Author Archives: Dr. Raffi Sharon

Exciting new development in my clinic: Rapid Strep Test

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When your child has a sore throat you may wonder if they could have a bacterial infection called “Strep Throat” (a throat infection caused by the Streptococcous group A bacteria). Some physicians might claim they can tell merely by looking at the throat whether there is a Strep infection or not. The truth is that the only way one can tell whether or not there is an infection caused by the Streptococcus bacteria, is to take a throat swab. Typically a throat swab is taken and a result is given after 48 hours.

In September 2012 a review came out by the Infectious Disease Society of America which clearly shows the merit of Rapid Strep Tests in the office setting (read more here). After discussion with our local Pediatric Infectious Disease specialists, I now have a Rapid Strep Test available in my office which gives me a result within 5 minutes. If it is positive, it indeed correlates with having a positive throat culture in 100% of the cases. If the rapid test is negative, there is a 3-4% chance there still could be strep. That’s why just to be sure, I will still do the 48-hr culture throat swab as well. However, if the Rapid Strep Test is positive (meaning there is Strep Throat), antibiotics can be started immediately.

Fever: Myths vs Facts

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Misconceptions about fever are commonplace. Many parents needlessly worry and lose sleep when their child has a fever. This is called fever phobia. Overall, fevers are harmless. Let the following facts help you put fever into perspective:

Myth: My child feels warm, so she has a fever.

Fact: Children can feel warm for many reasons such as playing hard, crying, getting out of a warm bed, or being outside on a hot day. They are “giving off heat.” Their skin temperature should return to normal in 10 to 20 minutes. Once these causes are excluded, about 80% of children who feel warm and act sick actually have a fever. If you want to be sure, take your child’s temperature. The following are the cutoffs for fever using different types of thermometers:

• Rectal, Ear, or Temporal Artery Thermometers: 100.4°F (38.0°C) or higher

• Oral or Pacifier Thermometers: 100°F (37.8°C) or higher

• Under the Arm (Axillary or Armpit) Thermometers: 99°F (37.2°C) or higher

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Myth: All fevers are bad for children.

Fact: Fevers turn on the body’s immune system and help the body fight infection. Fevers are one of the body’s protective mechanisms. Normal fevers between 100°F and 104°F (37.8°C and 40°C) are actually good for sick children.

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Myth: Fevers above 104°F (40°C) are dangerous and can cause brain damage

Fact: Fevers with infections don’t cause brain damage. Only body temperatures above 108°F (42.3°C) can cause brain damage. The body temperature climbs this high only with extreme environmental temperatures (eg, if a child is confined to a closed car in hot weather).

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Myth: Anyone can have a febrile seizure (seizure triggered by fever).

Fact: Only 4% of children can have a febrile seizure

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Myth: Febrile seizures are harmful

Fact: Febrile seizures are scary to watch, but they usually stop within 5 minutes. They cause no permanent harm. Children who have had febrile seizures do not have a greater risk for developmental delays, learning disabilities, or seizures without fever.

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Myth: All fevers need to be treated with fever medicine

Fact: Fevers only need to be treated if they cause discomfort. Usually fevers don’t cause any discomfort until they go above 102°F or 103°F (39°C or 39.5°C).

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Myth: Without treatment, fevers will keep going higher.

Fact: Wrong. Because the brain has a thermostat, fevers from infection usually don’t go above 103°F or 104°F (39.5°C or 40°C). They rarely go to 105°F or 106°F (40.6°C or 41.1°C). While the latter are “high” fevers, they are harmless ones.

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Myth: With treatment, fevers should come down to normal.

Fact: With treatment, fevers usually come down 2°F or 3°F (1°C or 1.5°C)

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Myth: If the fever doesn’t come down (ie, if you can’t “break the fever”), the cause is serious.

Fact: Fevers that don’t respond to fever medicine can be caused by viruses or bacteria. It doesn’t relate to the seriousness of the infection.

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Myth: Once the fever comes down with medicines, it should stay down.

Fact: The fever will normally last for 2 or 3 days with most viral infections. Therefore, when fever medicine wears off, the fever will return and need to be treated again. Fever will go away and not return once your child’s body overpowers the virus (usually by the fourth day).

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Myth: If the fever is high, the cause is serious.

Fact: If the fever is high, the cause may or may not be serious. If your child looks very sick, the cause is more likely to be serious.

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Myth: The exact number of the temperature is very important

Fact: How your child looks is what’s important, not the exact temperature.

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Myth: Oral temperatures between 98.7°F and 100°F (37.1°C and 37.8°C) are low-grade fevers.

Fact: These temperatures are normal variations. The body’s temperature normally changes throughout the day. It peaks in the late afternoon and evening. An actual low-grade fever is 100°F to 102°F (37.8°C to 39°C).

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Summary: Remember that fever is fighting off your child’s infection. Fever is one of the good guys.

Fever

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Definition:

Your child has a fever if:

– Rectal, Ear, or Temporal Artery (TA) Temperature: 100.4°F (38.0°C) or higher

– Oral or Pacifier Temperature: 100°F (37.8°C) or higher

– Under the Arm (Axillary or Armpit) Temperature: 99°F (37.2°C) or higher

– Limitation: Ear (tympanic membrane) temperatures are not reliable before 6 months of age

– Temporal artery and skin infrared temperatures may be reliable in young infants

– Use this guideline if fever is your child’s only symptom

Causes:

* Main Cause: Colds and other viral infections

* Fever may be the only symptom for the first 24 hours (ie, viral fevers). The onset of symptoms (eg, runny nose, cough, diarrhea) are often delayed. In the case of roseola, fever may be the only symptom for 2 or 3 days.

* The cause of fever usually can’t be determined until other symptoms develop. That may take 24 hours.

* Bacterial infections (eg, strep throat, urinary tract infections) also cause fever

* Teething does not cause fever

Fever and Crying:

* Fever on its own shouldn’t cause much crying

* Frequent crying in a child with fever is caused by pain until proven otherwise

* Possible causes are ear infections, urinary tract infections, and sore throats

Normal Variation of Temperature:

* Rectal: A reading of 98.6°F (37°C) is just the average rectal temperature. It normally can change from 96.8°F (36°C) in the morning to a high of 100.3°F (37.9°C) in the late afternoon

* Oral: A reading of 97.6°F (36.5°C) is just the average oral temperature. It normally can change from a low of 95.8°F (35.5°C) in the morning to a high of 99.9°F (37.7°C) in the late afternoon.

Return to School: Your child can return to child care or school after the fever is gone and your child feels well enough to participate in normal activities.

Call 911 Now (Your Child May Need an Ambulance) If:

* Not moving or very weak

* Unresponsive or difficult to awaken

* Difficulty breathing with bluish lips

* Purple or blood-colored spots or dots on skin

Call Your Doctor Now (or in Alberta, Canada call 780-408-LINK) If:

* Your child looks or acts very sick

* Not alert when awake

* Any difficulty breathing

* Great difficulty swallowing fluids or saliva

* Child is confused (delirious) or has stiff neck or bulging soft spot

* Had a seizure with the fever

* Child is younger than 12 weeks with fever above 100.4°F (38.0°C) rectally (CAUTION: Do not give your baby any fever medicine before being seen)

* Fever above 104°F (40°C) and not improved 2 hours after fever medicine

* Very irritable (eg, inconsolable crying, cries when touched or moved)

* Won’t move an arm or leg normally

* Signs of dehydration (eg, very dry mouth, no urine in more than 8 hours)

* Burning or pain with urination

* Pain suspected

* Chronic disease (eg, sickle cell disease) or medication (eg, chemotherapy) that causes decreased immunity

Call Your Doctor Within 24 Hours (Between 9:00 am and 4:00 pm) If:

* You think your child needs to be seen

* Child 3 to 6 months of age with fever

* Child 6 to 24 months of age with fever present longer than 24 hours but no other symptoms (ie, no cold, cough, diarrhea, etc)

* Fever repeatedly above 104°F (40°C) despite fever medicine

* Fever returns after gone for longer than 24 hours

* Fever present for more than 3 days

Call Your Doctor During Weekday Office Hours If:

* You have other questions or concerns

Parent Care at Home If:

* Fever with no other symptoms and you don’t think your child needs to be seen

Home Care Advice for Fever:

1. Reassurance: Presence of a fever means your child has an infection, usually caused by a virus. Most fevers are good for sick children and help the body fight infection. Use the following definitions to help put your child’s level of fever into perspective:

* 100°F to 102°F (37.8°C to 39°C): Low-Grade Fevers: Beneficial, desirable range

* 102°F to 104°F (39°C to 40°C): Average Fever: Beneficial

* Above 104°F (40°C): High Fever: Causes discomfort but harmless

* Above 106°F (41.1°C): Very High Fever: Important to bring it down

* Above 108°F (42.3°C): Dangerous Fever: Fever itself can cause brain damage

2. Treatment for All Fevers: Extra Fluids and Less Clothing:

* Give cold fluids orally in unlimited amounts (Reason: good hydration replaces sweat and improves heat loss from the skin)

* Dress in 1 layer of lightweight clothing and sleep with 1 light blanket (avoid bundling) (CAUTION: Overheated infants can’t undress themselves)

* For fevers 100°F to 102°F (37.8°C to 39°C), this is the only treatment needed (fever medicines are unnecessary)

3. Fever Medicine:

* Fevers only need to be treated with medicine if they cause discomfort. That usually means fevers above 102°F (39°C).

* Give acetaminophen (eg, Tylenol) or ibuprofen (eg, Advil)

* The goal of fever therapy is to bring the temperature down to a comfortable level. Remember, fever medicine usually lowers the fever by 2°F to 3°F (1°C to 1.5°C)

* Avoid aspirin (Reason: risk of Reye syndrome, a rare but serious brain disease)

4. Sponging:

* Note: sponging is optional for high fevers, not required

* Indication: May sponge if fever above 104°F (40°C) doesn’t come down with acetaminophen (eg, Tylenol) or ibuprofen (eg, Advil) (always give fever medicine first)

* How to Sponge: Use lukewarm water (85°F to 90°F) (29.4°C to 32.2°C). Do not use rubbing alcohol. Sponge for 20 to 30 minutes.

* If your child shivers or becomes cold, stop sponging or increase the water temperature.

5. Contagiousness: Your child can return to child care or school after the fever is gone and your child feels well enough to participate in normal activities.

6. Expected Course of Fever: Most fevers associated with viral illnesses fluctuate between 101°F and 104°F (38.4°C and 40°C) and last for 2 or 3 days.

7. Call Your Doctor If:

* Fever rises above 104°F (40°C) repeatedly

* Any fever occurs if your child is younger than 12 weeks

* Fever without a cause persists longer than 24 hours (if your child is younger than 2 years)

* Fever persists more than 3 days (72 hours)

*Your child becomes worse

Based on recommendations/advice in “My Child is Sick; Expert Advice for Managing Common Illnesses and Injuries”, 14th Edition, by Barton D. Schmitt

Vomiting without Diarrhea

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Definition:

* Vomiting is the forceful emptying (throwing up) of a large portion of the stomach’s contents through the mouth

* Nausea and abdominal discomfort usually precede each bout of vomiting

Causes:

* Main Cause: Stomach infection (gastritis) from a stomach virus (eg, rotavirus). The illness starts with vomiting but diarrhea usually follows within 12 to 24 hours.

* Food poisoning from toxins produced by bacteria growing in poorly refrigerated foods (eg, Staphylococcus toxin in egg salad, Bacillus cereus toxin in rice dishes)

* Serious Causes: If vomiting persists as an isolated symptom (without diarrhea) for more than 24 hours, more serious causes must be considered. Examples are appendicitis, kidney infection, meningitis, and head injury.

* Vomiting can also be triggered by hard coughing. This is common, especially in children with reflux.

Severity of Vomiting:

Te following is an arbitrary attempt to classify vomiting by risk for dehydration:

* Mild: 1 to 2 times a day

* Moderate: 3 to 7 times a day

* Severe: Vomits everything or nearly everything, or 8 or more times a day

* Severity relates even more to the length of time that the particular severity level has persisted. At the beginning of a vomiting illness (especially following food poisoning), it’s common for a child to vomit everything for 3 or 4 hours and then become stable with mild or moderate vomiting.

* The younger the child, the greater the risk for dehydration

Return to School: Your child can return to child care or school after vomiting and fever are gone

Call 911 Now (Your Child May Need an Ambulance) If:

* Unresponsive or difficult to awaken

* Not moving or too weak to stand

Call Your Doctor Now (or in Alberta, canada call 780-408-LINK) If:

* Your child looks or acts very sick

* Confused (delirious)

* Stiff neck or bulging soft spot

* Headache

* Signs of dehydration (very dry mouth, no tears, and no urine in more than 8 hours)

* Blood in the vomit that’s not from a nosebleed

* Bile (bright yellow or green) in the vomit

* Abdominal pain is also present (EXCEPTION: Abdominal pain or crying just before and improved by vomiting is quite common)

* Appendicitis suspected (eg, pain low on right side, won’t jump, prefers to lie still)

* Diabetes suspected (excessive drinking, frequent urination, weight loss)

* Poisoning with a plant, medicine, or other chemical suspected

* Child is younger than 12 weeks with vomiting 2 or more times (EXCEPTION: spitting up)

* Receiving Pedialyte (or clear fluids if older than 1 year) and vomits everything longer than 8 hours

* High-risk child (eg, diabetes mellitus, abdominal injury, head injury)

* Weak immune system (eg, sickle cell disease, HIV, chemotherapy, organ transplant, chronic steroids)

* Vomiting an essential medicine

* Fever above 104°F (40°C) and not improved 2 hours after fever medicine

* Child is younger than 12 weeks with fever above 100.4°F (38.0°C) rectally (CAUTION: Do NOT give your baby any fever medicine before being seen)

Call Your Doctor Within 24 Hours (Between 9:00 am and 4:00 pm) If:

* You think your child needs to be seen

* Has vomited longer than 24 hours

* Fever present for more than 3 days

* Fever returns after gone for longer than 24 hours

Call Your Doctor During Weekday Office Hours If:

* You have other questions or concerns

* Vomiting is a recurrent chronic problem

Parent Care at Home If:

* Mild to moderate vomiting (probably viral gastritis) and you don’t think your child needs to be seen

Home Care Advice for Vomiting:

1. Reassurance:

* Most vomiting is caused by a viral infection of the stomach or mild food poisoning

* Vomiting is the body’s way of protecting the lower intestinal tract

* Fortunately, vomiting illnesses are usually brief

2. For Bottle-fed Infants, Offer Oral Rehydration Solution (ORS) for 8 Hours:

* ORS (eg, Pedialyte, store brand) is a special electrolyte solution that can prevent dehydration. It’s readily available in supermarkets and drugstores.

* For vomiting once, continue regular formula

* For vomiting more than once, offer ORS for 8 hours. If ORS is not available, use formula.

* Spoon or syringe feed small amounts of ORS —1 to 2 teaspoons (5 to 10 mL) every 5 minutes.

* After 4 hours without vomiting, double the amount

* After 8 hours without vomiting, return to regular formula

* For infants older than 4 months, also return to cereal and strained bananas

* Return to normal diet in 24 to 48 hours

3. For Breastfed Infants, Reduce the Amount Per Feeding:

* If infant vomits once, nurse 1 side every 1 to 2 hours

* If infant vomits more than once, nurse for 5 minutes every 30 to 60 minutes. After 4 hours without vomiting, return to regular breastfeeding.

* If infant continues to vomit, switch to ORS (eg, Pedialyte) for 4 hours

* Spoon or syringe feed small amounts of ORS —1 to 2 teaspoons (5 to 10 mL) every 5 minutes

* After 4 hours without vomiting, return to regular breastfeeding. Start with small feedings of 5 minutes every 30 minutes and increase as tolerated.

4. For Children Older Than 1 Year, Offer Small Amounts of Clear Fluids for 8 Hours:

* Water or ice chips are best for vomiting in older children (Reason: water is directly absorbed across the stomach wall)

* ORS: If child vomits water, offer ORS (eg, Pedialyte). If child refuses ORS, use half-strength Gatorade

* Give small amounts —2 to 3 teaspoons (10 to 15 mL) every 5 minutes

* Other Options: Half-strength flat lemon-lime soda, popsicles, or ORS frozen pops

* After 4 hours without vomiting, increase the amount

* After 8 hours without vomiting, return to regular fluids

* CAUTION: If vomiting continues for more than 12 hours, switch to ORS or half-strength Gatorade

* Solids: After 8 hours without vomiting, add solids

– Limit solids to bland foods. Starchy foods are easiest to digest

– Start with saltine crackers, white bread, cereals, rice, and mashed potatoes

– Return to normal diet in 24 to 48 hours

5. Avoid Medicines:

* Discontinue all nonessential medicines for 8 hours (Reason: usually make vomiting worse)

* Fever: Fevers usually don’t need any medicine. For higher fevers, consider acetaminophen (eg, Tylenol) suppositories. Never give oral ibuprofen (eg, Advil); it is a stomach irritant

* Call your doctor if your child is vomiting an essential medicine

6. Sleep: Help your child go to sleep for a few hours (Reason: sleep often empties the stomach and relieves the need to vomit). Your child doesn’t have to drink anything if she feels very nauseated.

7. Contagiousness: Your child can return to child care or school after vomiting and fever are gone.

8. Expected Course: Vomiting from viral gastritis usually stops in 12 to 24 hours. Mild vomiting with nausea may last up to 3 days

9. Call Your Doctor If:

* Vomiting becomes severe (vomits everything) longer than 8 hours

* Vomiting persists longer than 24 hours

* Signs of dehydration

* Your child becomes worse

Based on recommendations/advice in “My Child is Sick; Expert Advice for Managing Common Illnesses and Injuries”, 14th Edition, by Barton D. Schmitt