Repeat after me. "FEVER IS OUR FRIEND (Unless my baby is under 2 months old, in which case I will call the doctor immediately!)."
Fever is present if the oral temperature is greater than 100 degrees Fahrenheit (37.8 degrees Centigrade) or the rectal temperature is 100.5 degrees Fahrenheit or greater. Axillary temperatures are variable but usually a fever is present with an axillary temperature over 99-100 degrees Fahrenheit. A child may "feel hot" without having an actual increase in body temperature so if you think your child may have a fever and are concerned, USE A THERMOMETER to check the actual temperature.
There are many types of thermometers available. We recommend digital thermometers. Thermoscans (thermometers which take the temperature in the ear) are fine for older children (over 3 years of age). If a child under 2 months of age is felt to have a fever, we request you check a rectal temperature before calling us. The thermometer strips available for use on a child's forehead are notoriously INACCURATE and not recommended. Mercury thermometers are also not recommended due to possible breakage and mercury exposure.
Mild fevers may be caused by too much clothing, recent exercise, hot weather or hot foods. A fever is expected after certain immunizations and is a normal reaction of the immune system to the vaccine.
Pediatricians as a group are very concerned about fever in infants under 2 months of age. This is because their immune systems are still developing, they cannot wall off an infection in their body, and they often do not have clinical signs of severe illness other than the fever.
After 2 months of age, we consider fever a NORMAL RESPONSE to infection. It should be treated only if your child is UNCOMFORTABLE or the fever is fairly high (over 104-105).
Either an acetaminophen product or ibuprofen (for infants older than 6 months) may be used to treat fever. The ibuprofen products are particularly effective but may cause stomach upset in some children and should NOT be given to children who are vomiting or having severe diarrhea.
CALL IMMEDIATELY IF YOUR CHILD HAS FEVER ASSOCIATED WITH ANY OF THE FOLLOWING:
- Age under 2 months
- Constant crying as if in pain
- Fever of 105 or higher NOT responding to medication
- Stiff neck
- Purple spots on the skin
- Difficulty breathing (other than a stuffy nose)
- Your child is becoming difficult to arouse, confused or delirious
- Your child appears extremely ill or has other signs that worry you
CALL THE OFFICE DURING REGULAR HOURS IF:
- Your child complains of sore throat or ear pain
- Your child complains of pain with urination or is voiding frequently or wetting the bed
- Your child has a significant cough or any other symptoms along with fever persisting beyond 48 hours.
As discussed previously, fever may be treated with medication such as acetaminophen (Tylenol) or ibuprofen (Motrin, Advil). These may be used together for high fevers, giving the ibuprofen every 6 hours and the Tylenol every 4 hours. Alternating the medication does not seem to help with the infection or fever. Having your child drink lots of cold liquids will help. Sponging in a bath with lukewarm water for 20-30 minutes will generally reduce a fever by 2-3 degrees. If this causes more “fighting” than helping, try a popsicle!
Note: Fevers are normal the first 24-48 hours after a DTAP vaccine and 5-15 days after MMR. Motrin works much better but should NOT be used if child is vomiting or borderline hydrated. Base dosage on weight, NOT age.
ACETAMINOPHEN (Tylenol/Tempra) DOSAGE CHART - Top
Under 2 mo.
| || || |
12 years and over
96 lbs. & over
IBUPROFEN (Advil/Motrin) DOSAGE CHART - Top (For older than 6 months)
50 mg/1.25 ml
Dose of Syrup
100 mg/ 5 ml
1 ½ teaspoons
2 ½ teaspoons
Babies usually have mushy, somewhat loose stools. Diarrhea is defined as a sudden increase in the number of stools and looseness of stools compared to your baby’s normal pattern. Breast-fed babies may have anywhere from 10 loose stools per day to one stool per WEEK and practically any consistency is normal for a breast-fed baby. (They usually resemble mustard water with a little curd thrown in!) However, if your breast-fed baby has a sudden increase in the usual number of stools, acts sick, has vomiting, fever or weight loss, then there is reason for concern. While bottle-fed babies tend to have some more formed and less frequent stools, the same basic rules apply.
Diarrhea is usually caused by a viral infection or occasionally a bacterial infection. It usually lasts several days, sometimes as long as 1-2 weeks. Infections cause diarrhea by causing temporary injury to the intestines which causes incomplete digestion and absorption.
Children who are otherwise alert and active and having only mild diarrhea do NOT necessarily require any dietary changes other than limiting juices and sugar-containing fluids. Although it may help to limit milk, it is usually safe and recommended to continue milk during a diarrheal illness.
If your child is becoming listless and having moderate to severe diarrhea, some simple dietary changes may be necessary, as follows:
Breast-fed babies continue to nurse. Nursing on only one breast but more frequently will supply smaller volume feedings and may be retained better than a full nursing if your baby has any vomiting associated with the diarrhea. An electrolyte-containing supplement (such as Pedialyte or Kaolyte) should be given in small amounts between nursings to replace the electrolytes lost in the diarrhea stools. These supplements can be found near the infant formulas in groceries and pharmacies. As long as your baby is having wet diapers, a few additional fluids should be all that is needed. Once stools have begun to improve, solids may be added back if your baby had been taking them prior to the diarrhea. Stick with the "ABC diet" - applesauce, bananas, and rice cereal - for a few days. Yogurt, toast and crackers are other bland foods that don't irritate diarrhea in most children. Boiled or baked potatoes without added butter and baked chicken may be added as well.
Bottle fed babies should receive an electrolyte supplement ONLY for the first 24 hours of significant diarrhea.
Good choices for electrolyte supplementation include:
- Pedialyte or Kaolyte, or a similar commercially prepared electrolyte drink. These are available near the infant formulas in groceries and are usually in ready-to-feed form. Adding crystal lite one teaspoon to 8 oz of pedialyte can improve the taste.
- Gatorade may be diluted to half strength with water and used until you are able to get to the store for a premade electrolyte drink. Any flavor is fine-whatever color stool you want to clean up from the diaper! Many children over 12-18 months find this very palatable.
- Jello water is not the first choice as a "clear liquid" in a child with diarrhea but will do in a pinch until you can get to the grocery. Just mix a box of jello with water as you normally would when making jello, then don't chill it but feed it at room temperature.
Bad choices for a "clear liquid" diet for diarrhea include:
- Boiled skim milk - Boiling milk is dangerous because it causes an elevated salt content in the milk.
- Kool-Aid, and juices - These contain too much sugar, which can worsen diarrhea. They also don't contain the appropriate electrolytes. Full strength Gatorade may have the electrolytes but contains too much sugar.
- Soda pop - Carbonated beverages often aggravate diarrhea, particularly if they contain caffeine. The electrolytes needed to replace losses from diarrhea are not present, once again.
- Water - Water alone can alter a child's electrolyte status and aggravate salt and electrolyte depletion caused by the diarrhea.
REMEMBER: When we say "clear liquids," we don't mean every liquid that is clear!
After 24 hours on a "clear liquid diet ," your child should be advanced to half strength formula. Mix his formulas as usual, then add Pedialyte or extra water to each bottle so the formula is only half as strong as usual.
After one day of half strength formula, you should be able to increase the formula back to the usual strength.
After your child is tolerating formula, the "BRAT diet" may be resumed if he has been taking solid feedings in the past. (Applesauce, bananas, rice cereal, yogurt, crackers, dry cereal, toast, plain baked potato and baked chicken.) During this time stools may temporarily seem to worsen but should begin to thicken and decrease in frequency over the next few days.
If your child's diarrhea worsens as the diet is advanced, call the office during regular hours for advice.
Older children follow basically the same plan; that is, clear liquids for 24 hours, followed by an ABC diet and avoiding juices or milk for a few days. Raw fruits, vegetables, bran products, beans and spices may aggravate the diarrhea as well. If your child continues with diarrhea after several days without milk, you may want to resume his milk intake but with Lactaid drops (available over the counter) added to the milk or with a lactose-free milk.
Medications are rarely recommended to slow diarrhea as they can actually make things worse. These usually just prolong the symptoms. If your child has had prolonged or severe diarrhea, this may be an option but always check with a pediatrician before using any anti-diarrhea medication.
You should call the office if:
- Diarrhea is severe (e.g., bowel movement every hour for over 24 hours)
- Stools don't improve after 3-4 days on the special diet
- Mild diarrhea lasts over 2 weeks
- You see blood or mucus in more than 1 stool
- Your child develops signs of dehydration (a decrease in the number of wet diapers/voids, dry tongue and mouth, increasing lethargy or refusal to drink)
- Your child's breathing becomes fast or labored
- Your child has severe abdominal pain
We should see your child if he or she has:
- Bloody diarrhea
- Persistent abdominal pain for more than 2 hours.
- Less than 3 wet diapers in a 24 hour period
- Stools every hour for over 24 hours
See within 24 hours if:
- Diarrhea for more than 2 weeks
- Fever more than 3 days
The most common cause of vomiting is a viral infection of the GI tract. Vomiting usually stops within 12-24 hours. It is best treated with clear liquids in small amounts. Wait 1-2 hours after your child's last episode of vomiting, then begin with just 1-2 tablespoons (1/2 – 1 oz.) at a time and gradually increase the amount every 20-30 minutes. Refer to the list of acceptable "clear liquids" listed in the diarrhea section for examples. There are also electrolyte popsicles available now, usually in the formula section near the electrolyte drinks (e.g. Pedialyte, Freezer Pops).
After 8 hours without vomiting, your child may begin the "ABC diet" as discussed in the diarrhea section, and then gradually resume a regular diet.
In occasional instances, a suppository for vomiting may be prescribed but these don't always work and can have significant side effects. For the most part, small amounts of clear fluids by mouth are the most effective and safest treatment of vomiting
You should call the office if:
- Your infant vomits for more than 24 hours or your older child vomits for more than 48 hours
- Your child develops signs of dehydration (decreased number of wet diapers/voids, dry mouth and lips, increasing lethargy, refusal to drink)
- Your child becomes confused or difficult to arouse
- Blood appears in the vomitus
- The vomitus becomes dark green in color
- Your child develops SEVERE abdominal pain or mild abdominal pain for more than 24 hours.
- Any other symptoms appear which bother you.
Sometimes a child wants what we are eating. The child’s stomach may not be ready yet and the vomiting comes back-so just start over with the clear liquids.
What about food poisoning?
Vomiting, abdominal cramps and diarrhea occurring 2-4 hours after eating unrefrigerated meat, dressings, pastry or cream sauces may be due to food poisoning. Treatment is supportive with clear liquids and symptoms usually resolve in about 6-12 hours. CONSTIPATION:
Constipation is never an emergency and should not be a reason for after hours calls. (Please see the information on normal stool descriptions in “Well Days” Section.)
Babies often grunt, strain, grimace and exhibit great effort in working up to a good bowel movement. A breast-fed baby may actually seem to be uncomfortable for 1-2 days before his/her “explosion” of a weekly bowel movement.
Apple juice or prune juice may help soften hard stools. Usually 1-2 ounces a day in young infants will do the trick.
If your infant is very uncomfortable, you may use 1/2 of a glycerin suppository (available over the counter) to help the passage of any stool. Insert rectally after lubricating the rectal opening with Vaseline.
Occasionally a child will develop constipation at the time of toilet training. This is very normal and everyone needs to “relax” and not increase the anxiety, as that just makes things worse. f your child has chronic constipation, please contact the office during regular office hours.COMMON COLDS:
Most children get around 6 colds per year, twice that many if they're in daycare. Colds (upper respiratory tract infections) are caused by direct contact with a person who has one. They aren't caused by cold air or drafts. Usually, fever lasts for 2-3 days and the runny nose, sore throat, etc. last for about 7-10 days.
Over-the-counter cold medications are not particularly effective as a rule, especially in young infants. In the first few months of life, it is better to avoid medications in favor of using a bulb syringe to suction mucus from the nose. Using a hot shower in the bathroom at bedtime may help to "break up" any mucus in your baby's nose so it drains more easily. You can also use saline drops to help loose secretions in your baby's nose. These are available over-the-counter (Ayr or Ocean Spray drops, etc.) or can be made at home by mixing 1/4 teaspoon of table salt with 4 ounces of warm water. Place 2-3 drops in one nostril at a time, then suction with a bulb syringe. This is most effective if done before feedings and at bedtime and naptime.
Left over antibiotics should NOT be used for colds. Decongestants may be tried and sometimes help slightly for "stuffy noses" in older children (e.g., Pediacare /Sudafed /Dimetapp). However, these medications can cause excitability or irritability in some children. A cool mist vaporizer may be helpful, particularly in the winter.
Your child should drink lots of fluids, particularly juices. Believe it or not, even chicken soup has been shown to have some beneficial effect on the common cold. (Grandma was right!)
While antibiotics do NOT help the common cold, if cold symptoms have lasted more than 7-10 days and/or any of the following signs appear, you should call the office.
Please call the office if:
- Your child's fever lasts more than 3 days
- Your child's eyes become matted
- Your child complains of ear pain
- Your child coughs up yellow mucus for more than 24 hours
- Your child's breathing becomes labored
- Your child develops thick, green drainage from the nose after having cold symptoms for more than 7-10 days
Coughing is a normal reflex to clear the lungs of mucus and protect them from pneumonia. During the winter months, viral respiratory infections of the trachea (windpipe) or bronchial tubes can result in a dry cough which persists for 2-3 weeks. Some children develop "cough variant asthma" with a persistent dry cough instead of wheezing. Chronic, loose night time coughs are often present with sinus infections in older children or may be seen in children with allergies.
There are several things you can do to make your child more comfortable during these coughing episodes.
A. HUMIDITY - Dry air tends to make coughs worse. Your child should drink plenty of fluids. A hot shower in the bathroom at bedtime will humidify the air somewhat and may help coughing. You should NOT use Vicks or any medication in a vaporizer for your child's cough; this can do more harm than good!
B. NO SMOKING - No one should smoke in the house or car around your child. This means no smoking indoors, even in another room of the house where the child isn't present. The smoke still gets into the air space in the house and eventually finds the child! MULTIPLE studies have shown that passive smoking aggravates chronic cough, asthma, respiratory infections and ear infections in children. If you would like a handout specifically addressing passive smoking and children, ask at the office and we will gladly provide you with one.
C. MEDICATIONS - If the cough is causing your child to lose sleep, call the office and we can prescribe a medication for use at bedtime. During the day, it is best not to suppress the cough as it serves as protection against developing infection in the lungs. However, in some children wheeze, which may be due to asthma, and a bronchodilator (e.g., albuterol) may be prescribed for use during the day. This won't suppress the cough but will make it more effective in clearing any secretions from the lungs.
You should call the office if:
- Your child has fever for more than 3 days with his cough
- Your child coughs up yellow mucus for more than 24 hours
- Your child's cough lasts longer than 3 weeks
- Your child seems short of breath
- Your child's cough worsens despite treatment
- The cough causes your child to miss school.
Note: If your child awakens at night, with a very BARKY COUGH and noisy breathing, place him in the bathroom with a steamy hot shower running. If he or she is having croup (a viral infection of the trachea) this should help. Sometimes taking a child out into the cool night air will also help. If these measures don't improve your child's breathing within 10 minutes, you should call for more instructions. Also, if your child is having severe throat pain with drooling or high fever, CALL!
Some fever is expected, but if the fever is above 104 degrees F, schedule an appointment the same day or the next morning to rule out bacterial infection in addition to croup.
If your child starts to get croupier during the night, try giving him/her a hot shower. Have your child sit in the bathroom for 10-15 minutes. This usually stops the attack temporarily so he/she can get back to sleep. If hot steam does not help within 10 minutes, take your child outside – the cold night air often works, too. If your child is still having distress after doing both these things, you should bring him/her into the office, or Emergency Room at night. EAR PAIN:
Ear pain is common in children and may be due to middle ear infections, outer ear infections ("swimmer's ear") and pressure from colds. It may also be seen in cold weather in a child who suddenly comes indoors; this is usually NOT due to infection but rather the sudden warming of air in the middle ear causing the air to expand, putting pressure on the eardrum. Infants will often pull on their ears not only from ear pain, but also when they are tired or teething.
If your child has a stiff neck or has had a pointed object placed in the ear immediately prior to complaining of pain, he should be seen immediately. Otherwise, he should be seen within 24 hours.
Call the office during regular hours if you think your child may have an ear infection. Signs include increasing irritability and not sleeping well at night after having had a cold for 3-4 days.
Until your child is seen in the office, give acetaminophen or ibuprofen (See dosage tables under "Fever" section.), elevate your child's head and use a heat pad or warm towel compresses to the ear. This should keep her comfortable until she can be seen. If all these measures aren't helping, call for a prescription for pain medication until your child can be seen. SORE THROAT:
Viruses and bacteria (e.g., strep throat) cause sore throats. Hot salt water gargles, cool foods, humidified air, acetaminophen or ibuprofen and lozenges for older children will help the pain.
Your child should be seen during regular office hours if:
- Sore throat has been present for more than 2-3 days
- Swollen or tender lymph nodes are present in the neck along with abdominal pain or a rash
- There has been recent exposure to strep throat or impetigo
- White spots are present in the back of the throat
Please do NOT use leftover antibiotics if your child has a sore throat. The antibiotics may be too old to do any good. Also, they don't help viruses. If we diagnose strep throat in your child, we will treat with an antibiotic at that time. After 24 hours of medication, your child may return to school or day care.CONJUNCTIVITIS (PINK EYE):
Conjunctivitis is inflammation of the white part of the eye and membranes lining it, with or without mucus production. Viral conjunctivitis ("pink eye") usually presents with no other symptoms. Bacterial conjunctivitis usually presents with more mucus, cloudy nasal drainage, cough and possibly fever.
Initial treatment at home should be washing the eye with warm water and a washcloth to remove the mucus.
If your child is complaining of ear pain or showing signs of bacterial conjunctivitis, call the office during regular office hours and we will help you decide if your child should be seen. CHICKEN POX:
Epidemics of chicken pox occur frequently. These appear first as small, red bumps resembling insect bites. Within 24-48 hours, they change to thin-walled blisters, then open sores and finally dry crusts. Repeated crops of these sores occur for 4-5 days and they may be present on any skin surface, even in the mouth. Your child will probably have a fever with the pox. They usually develop 2-3 weeks after exposure to a contagious person. A child may catch chicken pox from an older person with shingles by direct contact only, as shingles represent basically a reactivation of the chicken pox virus.
An experienced parent or grandparent can often diagnose chickenpox so an office visit isn't needed. If unsure whether your child has the pox, call the office and we will arrange to see him or her OUTSIDE of the regular office area to avoid exposing other children in the office.
Please call immediately if your child becomes difficult to arouse, confused or delirious, or complains of a stiff neck or severe headache.
Otherwise, your child can be managed at home. Cool baths will help the itching and WON'T spread the pox. Oatmeal soap is soothing and helps itching. Calamine lotion applied to the pox will also help the itching. Keeping the Calamine cool in the refrigerator seems to make it more soothing. Please note: CALADRYL is not recommended in children with chickenpox!! The Benadryl in that particular product is absorbed through the broken skin in children with pox and can result in toxic levels of Benadryl in the system. For the same reason, Benadryl sprays or any topical form of Benadryl is not recommended. If your child has severe itching, Benadryl MAY be given by mouth. ITCH-X and SARNA also can be used directly on the pox to relieve itching. If your child develops sores in the mouth, popsicles, milk shakes and cool liquids are tolerated best. Acidic and salty foods (soda pop, juices, pretzels, etc.) should be avoided until the sores have healed. Your child's fingernails should be kept trimmed and hands washed often to decease the risk of infecting the pox from scratching. If you suspect the pox may be infected (if they become soft and golden and drain pus), call the office. Fever may be treated with acetaminophen.
Your child will no longer be contagious after the pox have scabbed over (i.e., about 6-7 days). He or she may return to school or day care after a week and needn't wait until the scabs have all fallen off.LICE:
Nits are pearly white in color and attach firmly to the hair shaft and are not easily removed like dandruff. Lice bugs are 1/16 inches long and are difficult to see. Lice crawl, they do not jump or fly. They are often found around ears and the back of the neck.
- Nix cream rinse. Shampoo with any shampoo, then apply Nix and leave in for 10 minutes. Rinse. If the nits are strong, you can use ½ strength vinegar to help loosen them. Then, comb out with a fine tooth comb that comes in the package. One time only.
- Elomite- use as directed
- Mayonnaise (not fat free). Apply to entire head and sleep in a shower cap all night. This will smother the lice. Olive oil works too, but is more expensive and harder to get out of your child’s hair.
- Combs & brushes should be rinsed in Nix or Kwell.
- Combs & brushes should be placed in the freezer overnight.
- Sheets, pillowcases, hats should be run through the wash.
- After treated, your child can return to school.
- Most schools do require that all nits be removed, even if dead, because it is too hard for the school nurse to be sure all nits are killed.
- Items unable to be washed should be tied up in a plastic sack for three weeks.
Thrush appears as white, curd-like plaques coating the gums, tongue and sides of baby's mouth. It can't be washed away. Normally this is seen in young babies who are still nursing or on bottle feedings. Occasionally it is seen in an older child after a course of antibiotics. It is caused by a fungal ("yeast") infection. If you think your child may have thrush, call the office during regular office hours and a prescription can be phoned in to treat it.
All bottle nipples and pacifiers should be soaked in hot water for 15 minutes or boiled while the baby is being treated for thrush. The medication prescribed should be continued for 3 days after the thrush appears to be totally gone. When using the medication squirt ½ ml on one side of the mouth and scrub the cheek and tongue with a q-tip. Sometimes using vinegar or a paste of banking soda and water 4 times per day on a q tip also works either by itself or in conjunction with the prescribed medication.
Colic is seen in 10% of healthy, well-fed babies and usually begins around the third to fourth week of life. Though we do not have colic in our practice (be sure to tell your friends!!??), it hopefully ends by the third month. These babies have an excessive amount of fussy crying and appear to be in pain. There may be multiple causes for what we presently term "colic," but nobody is sure exactly what the causes are. It is seen in both breast-fed and bottle-fed babies. It is NOT the result of inadequate parenting so don't blame yourself if your child has this problem, or with dad for not helping enough!
There are several things to try to help the crying spells.
- Rhythmic, soothing activities -- Try carrying your baby in a front pack or pouch. An automatic baby swing, rocking cradle or buggy ride may help. Sometimes a drive around the block in the car may help. Putting the baby in an infant seat on top of the clothes dryer and then running the dryer with some sneakers in it will sometimes soothe the baby. (Be sure the seat is secured so it won't jiggle off onto the floor!)
- Sucking a pacifier calms some babies. If your baby has eaten in the past 2 hours, don't feel you must feed him so more, as that is just a sucking reflex and can actually worsen the problem. Colicky babies aren't usually hungry.
- Holding the baby and placing them on a warm water bottle wrapped in a towel or warm towel on her tummy or swaddling her may help. Be extra careful that the “warm” is not hot as a babies’ skin is easily burned.
- Soft sounds may calm your baby. Soft music or a recording of sounds from mother's womb may be used, quiet CD or radio also have the same effect.
If your baby is dry and has been fed, it is perfectly all right to close the door to his room and let him cry for a while. Check on him periodically, but try setting a timer for 20 minutes and use this time to do something YOU want to do! Colic can be very frustrating and exhausting for parents if you don't take "time out" occasionally. New mothers in particular should try to take at least one nap each day. You can also try to increase the amount of time your baby sleeps at night by not allowing her to sleep more than 3-4 hours at a time during the day. Again, be sure to allow Dad to take his “turn” and take the child for a walk or to allow you to go for that relief walk.
lnguinal hernias appear as bulges or swollen areas in your child's groin (or scrotum, in males). The bulges often change in size, becoming larger or smaller in the course of a day. They may be slightly tender. If you notice any swelling in your child's groin (boy or girl), notify the office. Hernias appearing in the groin area are not an emergency but do require surgical repair usually on an outpatient basis. It is only an emergency if the baby is very fussy, the area won't reduce (become smaller) with mild pressure or if the area is discolored and the baby is not feeding or is vomiting.
Umbilical hernias occur when a weakness in the muscle around the "belly button" causes it to protrude outward. These are very common and usually cause no problems. When a child cries, the umbilicus will protrude more, but it won't break! The hernia usually resolves on its own by school age without treatment. Taping a 50 cent piece over the area won't make things go away any sooner (don’t tell grandma that!) and your child could develop an allergic rashes from the tape.