Fever: What Parents Need to Know

When should a parent worry about a fever in their child? With the flu and cold season lurking just around the corner, now is a good time to know how to treat a temperature and when to report it.

First of all, some basic information is good to know. Fever is a normal response of the body’s immune system, and everything designed to kill infection works better when the core temperature of the body rises. When we sense a foreign invader, our “thermostat” resets to a higher temperature—101.5 taken rectally usually being the cut-off. (Remember that rectal temps are better indicators of core temperature and will generally run about a degree higher than one taken under the arm.)

It is important to note that very few fevers are dangerous, the rare exceptions being a “broken thermostat” which only happens in severe hyperthermia (heat stroke) and malignant hyperthermia (a rare condition brought on by anesthesia). As a matter of fact, many children go on with their normal routine and act happy.

So when do you treat fever? When the child is uncomfortable or it becomes difficult to determine just how sick they are. For instance, I only gave anti-pyretics to my kids when they looked sick—never simply in response to what the thermometer read. In these instances, Tylenol (acetaminophen) is the drug of choice, Ibuprofen as a second line drug. (Aspirin is never used in children because of the risk of Reye’s syndrome.)

It is important to be more aggressive when the diagnosis underlying the fever is in question—always in infants under two months of age. Also, because a child with a high fever can look very ill, observing what happens when the fever is brought down reassures us that nothing serious is going on in terms of infection. So, always call for fever in an infant under two months, and in children who don’t respond to anti-pyretics.

To Summarize:
• Most of the time fever is beneficial, helps us to get rid of the infection
• Treat only for comfort and to help aid in the diagnosis
• Call for any fever in children under two months, and also in children who you think may be ill (fever lasting more than a couple of days, or children who don’t respond when the fever comes down)
• While anti-pyretics such as Tylenol and ibuprofen are safe, they are not always necessary
• Always call if you are unsure about what to do!

Dr. Ron Grant
Pediatric Hospitalist
Meriter Hospital
meriterkids.com

National Turnoff Week

This week, September 19-25th, is National Turnoff Week. The Center for Screen-Time Awareness organizes this challenge which is endorsed by the American Academy of Pediatrics (AAP). Families are challenged to turn off their television sets, computers, electronic games and other electronic devices for the entire week. Most people in the United States, children included, watch too much TV and spend too much time in front of their computers.

Besides the negative health effects from these sedentary activities, studies have shown that children who watch too much TV are more likely to have behavioral and aggression problems. The AAP recommends that children have no more than 2 hours of “screen” time per day (TV, computer time, video games, etc.) and that children younger than the age of 2 years watch no TV at all. Despite these recommendations, the average American child watches 3 hours of television a day.

This week, think about stepping up to this challenge. Right now, you are probably thinking, “what on earth are we going to do instead?” Think about reading books, playing board games, putting together puzzles, doing an art project or redecorating a room in the house. If the weather is nice, take a nature walk, visit the zoo, clean up your neighborhood or plant some flowers. Visit an apple orchard, pick some apples and make an apple pie together. The possibilities are endless! The goal is to have fun and reconnect as a family.

Once you have done this for the week, think about making this part of your routine. Pick two or three days a week to unplug the electronics and “tune in” to each other. Your family will be happier and healthier because of it! Are you and your family up to the challenge?

I would love to hear what you think about this challenge and what activities you and your family have planned! Post your comments under the article on facebook.com/meriter.

Dr. Nicole Baumann-Blackmore
Pediatric Hospitalist
Meriter Hospital
meriterkids.com

Child Passenger Safety Week: What you need to know (Part 2)

As we approach Child Passenger Safety Week, here are some important things to think about and remember:

Even though it is not required, REAR FACING UNTIL TWO YEARS of age is safest. Children who are 12 to 23 months old are FIVE TIMES SAFER if they face the rear rather than the front. Some folks worry about injury to the legs, but lower extremity injuries are rare in the rear-facing position which offers much better protection against spinal injuries. Many car seats available today have higher height and weight limits allowing you to use them longer than older seats. Every seat has a height and weight limit, and these limits can vary depending on whether the seat faces the rear or the front.

Children younger than 13 years old should ride in the back.

Car seats have an expiration date, usually 6 years after the manufacture date. Please do not use a seat that is more than 10 years old.

Car seats need to be replaced after an accident. Some insurance companies will cover the replacement cost. It may be possible to reuse a car seat after a minor crash. See http://nhtsa.gov/people/injury/childps/childrestraints/reuse/restraintreuse.htm for guidelines.

Avoid secondhand seats unless you are sure it has not been in an accident and it has not been recalled. It should have a sticker stating the manufacturer, the manufacture date, and the model number. You will need an owner’s manual which is often available online.

Car sear injuries can happen OUTSIDE of the car, especially in children younger than 4 months of age. Suffocation or head injury due to falls can occur. If the seat must be elevated (like on a counter), then the child should be strapped in, the surface should be firm, the seat should be far from the edge of the surface, and there should be constant supervision.

If you plan on using a car seat on a plane, it should be FAA certified. Car seats are recommended on flights for children up to 4 years of age. Install them just as you would in a car with a lap-only belt. The car seat should be put in a window seat.

For an overall reference, check out http://www.healthychildren.org/English/safety-prevention/on-the-go/pages/Car-Safety-Seats-Information-for-Families.aspx.

Be safe and enjoy the ride!

Dr. Tracy Lee
Pediatric Hospitalist
Meriter Hospital
meriterkids.com

Child Passenger Safety Week starts 9/19 and ends with National Seat Check Saturday on 9/25

Motor vehicle accidents are a leading cause of injuries and fatalities in children. Many of these injuries can be prevented, but OVER 75% OF CAR SEATS ARE USED OR INSTALLED INCORRECTLY. In some places, that number is as high as 95%.

What goes wrong? The car seat is not fastened tightly enough to the car. The child is not strapped in tightly enough. Clips, straps, or the seat itself is in the wrong position. The child is advanced to the next level of restraint too soon. Not all car seats will fit all cars. That’s why it’s important to get your car seat checked.

Even if you can’t make it on Seat Check Saturday, you can find a nearby certified technician who will check your seat for free at http://www.nhtsa.gov/Safety/CPS.

Wisconsin law states that ALL passengers are supposed to be restrained regardless of age or position in a car. Straps should be at or BELOW the shoulders for rear-facing children. You must be BOTH 1 year old AND at least 20 lbs to face the front. Straps should be at or ABOVE the shoulders for forward-facing children. You must be BOTH 4 years old AND at least 40 lbs to sit in a booster seat. Booster seats help to position children so that they fit appropriately under a lap/shoulder belt (which is why booster seats are not appropriate for airplanes).

Children are not required to use a booster seat when they are 8 years old, OR they are at least 4 years old and over 57 inches, OR they are at least 4 years old and over 80 lbs. However, when graduating from a booster seat, the child should be able to sit up against the seatback with knees bent comfortably at the edge of the seat. In this position, the seat belt should be over the collarbone and hips, NOT the neck or belly. Children who move out of booster seats prematurely are at increased risk of internal injuries from the seat belt or even ejection from the car.

For more about child seat laws in Wisconsin, see http://www.dot.wisconsin.gov/safety/vehicle/child/docs/booster-seat-law-facts.pdf.

Check back tomorrow when I'll post additional important car seat safety facts!

Dr. Tracy Lee

Pediatric Hospitalist

Meriter Hospital

meriterkids.com

Rotavirus (or the lack thereof): A vaccine success story

As a hospitalist, I see a sicker patient group. Only when a parent is very worried or a clinic provider feels they need ongoing attention do I see a child in the ED or in the hospital. Now, as we approach the end of summer, I can’t help but feel like something is missing. Five years ago, it was common in the spring and early summer to have children in the hospital for vomiting, diarrhea and dehydration from rotavirus. Rotavirus is a common virus that infects most children under 5 years of age and is most severe for children under 2 years of age. Every year there was a significant number of children who needed to stay in the hospital for IV fluids while they recovered from this virus. So, where did it go?

If your child is less than 4 years old then you may remember an oral vaccine received at the 2, 4 and 6 month visits. In 2006, the FDA approved the vaccine RotaTeq® and shortly thereafter, it was recommended routinely for infants. Since that time there have been other similar vaccines approved as well. This vaccine is not 100% effective in preventing rotavirus, but its goal was to reduce the severity of illness and prevent the need for hospitalization.

Recently, there have been some published studies on the effect this vaccine has had in the United States. One study showed a 46% decrease in need for hospitalization. Another study showed 100% effectiveness in preventing hospitalization compared to children who did not receive the vaccine. Wow! As a younger physician, it has been wonderful to see the impact vaccines can have on the health and well being of our children.

Although I love meeting the children and their families, I am glad more kids are at home. Staying in the hospital is no fun for anyone. To rotavirus, I say good riddance and you won’t be missed.

Dr. Jim Bencivenga

Pediatric Hospitalist

Meriter Hospital

meriterkids.com

The New Rules of Head Lice: Part 2

Continued from yesterday's post ...

What should you do if your child has head lice? First, all other household members should be checked. So should any kids who were likely to have direct head-to-head contact. Anyone with live lice or eggs close to the scalp should be treated. Anyone who shares a bed with the infested person should also be treated.

Hair care items and bedding that have been in contact with the infested person in the 48 hours prior to treatment should be cleaned. (If it’s been longer than 48 hours, any lice will already be dead.) A temperature of 130 degrees or more (by washing or drying) will kill lice and eggs. Furniture, carpeting, and other fabric covered items can be vacuumed. Pediculicide sprays are not necessary. If there is a concern about eggs surviving and hatching, items that cannot be washed may be placed in a plastic bag for 2 weeks.

Unless there is known resistance in the community, the first step in treatment is permethrin 1% or pyrethrins which are available over-the-counter. Permethrin 1% is the most studied and the least toxic of the pediculicides (lice-killers). Conditioners and silicone-based additives will interfere with permethrin, as will vinegar which is often used in an attempt to loosen nits from the hair shaft. When rinsing off pediculicides, use a sink instead of a shower or bath in order to reduce skin exposure. Using warm instead of hot water will minimize absorption. There are many other prescription medications that can be used if these over-the-counter products fail.
For those who cannot afford or who would prefer not to use pediculicides, wet combing or using suffocation methods can be attempted. An example of suffocation would be applying petroleum jelly to the hair and scalp and leaving it on overnight under a shower cap.

Misapplication is the leading cause of treatment failure. No treatment will kill all the eggs, so retreatment at specific intervals is recommended. Shaving, although effective, is not recommended. Any product that is meant to loosen nits can also damage the hair itself. Acetone, bleach, vodka, and WD-40 do not loosen nits. Please do NOT use kerosene, gasoline, or any other such flammable or toxic substance. They are not effective; they are just dangerous. Do not use products that are meant for animals.

Infested kids should definitely get treated, but they should not be kept out of school. The chance of transmission may not be zero, but it is lower than in other settings where head-to-head contact is more likely. One study at a school where over 14,000 live lice were found showed zero lice in the classroom carpeting. In another study, infested people spread lice to pillowcases only 4% of the time. And remember, head lice don’t carry any diseases, unlike mosquitoes which transmit a large number of diseases.

Just to put things in perspective, dust mites (see photo) thrive in bedding, mattresses, carpets, furniture…anyplace where there are tiny flakes of shedded human skin. Their fecal matter is a leading cause of allergies and asthma exacerbations. They are much more insidious than lice, but they don’t keep kids out of school.

Dr. Tracy Lee
Pediatric Hospitalist
Meriter Hospital
meriterkids.com

The New Rules for Head Lice: Part 1

On July 26, the American Academy of Pediatrics updated its clinical report on head lice. It is common in school-aged kids, and it can be found all over the world. It affects all socioeconomic groups, and it can affect anyone regardless of hygiene. Mere mention of it can cause itchiness. It seems that resistance to standard treatments is on the rise. And yet, the AAP is pushing for kids to stay in school despite having lice. What’s going on?

Head lice are tan to grayish-white, and they are 2-3 mm long. Their eggs are even smaller. Their life cycle is about 3 weeks long. They feed by sucking tiny amounts of blood. Sensitization to their saliva as they feed is what makes us itchy, but this can take 4-6 weeks to develop. This means that by the time the diagnosis has been made, a kid in school has already been around other kids for a month. The good news is lice can only crawl; that means that they can only spread by direct contact. They cannot jump from head to head. This is also why brushing your hair will not prevent you from getting lice; it will only reduce the number of lice you are infested with. You are better off not sharing personal items (like hats, combs, brushes, etc.), but this is NOT an excuse to refuse to wear protective headgear. Lice that fall off or are combed off are usually injured or dead. Live lice and nits need our body heat to survive, so they are found close to the scalp (within 4-10mm). Farther than that, live lice only survive up to 48 hours, and eggs cannot hatch.

Many cases of “lice” are actually misdiagnosed. Dandruff, hair debris, dirt, and other insects have been mistaken for lice. This adds to the number of “resistant” cases. School screenings and forcing kids to stay home doesn’t reduce the incidence of live lice. Instead it means lost days in education and missed work days for the parents.

So what are we to do? The AAP does encourage parents to check their kids’ heads regularly and whenever the kids are itchy. Especially after sharing sleeping quarters, like at a camp, child care center, or sleepover. Using a louse comb on hair that is wet (with water, oil, or conditioner) is the easiest way to go about it. Eggs are most easily seen at the nape of the neck or behind the ears. Remember to look close to the scalp!

Please check back tomorrow, as I'll talk more about what to do if you find lice in your child's hair.

Dr. Tracy Lee
Pediatric Hospitalist
Meriter Hospital
meriterkids.com

Feeding your Baby: The Transition to Solids, Part 2

(This post is continued from yesterday's Part 1 segment)

So, when do you start your baby on solids? My advice is to watch your baby and see when he wants to start solids. It should not be until she has developed enough body and head control to be able to sit up in a high chair, but babies vary on when they can do this. It’s generally in the four to six month range. For my first daughter, it was at five months that she could sit in a chair, but she didn’t eat solids until six months of age. After your baby can sit up in the high chair, you’ll naturally start putting him there, likely with some toys on the tray, when you have things you need to do (like eat your own dinner!)

There will come a day when you see your baby watching the food make its way from the plate to your mouth with great interest. Then she’ll give you a look like “I’d like some of that!” This is when you need to convince him, at your next sit-down together, that what you were eating was mom’s milk (or formula) mixed with a small amount of rice cereal and "sure, you can have some." Just put a small amount in, and keep in mind that you want it to be runny at first, and the mixture will continue to thicken for a couple of minutes as the flakes absorb moisture. Put a small amount on a spoon and hold it up in front of baby. If she’s ready, she’ll lean forward and take the spoon into her mouth. If he doesn’t seem all that interested, it’s no big deal. The essential source of nutrition for a baby is human milk (or formula) from birth to six months, and from six months to one year, it’s still the major source for nutrition. You can try again later.

I do recommend starting solids by nine months, because by that time we’re talking about picking things up (like Cheerios) and learning to eat various things is an important part of brain development. Nutritionally speaking, a baby can do just fine on nothing but mom’s milk (or formula) until one year of age. Generally, everybody can’t wait to feed the baby, and I can recall only one time I’ve ever had to urge a mother to start solids with her baby at a nine month well child check.

Now, I just described using rice cereal mixed with human milk or formula because that’s been the most common first food advised over the past 40 years, and it’s what I gave my own kids. I should note, however, that not everybody agrees with this. Some feel that pureed meat should be the first food, because it is an excellent source of bio-available iron and zinc, for which some older babies have deficiencies. One thing is certain: do not give honey to a baby less than one year of age, due to the small, but real risk of infant botulism. If you’ve been nursing your baby, she’s been exposed to the variety of flavors that is in your own diet, so adding a little dried spice or herbs could be o.k., but don’t add salt or sugar to your baby’s food.

That’s all we have space for today — ask questions in the comment section and I’ll try to address them!

Dr. Julia Mason
Pediatric Hospitalist
Meriter Hospital
meriterkids.com

Feeding your Baby: The Transition to Solids, Part 1

If you have a baby, you’re probably getting advice (from all corners!) on how to feed her. Everybody can agree these days that mom’s own milk is the best food for babies, but after that, there can be a lot of confusion. I’m going to focus today on the transition from human milk or formula to “solid foods.”

Some new parents are being advised by relatives that they should start the baby on solids, (which usually means baby rice cereal) basically, as soon as possible. This may be because several years ago mothers were actually being advised by their pediatricians to start rice cereal at earlier and earlier ages. The hope was that adding rice cereal to the bottle (and that’s what we’re talking about, because a typical baby less than four months old is not going to slurp food off a spoon) would help the baby sleep through the night, or eat less often, or have less spit-up. This advice is no longer being given, except by the well-meaning grandmothers who are passing on what they were told. Still, you can find “infant feeders” in the baby section of stores which are basically just bottles with an extra large hole in the nipple, to allow the thicker cereal mixture to come through. (Just because something is sold in stores doesn’t mean it’s a good idea to buy and use, even with baby supplies.)

Giving a baby solid foods early is not going to make him sleep through the night at a younger age. Babies do tend to sleep longer periods of time as they get older, and they start solids when they get older, but giving solids to a three month old is not going to turn her into a seven month old. Babies sleep through the night when they sleep through the night (and you should know that the technical definition of this is "greater than five hours of sleep," not the eight hours you’re dreaming of). There are things you can do to encourage this behavior, but that will have to be the topic of another post. Feeding solids to a baby less than four months old is not going to get them to sleep for longer periods. It may help with spitting up, but I wouldn’t advise it unless the problem is severe. It will lead to weight gain, and I think we’ve all figured out that this is not necessarily a good thing. For many babies, rice cereal will cause constipation.

Visit again tomorrow for part 2, when I'll discuss the appropriate time to start the transition to solids.

Dr. Julia Mason

Pediatric Hospitalist

Meriter Hospital

meriterkids.com

What to Watch for: Hand, Foot and Mouth Disease

Summer is a time for children to play outside, be active, and enjoy freedom from the classroom. However, summer is also the season when some of the most common pediatric illnesses rear their ugly heads. One of these illnesses that is showing up recently in children in the Madison area is Hand, Foot and Mouth disease (HFMD).

HFMD is a viral illness that typically occurs during the summer months in children ages 10 years and younger. The usual symptoms include fever, mouth sores and a rash. The fever is often the first symptom to develop. This is typically followed by the development of blisters in the mouth, and sometimes on the hands and feet (hence the name!). Some children may also develop this blistery rash on their buttocks and genitals. As one can imagine, with these blisters, children may refuse to walk, eat or drink and may cry with urination.

Unfortunately, there is no specific treatment for HFMD. The most important steps a parent can take to help their child through this illness is to give acetaminophen or ibuprofen for comfort and fever reduction and to make sure that the child is getting plenty of fluids. Children with HFMD are at risk for dehydration because the mouth pain prevents them from drinking enough liquids. Offering popsicles or soup can help to soothe the throat while also providing fluids.

If you fear that your child may have become dehydrated or have other complications from HFMD, please contact your child’s primary care provider.

The best way to fight HFMD is through stopping the spread of the virus. Help children have a happy and healthy summer…teach them good hand washing!

Dr. Nicole Baumann-Blackmore
Medical Director, Pediatric Hospitalist Program
Meriter Hospital
meriterkids.com

Get Rid of Your Unwanted Medications at MedDrop

With the recent voluntary recall on Infants’ and Children’s Tylenol, Motrin, Benadryl, and Zyrtec, you may have some bottles sitting around in the cabinet gathering dust. (For more information about the recall and to get a refund or product coupon, please see http://www.mcneilproductrecall.com/.) Maybe there are some nearly empty vitamin drops, unfinished antibiotics, old inhalers, or even unused pain pills? Maybe there are medications that have expired, and you just haven’t gotten around to disposing them?

There’s no point in keeping them in the house. Expired medications can be ineffective. Leftover meds can be a safety risk with kids or pets in the house. But, throwing medications into the trash or flushing them down the toilet can harm the environment, affect our water supply, and in the end, come back to us in ways we don’t want.

MedDrop is a volunteer run program where you can drive through with your meds, answer some very basic questions (e.g., what is your zip code; is the drop-off place a good location for you), and feel good that the meds will be disposed of in a safe manner.

Saturday, June 5, from 9am to 1pm, volunteers will be at three locations: LaFollette HS, Middleton HS, and the Sun Prairie Recycling Center. You can bring prescription meds, over-the-counter meds, meds for pets, inhalers, vitamins, and even illegal drugs (which will be taken with no questions asked). If possible, please keep them in their original containers. The meds and their containers will be disposed of in a way that will maintain patient confidentiality, but feel free to cross off your name and other personal info if you like. Just leave the name of the medication visible, so the volunteers can properly dispose them.

For addresses, detailed instructions, background information on the program, volunteer opportunities, and lots more, please check out their Web site.

Dr. Tracy Lee
Pediatric Hospitalist
Meriter Hospital
meriterkids.com

Get in Shape this Summer

Looking to run a road race this fall? Preparing your son or daughter to join the cross-country team? Just want to shed a few of those hibernation pounds? Nothing like a good jog on the Lakeshore Path or a run through the Arboretum to get yourself ready for the upcoming year! Experienced runner or novice jogger can “shape up” in a matter of 6-8 weeks by following a couple of simple rules.

• Train a minimum of four days a week. If you’ve never run before, start by using a combination of walking/jogging for a couple of miles every other day. If you’re an experienced runner start at a daily mileage you feel comfortable with.

• Increase your distance by about 10% a week. (i.e., if you just ran 25 miles, move up to 28, then 31, etc.) For variety, add in a short temp run by increasing your pace to the point where it just becomes difficult to converse. Once a week, try to go “long and slow.” A good mid-preseason schedule might have two easy runs, one tempo run, one long run and one medium distance run.

• Vary the scenery and the terrain. Madison has so many wonderful places to enjoy. And don’t forget to keep yourself well-hydrated!

• Go for a family run! Baby joggers (for children up to four) and bicycles can be a great way to get everyone involved in the outing!

Dr. Ron Grant
Pediatric Hospitalist
Meriter Hospital
meriterkids.com

What is the Meriter Pediatric Center?

I am so excited! Not only is this my first opportunity to write a blog, but also the long-awaited opening of the Meriter Pediatric Center is only a day away! On Tuesday, May 18th, the hard work of so many over the past two years will finally come to life. A Pediatric Center is a new concept for many of us, so I thought I would take this opportunity to explain what you can expect of a visit to the Meriter Pediatric Center.

The Meriter Pediatric Center is an 8-bed unit, located adjacent to the Emergency Department, which is staffed by Nurses, Physician Assistants, Pediatricians, and Emergency Physicians, all of whom are trained to care for children. The Center was designed specifically with children and their families in mind, and will centralize care for the majority of children receiving emergency and inpatient services at Meriter Hospital. For children 17 years of age and younger who come to Meriter for non-life-threatening emergency visits, there are 5 exam rooms dedicated to their care, along with a pediatric-only waiting area. There are also three inpatient beds which will be reserved for children 15 years of age and younger who require hospital admission for observation, further treatment or post-surgical care.

Outside of the Pediatric Center, children will continue to be cared for across the entire hospital for a host of other services, including outpatient surgical procedures, medical imaging procedures, and therapy visits. In addition, patients with severe illness and injury will continue to be cared for in the main emergency department. Children ages 16 and 17 years who require hospitalization will be admitted to the appropriate specialty unit, but will be cared for by pediatricians, surgeons or family medicine physicians.

I hope that you and your child never need the services of the Meriter Pediatric Center. But if you do, know that your child will be in the excellent hands of caring and professional staff who are all dedicated to providing the best care possible for children.

Have a Happy and Healthy Summer!

Dr. Nicole Baumann-Blackmore
Medical Director, Pediatric Hospitalist Program
Meriter Hospital
meriterkids.com