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!!!

Tummy Bug Basics/Poop Puns because you may need to laugh

 

Tummy Bug Basics

Norovirus is making the rounds. Dr Ted and I decided that this is a good time to update our tummy bug post from a couple years ago.

By far most of the tummy bugs that people get resolve on their own. A tincture of time will usually take care of them. The typical symptoms are stomach aches, vomiting, loose stools and sometimes fever. Not everyone has every symptom. Vomiting without the loose stools could also indicate something else going on, like strep throat, a urinary tract infection, an ear infection or even appendicitis. When the diarrhea comes along, the good news is that it usually signals that we can narrow our attention to some type of gastro-intestinal issue. The bad news of course is that when the patient is losing fluids from both ends, dehydration now becomes more of a concern. I also don’t want to minimize how miserable it is when you are in the full throes of an acute GI episode and don’t know whether to sit on the toilet or kneel at it.

How do they spread?

Viruses like the Norovirus or Rotavirus are spread in a variety of ways including

• Having direct contact with an infected person

• Consuming contaminated food or water. If an infected person is involved in preparing the food, tag, you’re it

• Touching contaminated surfaces and then putting your unwashed hands in your mouth. For parents of kids who are vomiting, be careful when you are cleaning up after them. This can easily go from family member to family member

• Note: A swipe of hand sanitizer isn’t going to help all that much. It doesn’t kill these viruses. For handwashing, you need soap and water. For surfaces you need something that contains bleach.

For young babies

If your baby is under two months old and you suspect that they have a tummy bug, it is important to monitor them closely. Young babies can get dehydrated much more easily than a larger child or adult.

Of course it is not always easy to know what's up with the little ones. Many babies spit up on a regular basis daily. Actual vomiting will usually have a larger volume and be more forceful. Baby poop can seem pretty liquid and diarrhea-like even when everything is perfectly normal.

It may be worth checking in with a doctor if the stool is copious, watery, and clear, there has been more than one episode of vomiting in a several hour period, and they are fussier than usual.

If they are nursing well, and peeing fine, that is very reassuring, but if they are little and you are worried, go ahead and get them checked.

How to assess hydration

If your child is running around and has good energy, I am usually not too concerned. There is a big difference between subdued and lethargic. Some kids are well hydrated but still feel lousy and are quieter than usual. We can call them subdued. If you have a kid with big juicy tears and lots of drool, they are probably not terribly dehydrated. The body doesn’t waste the fluid.

On the other hand, a dehydrated child is lethargic. They do not want to play. The urine is more concentrated (darker and smellier) and way less frequent. Their mouths feel dry. Their breath might be stinky (of course if they have been vomiting that is probably a given.) Their skin may be dry. Normally if you pinch up a bit of skin on the wrist, it will immediately correct itself. If someone is dry, it may remain up in the pinch for a moment.

Please note, so that you don’t freak out, right before someone is going to vomit, it is normal for them to look quite miserable. Some kids get very pale and shaky. Some folks actually look greenish. Once they throw up, most of the time they feel a bit better and the color normalizes.

Home treatment is usually adequate

Frequent but tiny amounts of fluids is a remarkably effective approach. If you are breastfeeding, smaller, more frequent feeding will often be much easier for the baby to keep down. It is okay and even expected for the patient to have less of an appetite for food for a few days. Unless the person is extremely slender, we are not too worried about a bit of weight loss. Most folks will gain it right back up when this passes. Don’t stress about the food intake. Pushing food will likely just aggravate the situation if they aren’t hungry.

Your only job is to make sure that they are getting adequate fluids.

Dr. Ted reminds us that children can technically go seven days without a bite of solid food before it’s medically a problem. You just need fluids with electrolytes to survive. Start by giving clear fluids (breast milk is great if you have it.) Because we lose lots of those electrolytes when we vomit or have diarrhea, it is best to replace the fluids with something that replaces the electrolytes as well. Water is not your best choice (but works if it’s all they’ll take). There are products on the market that are specially formulated for this purpose.

Pedialyte is the classic brand that has been around for many years. They have significantly improved the taste over the years. It used to taste like soap.

The exercise drinks like Gatorade are another option but have more sugar than the Pedialyte. Pedialyte is one of the products that is worth keeping on hand so that you are prepared if a tummy bug strikes. It also comes in popsicle form which is great for older kids, as well as a little tube of powder that you mix yourself. (I believe that it makes a great addition to any travel emergency kit.)

I don’t have any hard and fast rules about fluid amounts. Electrolytes are the better choice, but you have to do the best you can if they simply refuse those. Try some diluted juice, coconut water, ginger ale, or colas that have lost some of the fizz. Whatever they are agreeing to drink, wait a bit after they have thrown up before offering anything. There is nothing exact about the timing. I generally try to wait 30 minutes after they vomit before giving anything. Many folks tell you to wait longer than that. But if they are begging you for sips, go ahead and offer something.

Think of a drip irrigation system. If all you can get in there is a dropper-full, that’s okay! Get that fluid in, drop by drop, ice chip by ice chip. Do the best you can. Plus, if someone is busting your chops for a cracker, a nibble of a saltine may actually feel a bit soothing. If the worst comes to worst, and you move too fast, they will just throw up again and you will know that you need to wait a bit longer before offering the next sip or nibble.

Don’t let them guzzle. Stick with an ounce at a time. If you have a tiny tea set, or a fancy shot glass, those are fun ways to measure small amounts. You can have a star chart for the reluctant drinkers.

If your child has an elevated temperature as part of this illness, a tepid bath can help get the fever down. If the bath hasn’t done the trick, the fever is over 101, and your child is miserable, it is worth giving some fever-reducing medicine. Ibuprofen tends to be a bit harder on the stomach so I would choose acetaminophen (Tylenol) when I have an illness that includes tummy symptoms. Another advantage to the Tylenol is that it comes in suppository form, so it is more easily tolerated by a vomiting kid (Tylenol/Advil Dosage Chart).

Generally, vomiting is the first thing to ease. If they remain nauseated, there is a magic pill called Zofran. This is an effective but strong medication. Most doctors would like to do a quick evaluation prior to prescribing this, to make sure they are not ignoring an underlying cause that needs treatment.

Time to get evaluated

If they are refusing fluids or can't keep down anything, you need to check in with your doctor’s office. That is a signal that their tank is really empty and they need help turning things around. These are the kids that are significantly low energy. It is worth remembering, however, that most doctor’s offices don’t do IVs.

If the child is truly lethargic (can’t be roused for more than a couple seconds) and you have been attempting small amounts of fluids and failing, or if they are vomiting up blood, or anything that looks like copious coffee grounds, or bile (bright green, not just yellow) then a trip to the emergency room is appropriate. Once there, your child may get some IV fluids which will often perk them right up.

For adults, just google mobile IV services to see if you live in an area where that is available. If you know you simply need fluids, this is a great way to avoid a trip to the emergency room. If you don’t know what is going on, it is worth seeing an MD

Recovery and advancing the diet

Once your child has started keeping down fluids, it is okay to advance the diet if they are interested in food. More often than not, we expect the stools to continue to be looser than normal for a bit longer. Dr. Ted observes that the younger the child, the longer the stools tend to remain loose. Trust your kids to some extent. I find that most of the time they crave the foods that their bodies can handle. If you have an outlier asking for a hotdog, follow your instincts and say no.

Bland starchy foods are your best bet. I suggest a modified BRAT diet. Bananas, rice, applesauce, crackers, toast, potato, pasta, boiled chicken and watermelon are all okay. I find that folks have a quicker time getting over this if they avoid dairy (some folks can stay on yogurt and tolerate that fine). There are plenty of dairy alternatives.

In my experience, getting started with probiotics right away can be helpful in getting over this quickly. Fermented foods are also very beneficial when they can handle them. We need to get the gut healthy again so that it can tolerate a normal diet and the good bacteria in the probiotics is critical to this. There are plenty of good brands out there. Jarro is usually easily available at Whole Foods and has a baby formulation.

One of the most common calls to the doctor’s office after a tummy bug is when a patient seemed like they were improving and seemed to have had a bit of a relapse. This is usually caused by advancing the diet a little too quickly (especially dairy.) You may need them dairy free for a week before things return to normal. Yes, this includes cheese. See Dr. Ted’s tidbits below for an explanation about this.

What if it isn’t a virus?

It could be bacterial. If you or your child has a fever, chills, bloody diarrhea and vomiting, that could be bacterial food poisoning. The most common culprits are E. Coli, Salmonella, Shigella and Campylobacter. Sometimes the symptoms might not show up for a few days, making it hard to identify the source.

Even though many of those illnesses are self limiting, getting seen is a good idea. Your doctor may send a stool sample to the lab to check for a bacterial stool culture. If testing is positive, doctors are mandated to report these diseases to Centers for Public Health (so that outbreaks can be tracked). There are usually special containers required for this.

It could be parasitic. If you or your child are just back from travel or camping and have awful gassy, incredibly stinky stools with bloating, we should make sure that you don’t have giardia or some other parasite. If that is a possibility, we would send another type of stool sample to the lab that requires a different set of specialized containers. This is called an O&P (ova and parasites.) As opposed to many of the other tummy issues, these do not usually resolve without help of some medication. Even if you haven’t been around any obvious sources, if you have a pet with loose poops, that can be an important clue. Dogs can get it from drinking nasty water and then can spread it to their humans.

Dr. Ted’s Tidbit

The intestines can take a long time to recover after an infection. It’s important to understand that vomiting or diarrhea after recovering from a tummy bug are not necessarily signs that the infection is still active. Up to one third of patients will have weeks of irritable bowel symptoms after recovering from bacterial gastroenteritis. Many symptoms after recovery from a tummy bug can be explained by understanding the physiology of the intestines. The intestines represent your largest internal organ and demand a ton of cellular energy. Often-times, the entire internal lining can be significantly damaged after a tummy bug. In the weeks it takes to repair all that lining, patients can feel unbelievably drained because of the energy required to create new cells. The damaged intestinal walls also may lack the enzyme lactase, which typically sits in the walls of the cells that line the intestines and can be lost after infection. That may cause new symptoms of lactose intolerance, diarrhea, bloating, or even vomiting or reflux after having dairy or other large meals. If you’re experiencing symptoms after recovering from gastroenteritis, stick with Nurse Judy’s advice and eat small, easy to digest foods.

Extra discussion points

• With anything poop related, often defense is your best offense. Wash your hands!!!

• While it is quite normal to lose a little bit of weight, getting a baseline and monitoring recovery is important.

• Any steady abdominal pain that is lasting more than several hours should be evaluated.

Most of the things we discussed above can be considered acute issues. Ultimately with time or appropriate treatment they will be relegated to just a bad memory.

When you don’t find an answer and the symptoms continue to be an issue, I would no longer consider it to be acute.

Chronic intestinal issues should not be ignored. Many times general tummy pain in an otherwise healthy child is from constipation. Gas pains tend to be sharp and intermittent. Start keeping track. When and if you do see a doctor this data will be valuable:

• Where is the discomfort?

• How long has this been going on?

• Do other family members seem to be impacted?

• How severe are the symptoms?

• Does it get better or worse with food?

• Does it come and go away on its own?

• If not, what did you try the may have helped?

• How often are the poop? Are they hard or soft?

If you’re in the mood for it here are the poop puns

Many years ago when I was working at Noe Valley Pediatrics, Norovirus was out in force and was making headlines.

One of our patients' moms was a reporter on a local news station. She wanted to interview one of the providers about what we were seeing. I cajoled the doctors to no avail and ended up being the only one willing to be on camera.

Later that day I did a little facebook post letting folks know that they might get a glimpse of me on television.

My facebook post took an unexpected turn.

My family can’t pass up a good opportunity to make puns and they jumped right in.

They were joined by an assortment of friends and family. The thread comes up on my facebook memories every once in a while.

If you are one of the unfortunate folks who is trying to decide between sitting on the toilet or kneeling by it or is busy cleaning up someone else’s poop or puke,I am going to attempt the challenge of giving you something to laugh about.

Judy: I had 30 seconds of fame on the local news….talking about poop

Several friends asked for the link and then the puns started to roll in

Lauren ( my oldest daughter): mom, i believe it is your doody to share this link with us

Lena (my niece):Bahahah.

Judy: well, number #1, I don't have the link yet and number# 2 Lauren, do you really want to go down that road??

Alana (youngest daughter): Awww shit. More puns?

Sandy (my partner):I almost fell off my stool!

Lena: Impressive dedication to defecation!

Alana: Now you're just talking crap, daddy

Aza( Alana’s friend) You guys…just can it

Alana: Oh come on, we’re just getting loose

Sandy: Well, this is a well formed discussion, but it does occasionally get a little loose

Emily (friend of Alana) Alana invited me to come join the potty, so I figured I’d dump everything else

Lauren: There are so many crappy puns floating around enema head, I don’t think I could flush them out if I tried

Anya (Alana’s friend): Well lookie-loo what do we have here? Do I need your permission toilet me join in the fun?

Sandy: I wish I had a pun to add to this, but I feel like I’m constipated

Anya: Well maybe you need to try some re-laxative breathing

Lauren: I just hope these puns don’t get too corny, because you know they’ll stay that way for days

Anya: Don’t make me Crohn

Lauren: You know, intestine me with your puns, you’re making me want to keep going, but for everyone’s sake we should take some time to digest what just happened on Judy’s wall. Log it away as a complete waste of time...and just stop and enjoy this video

And with that I bid you a-doo

Anya: You’re correctum, I should probably get back to anal-lizing my homework. Toot-eloo

Judy: I feel like I must apologize to the innocent original folks who commented on my status without knowing what they were in for

Anita (one of my best friends): Wow, I’m impressed by all the really good puns. I can’t seem to pinch one out myself

Aunt Millie: Well, my thoughts on this. DEPENDS on a myriad of…. SO proud of my family!

Lena: It’s a very odd thing to be proud of, but I have to agree. I may or may not be posting a screenshot of this to Reddit. And when I changed people’s names to protect the innocent, Alana may have become cousin #2…sorry

Laurie P (a friend of mine): This has got to be way more entertaining than the orig-anal airing

Sandy: Enough of this, I’m pooped

Lena: I thought I had a good pun to add here, but it seems to have been wiped from my memory

Jim (my Brother in Law): I’ve been straining all morning to come up with a pun to add to this thread, but it’s just not happening right now

Amy (my sister): I too have the urge to contribute to this pile but I’ve got nothing…besides this conversion is becoming ab-turd

Judy: I thought you were al colon it quits but these puns keep coming

Aunt Millie: Ha, this is becoming fumier and fumier, tee-hee to the French

Jeannie (an old friend from nursing school): I’d still like to see the original news clip to see if it is as funny as all of the comments

And over the years when it came back as a facebook memory it still gets a few random comments

Lena: Are we all going to start droppings in here again?

Judy: I was looking for this link to show to my Oath team, time to wipe it off

Alana: Just a reminder that this exists

Sandy: Alana, you little turd, you had to bring this up again?

Kenna sera: #1 I still never got to see the clip and #2, I’m genuinely impressed by the puns and the effort

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And there you have it. Can you think of another pun that didn’t make it to the list?

The Christmas Cactus

 My grandmother had an enormous plant known as a Christmas cactus. These plants are expected to bloom once a year. December is the common time for the flowers to come out, hence the name.

Grandma gave a cutting to my mom.

The cutting that my mom had thrived. It didn’t know that it was supposed to bloom just annually and would occasionally burst into bloom throughout the year.

Regardless of what was going on in the world or her personal life, mom would be joyful every time the plant bloomed. For her it was a signal of hope and positive energy. It was infectious and the entire family would somehow feel a lift.

When my parents were still alive, I made sure to go home to Pittsburgh every four months or so; these visits were even more frequent as both my parents got older. Scoff if you like, but more often than not, the plant would flower right before my visits and stay that way for several weeks.

My older sister inherited Grandma's plant which also seems to have a mind of its own.

When mom died, my sister gave me a cutting of the plant. To say that I have not been very good at keeping plants alive is an understatement. Fortunately, Sandy has taken on the role of the plant tender.

Historically he was no better at gardening than me, but after years of killing anything even remotely green, we now have an array of indoor plants that are flourishing under his care. The centerpiece is the offspring of the family plant. It has quadrupled in size since we have had it. It now has several offspring of it’s own.

This month right before my grandkids came to visit, it burst into bloom with gorgeous pink flowers.

Coby was captivated and we spent quite a bit of time directing him away from the plants. He really wanted to see how they taste.

The kids left, but the plants are still flowering. They magically fills me with a sense of joy. I feel my mom’s presence.

Goodness, we all need hope and optimism more than ever for this new year. There is so much going on.

If you are feeling down, please hang in there. The cactus is blooming.