure to keep a hand on it. I had a little patient reach over to grab a box of cereal and she toppled the entire cart over!

• Choose playgrounds that have a safer ground to fall onto. Sand beats concrete anytime!

• Sometimes all of this feels more traumatic for the parent than the patient!

Dr. Ted tidbits:

You can’t keep your child on a leash. A bonk on the head at some point is inevitable. It is a question of when, not if.

If you haven’t done something egregiously careless, then don’t beat yourself up when these little accidents happen.

If there is something going on inside the brain, it is not silent or subtle.

Stay safe!

I have quite a few readers who swear that my posts are eerily timed. I hope this one is full of information that nobody is actually going to need any time soon. With the Super Bowl this weekend it felt timely.

Nurse Judy’s Substack is free. I have no current plans to add a payment option. But feel free to pass these along and share.

Fevers/when to worry/how to treat

 One of the wordle answers this week was FEVER. That same day my grandson Elliot needed to stay home from preschool because he had an elevated temperature.

For everyone who doesn’t have a grandma on speed dial, here is the blog post that can answer all of your fever questions.

Everything you need to know about Fevers

Fevers tend to get parents very worried, but an elevated temperature is only one of the factors that you need to consider when evaluating a sick child. I am actually more interested in your child's overall mood and behavior than I am in any specific number on a thermometer.

An adult with a high fever is usually more miserable and needs to be evaluated sooner to figure out what is going on.

For kids, fevers are a right of passage. There are advantages for them to get all the common illnesses out of the way when they are young. Most of these offer some degree of immunity so they don’t catch them when they are adults. All of you parents who caught hand foot mouth from your kids because you somehow avoided it growing up, are nodding vigorously.

There are many methods out there for measuring body temperature. I personally don't feel the need to invest in any expensive thermometers. I am generally quite satisfied with digital underarm reading. The important thing is that however you measure it, your thermometer seems accurate. Test it on yourself or other family members and take your child's temp when they are healthy to make sure you trust it as well as to establish what the normal baseline is for your child. While 98.6 is considered an average ‘normal’ temperature. Some people run a little hotter or colder.

Here are a couple of links that give a good description of some of the thermometer options

https://www.nytimes.com/wirecutter/reviews/best-thermometer-for-kids-and-adults/

https://www.health.com/condition/infectious-diseases/best-thermometers

Years ago when I was still working in the pediatricians office, ear thermometers were notorious for giving absurdly high and inaccurate readings that would induce panic in their parents. The newer generation of devices may be more accurate, but keep the following in mind:

If your child looks quite ill and the high temperature correlates with symptoms, then take appropriate action.

If your child looks fine, please don't let a number on the thermometer freak you out. Instead, take a deep breath and look at your child! If they are grinning at you and singing, that is not someone I am terribly worried about.

Temperatures can be measured in either Fahrenheit or Celsius

Here is a quick conversion chart.

98.6 F=37 C

99.5F=37.5C

100.0F=37.8C

100.4F=38C

101F=38.4C

102F=38.9C

103F=39.5C

104F=40C

105F=40.6

For this post, I will be referring to the temperatures on the Fahrenheit scale.

However you take it, the route of measurement is important data to your reporting. 99 degrees under the arm is not quite the equivalent to 99 degrees rectally. Axillary temps can be roughly a degree lower on some kids. It is still perfectly fine to use the underarm method. Most of the time we are just getting a sense of the range. There is no clear consensus, but most doctors would consider any temp below 100.4 to be low grade.

For any child older than 3 months

As long as your child is active and happy, I generally don't feel the need to "treat" a fever unless it is over 101.5 or so.

I am much more concerned about the lethargic, whimpering child who has a normal body temperature than I am the singing child with 104. But, here is……

“Nurse Judy's rule’ about fevers:

If the fever is over 102 (it doesn't matter how you measure, just be consistent):

• Treat with proper dose of Acetaminophen or Ibuprofen

• Do a tepid bath or place cool compresses on the forehead, insides of elbows and neck

• This is not the time for fuzzy pajamas!

• Get them drinking. Little sips at a time are fine. A Popsicle or ice-chips are good for older kids.

• If you have a stash of breast milk, you can offer a ‘milksical’. Put frozen milk in one of the mesh feed bags and Voila.

• When we are trying to push fluids, adding a little splash of juice to their water is perfectly fine at this point; you are doing whatever you can to get the hydration going.

• re-check the temp in 45-60 minutes. We want to see some improvement by the 45 minute mark, but it can take 90 minutes before you get significant improvement.

• If the temperature is STILL over 102 after the medication and hasn't budged at all, we are dealing with a fever that needs to be evaluated.

If a fever higher than 101 degrees lasts for more than 3 days, even with a happy child, I consider it time to have a look so that you can make sure there isn't an infection source (like ear infection, urinary tract infection, strep throat or pneumonia.)

I would allow five days for low grade temps before taking them in.

Fussy kids who are inconsolable need to be seen sooner than that, fever or not.

During flu season, sometimes there are kids with fevers that are hanging on for five days or longer. If there is a known virus actively circulating in your area, your doctor may be okay ‘watching and waiting’ for another couple of days before asking you to come in for a visit. This would likely depend on if your little one is managing (drinking, peeing, easy breathing, consolable, fever responds to medications.)

Many viral syndromes "wave goodbye" with a rash. Roseola is a classic example. When I have a happy kid with a high fever, it is pretty common at day three for the fever to be gone. Now you have a fussy kid with a rash on your hands, but you also have an answer.

https://nursejudynvp.blogspot.com/2014/04/roseola.html

Time is the great fixer here, there is no need to be seen.

With most rashes, including roseola, when you push on the skin the area should lighten. This is called blanching. A purple rash that does not get lighter when you press is always worth calling your doctor about. Any fever that comes along with a purplish rash could be an emergency like meningitis. Don’t wait to be seen.

I remind you that your child’s activity and energy level are still the biggest clues. Generally with something serious it is clear that something is wrong. These kids are not running around babbling and playing. They are sick, and it is obvious.

It is useful for you to know that when children are in the process of spiking a fever, it is not uncommon for them to tremble and look shaky. This is normal.

Children with fevers may have a higher respiration and pulse rate.

When fevers are breaking it is common to have lots of sweating. They can soak right through the sheets!

It is also important to be aware that about 4% of children can have something called a febrile seizure. This is not the same as the trembling that I mentioned above.

Febrile seizures can be terrifying to watch, but they usually stop within 5 minutes. They cause no permanent harm. Trust me, if you have never heard of this, watching your child have a seizure has been reported as the scariest experience EVER.

Having the prior knowledge that they do happen once in a while and are generally harmless should help keep you from freaking out. If your child is having a seizure they may have large jerky motions and their eyes may roll back. Make sure their airway is open. It is perfectly reasonable to call 911. Your job is to stay calm.

If your child has had even one febrile seizure, your medical team is likely to be more aggressive with fever control and might advise you to treat even a low grade fever. It is important to talk with your doctor about this so that you have a plan in place that you are comfortable with. Fortunately, most kids grow out of seizures by the time they are 5 years old.

If your infant is under 3 months of age, it is important to pay much closer attention to any elevated temperature

Where infants are concerned, there are a few common causes:

*over bundling....

Seriously, When I was working at Noe, sometimes the new babies would come into the office with piles of blankets wrapped around them even on a warm day. I know that many of us have the tendency to bundle up an infant but the best rule of thumb is to dress them in one layer more than you are wearing. If your baby was indeed over bundled, get some of those layers off and re-check the temp in about 10 minutes to see if they have cooled down.

*dehydration...

Sometimes if mom's milk isn't in yet, babies can be simply dehydrated and need to get some fluids. This is the time that you need to squirt some milk or formula directly into your baby's mouth. You can use a syringe or a dropper. In some cases the elevated temperature will normalize fairly quickly from some fluids.

If there is no obvious cause for an elevated temperature, and it doesn't resolve within 15 minutes, your baby needs to be evaluated. Giving a fever reducing medication to a newborn should only be done under strict guidance from your pediatrician.

With the younger babies, it is always better safe than sorry. Certainly there is no down side for calling and checking in with your doctor just to be on the safe side.

Some general fever facts:

• Fevers turn on the body immune system. They are one of our body's protective mechanisms

• Many fevers can actually help the body fight infection.

• Fevers that are associated with most viral syndromes and infections don't cause brain damage. Our normal brain's thermostat will not allow a fever to go over 105 or 106.

• Only body temperatures higher than 108°F (42.2°C) can cause brain damage. Fevers only go this high with high environmental temperatures (e.g., confined to a closed car.)

Bonus tidbits from Dr Ted:

I have to reiterate everything that Nurse Judy has said above! Fevers are a difficult concept for a lot of parents to wrap their heads around, especially the first time they see one. It’s useful to remember that everybody’s immune system is different, and the exact same virus can cause a fever to 104 in one kid and pass without symptoms in another. An increase in body temperature is the body‘s response to “inflammatory cytokines“, chemicals released by your body's healthy tissues when they are under stress, like being attacked by a virus. Some bodies release more of these chemical signals than others, which is why different bodies have different temperatures to the same viruses. Immune systems also have different abilities to fight off different viruses within the same family, which is why some viruses pass without any symptoms at all in some children and the same virus can wreak havoc in others.

Parents always asked me, “At what temperature do I panic?“ My answer is 106. If you can trust that your child’s temperature is truly at or above 106, using Nurse Judy‘s techniques above, you must go to the emergency room. Anything below that is a question should be based on the child’s appearance.

Colds, Coughs and Congestion: when to worry. How to treat

 My grandson Coby is currently 10 months old and has a pretty constant runny nose. My daughter Lauren actually suggested that we work on this topic and call it, “Will I ever be healthy again?”

There are lots of colds going around. Dr. Ted and I are both fielding questions from friends and patients about kids who are frequently snotty and appear to be getting one thing after another.

We are right in the peak of the respiratory illness season. While it is never wrong to get tested for what’s causing a cold, it is generally more important to focus on the symptoms instead of a specific diagnosis.

Our primary goal with this post is to give some guidelines to help you figure out when a trip to the doctor's office is indicated. Many times, there is nothing to do but wait it out, so we are including some tips to help you and your child get through the illness as comfortably as possible. I have included standard treatments along with plenty of alternative options at the end of the post. I am comfortable trying some of the more natural approaches AS LONG AS you or your child are dealing with something mild. At the end I add some prevention tips.

Even if you don't have young children, colds and coughs can nail any of us. But if you are a new parent, buckle your seat belt. Studies say that most children will have an average of 9.4 symptomatic viral infections each year in the first two years of life. Think about that: if they’re clustered in the winter, that’s more than an illness every month. No wonder parents come in asking “will my child ever be well again?”

Most of the time the congestion is caused by a viral syndrome. Allergies and teething* can also be the underlying culprits.

{*Medical literature often disputes whether or not teething is connected to any symptoms, but I still maintain that at times it feels like it is an x in the equation.}

All that mucus is the perfect breeding ground for bacteria, which is why something that starts as a virus can turn into a bacterial infection. I have seen ear infections come on in a flash, riding the heels of mucous that’s backed up from the nose.

What symptoms do you need to pay attention to?

If you are dealing with a congested or coughing family member, consider the following questions. The most pressing concerns are listed first, and then go in order of decreasing importance:

Is there any labored breathing?

If someone is gasping for air and changing colors, stop reading this and call 911! This is on the top of the list because it doesn’t matter what else is going on. If there is any labored breathing or wheezing the patient usually needs be assessed. Grunting during an exhale or wheezy whistling sounds can indicate trouble.

When someone is working hard to breathe, respirations are faster and actually look different. You might see retractions, where it looks like the areas at the base of the throat, the sternum and between the ribs are actually sucking in. The nose might be flaring. The patient's color might be pale or bluish around the mouth. With young babies you might see their little tummies going in and out more than usual. Think about what your child might look like after running a baby marathon. It’s like that.

These kids that we are really worried about are never the ones happily running around and playing. They are low energy and look distressed.

Of course, simply noisy breathing isn’t always something to worry about (a congested nose can sound like a wheeze or a whistle), but it can be a clue.

Sometimes a big mucus plug may be momentarily blocking an airway, causing a minute of distress that clears with a big cough. If coughing and steam are able to clear things up, it is more likely that it is upper airway congestion which is not as much of a concern.

If you find that you are having a hard time assessing the respirations, try sticking your ear up to their lungs and see if you can hear anything. If you can hear nice clear swooshing air noises, that is great. If you hear whistles or squeaky noises, that may mean the congestion has spread down to the lungs. Using your ear as a stethoscope doesn’t always work; more than half the time you won't be able to hear anything, but once in a while parents are able to get some important clues from the "ear to chest" evaluation.

If your child is old enough to cooperate, have them take a great big deep breath, in and out.

If they are wheezy or have any inflammation in their lungs, that deep breath will often trigger a bit of a coughing fit.

It is a great idea to get a sense of what “normal” looks like. If you are lucky enough to be reading this when your child is healthy, lift up their shirt and watch them breathe for a minute or two. How fast are their normal breaths?

Check out the Tik Tok that Dr. Ted and I did. This was from our RSV post from a couple of years ago, but it is a really good illustration of what labored breathing actually looks like. A video is worth 1000 words.

(if someone had told me a few years ago that I would be doing TikToks, I would not have believed them.)

Knowing the actual oxygen level can be a good data point. There are oximeters available that can measure this. A number above 92% is generally considered adequate. Keep in mind that the oximeters out there that are available to consumers might not be as accurate on kids. With a little one, try using a toe instead of the finger. A low number might be garbage, so please don’t freak out. Remember: how a child looks is more important than a number from any device. If they have rosy cheeks, are running around and are smiling, we promise their oxygen is not truly below 86%. Remember, it is only one data point; one of the team members who summitted Kilimanjaro with Lauren and Sandy did so with a pulse ox of 70; that was his only symptom and he was fine.

Are they dehydrated?

If your baby is nursing well, that is very reassuring. We don’t get too worried if your child isn’t too interested in solid foods for a couple of days, as long as they are drinking. A sick child may not want to eat, but as Dr Ted often reminds his patients, they can technically survive up to 7 days without a single bite of solid food (although watching them temporarily lose weight drives parents nuts).

Hydration, on the other hand, is essential. If your child isn’t urinating 3 times per day, if they aren’t capable of making wet tears or have a dry mouth with cracked lips, you should call your doctor. Dehydrated kids are usually very low energy. There are hydration tips down below in the management section.

Do they have a fever?

Plenty of colds come with fevers. A fever that doesn’t go below 102 ninety minutes after the proper dose of medication, or a fever that is lasting more than 3 days should be checked.

More on fevers here.

How is their mood?

Anyone is going to be grumpier than usual if they have a cough or cold, but if your little one is really fussy and doesn’t have the language to tell you what’s wrong, I might suggest getting their ears checked to rule out an ear infection. Not all ear infections need to be treated, but it is worth seeing what’s going on in there. A dose of Tylenol or Advil usually makes a huge difference with the mood when a child is sick. If you have a miserable kid on your hands or if your child is still looking very out of sorts despite their fever being controlled, that might be a reason to get checked.

What’s the quality of their cough?

There are a lot of different coughs. Wet coughs, dry coughs, coughs that come in spasms, and coughs that are so forceful they can break blood vessels in the eyes. Not all wet and productive coughs need to be seen, nor do all of the frequent dry coughs. Here are some of the coughs that should be seen sooner than later. Coughs that:

• Are associated with respiratory distress (see above)

• Come with blood

• Cause repeated vomiting

• Break multiple blood vessels in the face or eyes

Are they sleeping well at night?

A cough that consistently wakes a child up from sleep is worth getting listened to. The congestion and coughing alone can be a reason that it is hard to sleep, but if the ears are an issue, ear pain is worse when your little one is in a flat position, so we would want to rule out an infection if you have more than one completely miserable night.

What color is the mucous?

We are more interested in mucus that is getting thicker and greener. Green mucus does not automatically signal a problem (green mucous signals length of illness time, not necessarily the presence of a bacterial infection); it is just one more clue. It is common for mucus to have more color when they first wake up and then to clear throughout the day.

How long has this been going on?

Most colds and coughs can last between 1 and 2 weeks but it is common for some coughs to linger for another couple of weeks before they are completely gone. It is also possible that they caught something new. Sigh.

A 6-week cough in and of itself is not a concern if it’s not getting worse.

It is okay to play the wait and see game if your little one is:

• Reasonably consolable

• Mucus is mostly clear (greenish in the morning that clears throughout the day is fine)

• Staying hydrated (drinking and peeing)

• Sleeping isn’t horrid

• No breathing concerns between coughs

• Fever controllable and lasting less than 72-96 hours

If your baby is less than 3 months we are often quicker to get them checked out.

Tell your doctor if there has been a recent exposure to Covid or another illness. If family or friends are having similar symptoms, that information will be useful.

Nurse Judy’s Management tips

Hydration is key! The best way to manage congestion at home is to make sure your little patient is getting plenty of fluids. This will help to keep the mucus thinner; it will also keep the mucus membranes moist, which in turn makes it easier for them to clear debris. It’s also the one thing they can’t go without.

With some older kids, cow's milk may not be the best choice because it can increase the amount of mucus (it doesn't impact everyone the same way.) I have plenty of patients who love their milk, and taking it away for a couple of days is not a reasonable option (without kids and parents having a panic attack). Relax, sometimes thinning it with a bit of extra water is a good compromise. Breast milk is the perfect liquid if you are lucky enough to have it.

Warm tea with honey (for kids over the age of one) can soothe the back of the throat and ease the coughing.

I am not a big ‘juice’ fan, but a splash of some juice into their water can sometimes be the magic that gets them to drink a bit more.

Perhaps make a sticker chart to incentivize sips.

For older kids and adults, don't minimize the value of chicken soup!

Steam is great. As we mentioned above, moist mucous membranes in the nose clear debris much faster. Hang out in the bathroom when anyone takes a shower. Running a humidifier or vaporizer at night can be very useful. Turn it off during the day and give the room a chance to dry out so that you don't grow mold. Make sure you change the water daily. And don’t forget to periodically clean the unit. As long as you follow those rules, I don't have a preference between warm or cool mist.

Keeping the head elevated makes a huge difference. Some of the younger babies will do best napping someplace where they are on an angle. This is fine as long as they are monitored. For night time, if you want them on a little slant, according to the new AAP guidelines it shouldn’t be any greater than 10%.

You can put saline drops or breast milk into the nose (and then suck it out with a nose frida. This is likely the best way to actually clear the nose. Your baby will no doubt hate this, but if you can manage to do it about ten minutes before a feeding, it may clear the nose up enough to make eating much easier.

I really like xlear nose spray. But I am realistic enough to recognize that it is the rare toddler who is going to cooperate with any drops or spray of any kind in the nose. If that is the case for you as well, try the AYR saline gel. When my grandson Elliot was younger, Lauren got creative and convinced him to ‘see if he could smell it’ and it worked well. Now he is four and actually likes the spray when he is in the mood. Don’t give up.

Some of my parents really like the Oogiebear nose and ear cleaners. These are safe, soft little plastic scoops that allow you to remove stubborn little boogies.

Consider acupuncture! One of our neighborhood acupuncturists gets some good results from her treatments for your basic coughs and colds. Her treatment of children often does not use any needles. She also has some Chinese herbs that can be very helpful. Find her at: The Acupuncture Den

Is there something I can give them?

The standard cold and cough meds that many of you grew up with are no longer recommended for children under the age of 6 years. If your kids are utterly miserable and are having an impossible time sleeping due to coughing and congestion, many seasoned pediatricians may recommend a dose of Zyrtec or Benadryl at night to help dry the kids up and give them (and you) a break. Before I would do that, I would want them checked out to make sure the lungs and ears are clear.

Homeopathic and Other Remedies

There are some homeopathic remedies. Boiron and Zarbees are two popular brands. They both have products that are safe for infants. Make sure that anyone under a year uses the appropriate formulation.

There is another product on the market that you likely haven't heard of. Dr. Loo, a local physician, has created a patch to treat the symptoms of congestion with chamomile and ginger.

Dr Loo Harmony Patches

These are safe for any age! Several years ago she gave me samples for my patients to try. In some cases, the parents reported that they thought they indeed seemed to help. In any case, they are not terribly expensive and there are no safety concerns.

For night coughs, without taking anything orally, you might try a bit of Vicks Vaporub on the feet! Trust me, I scoffed at that as much as anyone, until I asked my patients to test it out and was shocked at how much it seems to help. A little dab under the nose can also sometimes help clear things up. Do NOT place it inside the nostril.

Prevention

For parents and big kids I really like

• Sambucol

• zinc lozenges.

• Ester C

I have heard folks consider these to be placebos, but in my case I say "bring it on" because they seem to work.

Remember that I used to work in what could have been considered a veritable germ factory and (knock wood) I usually managed to avoid many of the things I was exposed to. The second I feel that little tickle in my throat or any tell-tale signs of an illness I take a zinc cold therapy lozenge and a Sambucol lozenge twice a day.

Nasal/sinus irrigation

Another very good thing to do for folks who are old enough is to use a Neti Pot or sinus irrigation. Make sure to use distilled water. NeilMed has quite a few excellent products to help clear out the nose. For nursing moms, this is my absolute favorite remedy. If you have a deviated septum, this may not work well for you.

Teach your kids who are old enough how to blow their noses.

Lots of kids have ZERO idea how to do this, so they need to be taught. Important factoid: never blow both nostrils at the same time. That’s more likely to send mucous into the ear canals. Instead, plug one nostril at a time and blow. Play games with a tissue. See if they can make it dance by blowing on it. Start with the mouth and then see if they can make it move by blowing it with their nose.

It is also good to teach your kids to cover their sneezes and coughs when possible by coughing into their elbow

Good hand washing is of course essential.

Related posts:

• When is your child contagious?

• Croup

• RSV

• Boosting your immune system

Thank you to my models Sawyer, Elliot, Noam and Aviv!!!