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CLICK HERE TO SEE CONVERSATIONS FROM THE AMERICAN COLLEGE OF PEDIATRICIANS ON A VARIETY OF ISSUES.

Table of contents on handouts from CPAC:

1)Fever


2)Treating your child's cold (including the truth about cough suppressants)


3)Losing weight -  A healthful way that works.


4)Taking your baby home from the hospital.


5)The Truth about RSV.


6)Routine immunizations

7)flu vaccine

(scroll down to the information sheet that you wish to view)

Thermometer

1)Fever
What is fever?

Fever is an elevation in temperature that is higher than normal. Therefore, fever is a temperature 100.5 or higher. Everyone’s temperature varies normally through the day from 96 F through 100.4. If you measure all the temperatures taken throughout the day, the AVERAGE of all these temperatures is 98.6. Fever is known to help fight infection. It fights both viral and bacterial infections. Having a fever is a sign that the body is fighting infection so you do not want to prevent all fevers. Fever itself is never dangerous. It is not possible for the body to produce a fever high enough to cause brain damage or death. However, some types of infection CAN cause brain damage or death and the body produces a fever to fight these infections.

Mild fever............100.5 - 101.5 (too low to treat - many sources state up to 102)

Moderate fever....101.5 - 104 (may treat for discomfort)

High fever............over 104 (may treat for discomfort)

What information does a fever provide?

Fever lets us know that there is an infection going on. How high a fever is, may not be a good indication of how mild or severe a disorder is. For example, Roseola (a completely harmless viral infection) is well known to cause fever up to 106, while certain pneumonias may cause a very low-grade fever or no fever at all. Many cold or flu viruses may cause fever over 104. If you do not know what is causing the fever, your child needs to be seen.

What about febrile seizures?

Febrile seizures are NOT caused by how high a fever gets but rather how rapidly fever changes. A fever of 106 will not cause a febrile seizure if it goes up slowly enough but a fever of 101 CAN cause a seizure if it gets there rapidly. Cool water and alcohol sponge baths actually TRIGGER febrile seizures since they cause RAPID change in temperature. Febrile seizures CAN occur in children from six months of age to six years of age but are actually quite rare in children over 4 years of age. Although frightening, febrile seizures are harmless if they last less than an hour. They do not cause epilepsy, brain damage or death. Using ibuprofen, Tylenol, or other antifever medicines do NOT decrease the risk of febrile seizures since they do not affect how rapidly the temperature changes. They only affect how high it goes.

What is the best way to take a temperature?

- a rectal thermometer in an infant or young child.

- an oral thermometer in an older child or teenager

- an ear thermometer, although not quite as accurate as the oral/rectal thermometers is reasonable in children older than one year of age (sometimes the ear canal in babies is too small to get an accurate reading).

Underarm temperatures, forehead strips, and pacifier thermometers are so inaccurate that they should not be used (you don't add a degree or take away a degree.  They are so inaccurate, it is the same as not checking).

How do I use a thermometer?

Digital thermometers are best.

- Rectal - lubricate the thermometer with vasoline or cool water. Hold the child facedown on your lap. Gently insert the thermometer about an inch into the rectum. Rest your hand on the buttocks, holding the thermometer between the bases of two fingers to prevent the child from forcing the thermometer out. When the thermometer beeps (digital) or the numbers stop changing (about 2-3 minutes usually) remove and read the thermometer.

- Oral (primarily for children over 4-5 years old if they will let you. Otherwise do rectally)

Wait 10 minutes after the child has had something to eat or drink. Put the thermometer under your child’s tongue. Tell your child to close his lips but not to bite. When the thermometer beeps or the numbers stop changing (2-3 minutes), remove and read the thermometer.

How do I treat a fever?

Do not awaken your child to check a temperature nor to treat. Fever is treated to decrease discomfort and if your child is comfortable enough to sleep, it does not need treatment.

For pain or fever over 101.5, you may give Tylenol every 3-4 hours. Ibuprofen may be given every 6 hours as needed for fever over 101.5 or pain. You may use them in combination but NOT AT THE SAME TIME. If you give ibuprofen every 6 hours, Tylenol may be given right in between so that your child is getting one or the other every 3 hours if needed (only for pain or fever over 101.5). Do not use ibuprofen if there is nausea or vomiting since ibuprofen can worsen an irritated stomach. Your doctor can discuss the dosages needed.

Never use aspirin for fever. If, after 45-60 minutes the temperature is over 104 F despite Ibuprofen and/or Tylenol, you may sponge bath with lukewarm (never cool) water. The water ought to be warm enough that you would be comfortable in it. If your child is shivering, the water is too cool. Never use cool water or alcohol to treat fever.

How long should a fever last?

Most fevers do not last over three days. Bring your child to be seen if the fever lasts longer than three days.

Is there an age when fever should be a concern?

Children three months of age or younger are at higher risk for the dangerous bacterial infections. Any child this age or younger with a fever needs to be seen as soon as possible.

2)Treating your child's cold

1. Chances are, your child will get at least one cold during the year. Many kids have as many as eight or nine colds their first year alone. This trend is discouraging but not unusual so don’t get overly worried. After the first year, children are exposed to more playmates and generally get eight - twelve colds per year (more, if in day care or if smokers live in the household). Older children have built up some resistance and usually get fewer colds..

2. Signs of a cold include a runny or stuffy nose and possible coughing. They may also have a fever usually during the first few days.

3.With a stuffed up nose, your child is breathing through the mouth so it is harder to eat since they have to use the mouth to breathe as well. Additionally, things don’t taste the same with the nose clogged up. Also, post-nasal drip causes the stomach to feel more full ...and may even cause nausea. Additionally, babies often have increased spitting when they have a cold. Don’t worry about decreased appetite. If your child goes a week without eating, they will be fine as long as they are drinking well. Push fluids!

4.FOR BABIES YOUNGER THAN 24 MONTHS: To help unclog your infant’s nose, use a suction bulb. If the secretions are too thick to be easily suctioned, administer saline nose drops (at any pharmacy or you may make your own with ½ tsp. salt in eight ounces of water). With the infant lying on his back administer two drops in each nostril. Wait 45-60 seconds before suctioning to allow the saline drops to help break down the thick mucus. Studies suggest that generally decongestants are not effective in children younger than two years of age (and may in fact, be dangerous).

5.For children 2 yrs and older, decongestant/expectorant combinations may be used.

6.A humidifier is helpful in thinning out nasal mucus. A cool mist humidifier is recommended since the hot vaporizers are more likely to be a burn/scald hazard.

7.Positioning may also decrease cough especially at night. When a person with a cold lies down, the mucus drips back toward the throat and trachea (breathing tube) which induces cough. Propping children up such as letting them sleep in a car seat, carrier, or recliner (depending on the age) helps decrease the drainage toward the lungs and can help them sleep better. Extra pillows may also be used to prop them up.

8.If your child seems very weak and sick, has no energy, feeds very poorly, or doesn’t wake up to be playful for even a short time, consult your doctor immediately. These indications may be signs your child has more than just a cold. Colds do increase the risk of ear infections, bacterial sinus infections, and bronchiolitis/pneumonia. If your child seems to be in pain (possible ear infection), has congestion for over two weeks nonstop-regardless of the color of nasal discharge, (possible bacterial sinusitis) or coughs to the point of awakening or vomiting (possible pneumonia, croup, or bronchiolitis), please bring your child to see the doctor.

9.Regardless of age, you generally need to avoid cough suppressants. Studies show that they do NOT decrease cough enough to give comfort but do blunt the protective cough reflex enough to increase risk of pneumonia, bronchiolitis, RAD and asthma.

10. Nasal allergies are relatively rare in children younger than 5 yrs of age (it typically takes several years of exposure to develop allergies) but become progressively more common in children as they get older. A simple blood test may be used to check for allergies if you are concerned.


3)Losing Weight -A Healthful way that works.

The cause of obesity

Lack of will power is not the problem. Too much insulin production is the ultimate cause of obesity. Although insulin is required to process sugars and starches (carbohydrates), too much insulin production can wreak havoc with activity levels and appetite. One person may eat a slice of bread and produce just the right amount of insulin. That person remains slim. Another person may eat an identical slice of bread but produce three times the amount of insulin needed. Producing too much insulin induces low blood sugar (which causes fatigue), and increases the appetite -specifically causing cravings for more high carbohydrate foods. Decreased activity stemming from fatigue in addition to increased appetite is a recipe for obesity.

The solution:

Insulin is produced in response to ingestion of carbohydrates. By decreasing carbohydrate consumption, less insulin is produced. Since blood sugar does not drop, there is no fatigue. Additionally, there is no insulin-induced cravings for more food. Increasing activity (from eliminating fatigue) and decreasing the appetite will induce weight loss. As an added benefit, since the appetite decreases, the body burns fat. Ketones, produced as a side product of burning fat, further suppress the appetite. In fact, too much ketones can even cause some nausea. That rarely happens but if it does, a very small amount of carbohydrates can alleviate this problem.

Putting the solution in practice:

Foods can be divided into three groups

1)Food you can eat all you want - eggs/meat/cheese. Trying to starve yourself does not work. When you are hungry, you should eat. However choose foods primarily from this category.

2) Foods you should avoid completely - sugar/flour/starches. Starches include foods such as rice, corn, bread and most beans (green beans are low carb however). If you cheat, it generally takes at least a week to get the carbohydrates out of your system so the body can start breaking down fats. Even a little starch (such as the breading on fried chicken) can completely ruin the effect of this diet

3)Foods you can eat in moderation - You just have to know how many grams of carbohydrates are in the food. These foods include most vegetables. A whole 3 inch diameter tomato has about 5 grams of carbohydrates for instance. Cucumbers, lettuce, and cabbage have essentially none. The Doctor Atkins book (among others) can give the carb count for most common foods. For most people, losing weight will occur easily when eating 20 grams or less of carbohydrate / day. After a few weeks, you may be able to add some more carbs and still lose weight. Some people may produce just a little too much insulin. They may be able to lose weight while eating more than 20 gram. Other people produce way too much insulin and will have to restrict their carbohydrate consumption more aggressively.

An excellent book on losing weight using this method is "Dr Atkins New Diet Revolution.*" Obviously it goes into much more detail than this handout. I suggest you read the book twice before embarking on this diet.

Common Questions

1)Won’t eating all the bacon, eggs and hamburger meat cause my cholesterol to go up?

Typically the opposite occurs if you are following the diet correctly. Insulin is required to absorb cholesterol. If you are restricting carbohydrates sufficiently, you can eat all the eggs, meat, cheese and bacon you desire but your blood cholesterol will drop since the cholesterol will not be absorbed.

2)Can this diet injure my kidneys?

No. However, if you already have kidney problems from diabetes or other causes, the high ketones caused by burning fat may be problematic.

*To order the book, you may call Barnes and Nobles at 1 800 THE-BOOK. They have versions both in English and in Spanish.


4) Taking your baby home from the hospital

Feeding - Once you leave the hospital, your baby should not be on a schedule of feeds. Your baby should decide how much to eat and how often. New parents are often surprised at how much babies eat. Eating much or frequently is NOT an indication that your baby is ready for solids. That is just an indication that they need MORE formula or breastmilk. Most babies lose about 10% of their birth weight normally by discharge.   We will need to check your baby in two to four days. At that time, if your baby is not doing well, then scheduled feeds may be necessary. Otherwise, as long as your baby is eating, urinating and stooling well, you should continue to feed on demand. If you are breast feeding, you may need scheduled feeds just until your breastmilk supply is well established. Once the breastmilk supply is well established (usually about three days), go to feeding on demand instead of scheduled feeds. You will find that over time, babies develop their own schedule.

Gas -Gas is caused by the body breaking down the carbohydrates in breast milk and/or formula. It is not caused by anything you are doing wrong. As the diet gets more varied at 6 months of age, the gas decreases. Gas drops, though harmless have been shown in multiple studies to have no effect.

Water -There is no reason to boil water to make formula. If the water is safe for you to drink, it is safe for the babies. Boiling water is only needed in third world countries where there is not a safe water supply. Babies should not be given water to drink until starting solids at about six months of age. They get all the water they need from the formula/breastmilk. There is no advantage to buying the so-called "nursery water."

Sterilization -There is no advantage to boiling bottles, nipples or pacifiers for healthy babies. Normal washing is adequate.

Formula - Formula may be used unless kept out of the refrigerator for over two hours. It is good in the refrigerator for up to 24 hours. There is no medical reason to warm formula before feeding it to a baby. Straight out of the refrigerator is perfectly fine and will not cause stomach upset or any other problem. If you do decide to warm formula for personal preference, avoid using the microwave as this practice can cause hot spots in the formula and lead to burns.

Follow-up - As stated above, babies usually lose about 10% of their birth weight in the first few days. Then they start to regain. If they lose too much weight, we may need to schedule feeds.  Therefore your infant will need to be seen 2-4 days after hospital discharge for us to evaluate.  We do not expect them to be at birth weight until two weeks of age. We will need to see your baby at that time as well to asses their weight and do a careful physical. Certainly if you have any concerns, please call our office for an earlier appointment.

5) What is RSV?

RSV (respiratory syncitial virus) is the name of a virus that causes colds. It is not the name of a disease. When people say "my child had RSV," they often mean that the child had bronchiolitis, which can be caused by any number of cold viruses. However, the great majority of people, when infected by the RSV, only get a cold which resolves in 10 - 14 days. In fact, by two years of age, almost 100% of all children have been infected by RSV. In only a small percentage do these colds lead to bronchiolitis.

What is bronchiolitis?

Bronchiolitis is the inflammation of a part of the lung called the bronchioles by any cold virus. In bronchiolitis, the viral inflammation has spread beyond the area of nose/throat/sinuses that is normally affected by a cold. Although, depending on the season, RSV may cause 60-80% of bronchiolitis, many other cold viruses can cause it. Typically bronchiolitis occurs in children 2 years of age or younger. Children who get bronchiolitis have a 50% chance of developing asthma as they get older. There is no lab test or x-ray to diagnose bronchiolitis. The diagnosis is based on the physical exam.

How do you treat a cold caused by RSV?

Treat it the same way you treat any other cold: lots of fluids, humidifier, decongestant ( if age-appropriate), and time. Antibiotics do not treat colds whether caused by RSV or not.

How do I treat RSV bronchiolitis?

Treat it the same way you treat any other bronchiolitis caused by any other cold virus: generally bronchiolitis is treated with a medicine given in mist form by a nebulizer. Most bronchiolitis can be treated at home but it sometimes requires hospitalization. Antibiotics do not treat bronchiolitis whether caused by RSV or not.

Should my child be tested for RSV?

In general, the answer is "no." The treatments for a cold or for bronchiolitis remain unchanged whether they are caused by RSV or any other cold virus. The one possible exception may be if a child has bronchiolitis so severe that they are on a ventilator (this situation is exceedingly rare). There is a medication called Ribavirin that can be administered using the ventilator but only if the bronchiolitis is caused by RSV. There is much controversy about whether or not Ribavirin helps even then. Most hospitals do not use Ribavirin (even on ventilator patients).

Are certain children at higher risk for bronchiolitis?

Remember that nearly all children will have an RSV- caused cold in their first two years and will recover from it in 10 - 14 days as from all their other colds. Certain children are at much higher risk for severe RSV- caused bronchiolitis. These are primarily children younger than two years of age who were born very prematurely and/or have chronic heart or lung disease. These children need a monthly injection of a medication called Synagis throughout RSV season (October through April most years). Since these monthly injections are very expensive, insurances will only pay if you meet very strict risk criteria.

How can I prevent bronchiolitis?

Again, bronchiolitis is inflammation caused by a regular cold virus that then spreads to the lungs. Almost everyone who develops bronchiolitis starts out with just a regular cold. Careful handwashing will minimize the risk of transmitting colds which can later lead to bronchiolitis. Children who live in smoking households are MUCH more likely to have their colds lead to bronchiolitis. STOP SMOKING! Keep your child away from crowds and from people with colds. Wash your baby’s toys often.

Syringe

6) Routine immunizations

Birth - Hep B

2mo - Pediarix*, Pneumococcal, Hib, oral rotavirus 1

4mo - Pediarix*, Pneumococcal, Hib, oral rotavirus 2

6mo - Pediarix*, Pneumococcal, Hib, oral rotavirus 3(depending on type available, 2 or three may be needed), flu**

9 mo- catch up any missed vaccines and well check

12 mo - MMRV (preferably given as combination if available), Pneumococcal, Hib

15 mo - Hep A 1

18 mo - Dtap

2 yrs - Hep A 2 (must be at least 6 mos after Hep A 1)

4 yrs - DtaP,IPV (often given combined as Pediarix - the extra Hep B is no problem), MMRV (preferably given as combination if available).

9 - 12yrs and older  - HPV at 0, 2, 6 months (given routinely at age 12 but may be given as early as 9 yrs of age if high risk/desired)

11 yrs - TdaP (Give later if missed)

12 yrs - meningococcal #1/Start HPV series routinely

16 yrs - meningococcal #2

*Pediarix contains DtaP, IPV, Hep B in one shot

**Given Aug - April if 6mo - 18 years old or any other risk factor - ONE year given must repeat in one month for children younger than 9. Entire family needs if any high risk person (high risk includes if anyone in household is younger than age 18, older than age 65, has a chronic heart or lung disease such as asthma, is immunocompromised or has any other significant chronic health condition, such as Cerebral palsy, diabetes, etc.)

7) Flu vaccines

INFLUENZA (FLU) VACCINE INFORMATION

If your child or anyone in the household meets ANY one or more of the criteria below, EVERYONE in the household (six months of age and older) needs to get the flu vaccine as soon in the season as possible.  The best time is Aug/Sept. 

- Has asthma or any other chronic lung disease (COPD, emphysema)

- Has any cardiac (heart) disease

- Is 18 years of age or younger; or older than 65

- Has any chronic condition (diabetes, sickle cell, cerebral palsy, spherocytosis, etc.)

- Is immunocompromised

If your child is younger than 9 years old, ONE year they get two vaccinations, in the same season, at least one month apart (even if they had a single vaccine in a previous season). From then on, only one/yr is needed.

The BEST time to get the flu vaccine is Aug/Sept but it may be given as late as April.  For children requiring two flu vaccines, the first may be given as late as March and finished in April.  The earlier you get the vaccine, the better. It takes a couple of weeks for the antibodies induced by the vaccine to be effective.

Two types of vaccine are available.

- shot - Not quite as effective as nasal spray but cheaper so pretty much all insurances pay.

- nasal spray - More effective and NOT a shot.   Your child must be two years or older to recieve this vaccine.  Not currently FDA approved for asthmatics although multiple studies demonstrate that it is safe and effective for asthmatics as well. (insurances may not pay for the nasal spray form if your child is asthmatic although they pretty much always pay for the shot form).

Although we order our vaccines as early as a year in advance, we never know when they will arrive. You may call the office starting early August to see if they have arrived before coming for the vaccine. 642-2642

Interesting fact:  In the history of medicine, not ONE person has ever gotten the flu from the flu vaccine.

From CPAC