Sick Child Resources
Tylenol and Motrin Dosing Information

Acetaminophen (Tylenol) and Ibuprofen (Advil/Motrin) Dosing
The tables below provide recommended dosage charts for acetaminophen (Tylenol) and ibuprofen (Motrin/Advil). Here are some important general guidelines for using these products:

We recommend acetaminophen/Tylenol for low grade fevers and mild pain. We recommend ibuprofen/Motrin/Advil for higher temperatures, more severe pain, inflammation or for when acetaminiphen is not effective or you need 6 hours of relief vs. 4 hours. You are treating your child, not a number on the thermometer. Your goal in treating a fever is to make your child comfortable, not to make the number lower. Whenever possible, use your child’s most current weight when choosing an appropriate dose of medication. Ibuprofen should be effective when acetaminophen is not. Both drugs can be given concurrently (acetaminophen every 4 hours and ibuprofen every 6 hours) if ibuprofen is ineffective alone. Temperature should be measured rectally in children under 12 months; ear (otic) thermometers should be reserved for children over the age of 12 months. An oral thermometer is not appropriate until your child can hold it under his tongue for several minutes without biting (usually around age 5). Never give acetaminophen or ibuprofen to an infant under 2 months of age. In addition, do not give ibuprofen to an infant under the age of 6 months without specific direction from a physician. Acetaminophen rectal suppositories can be purchased at your pharmacy without a prescription. Feverall is a brand that is readily available. They are helpful to have on hand in case your child has fever or pain and is vomiting and can’t keep down acetaminophen by mouth. Use K-Y Jelly or Vaseline to lubricate the suppository and insert in the child’s rectum every 4 hours as necessary.

Colds and Cough Symptoms

This page provides general advice about dealing with colds and the flu, including dosage recommendations for some commonly used OTC medicines. Please note that many cough/cold products have been reformulated recently. In part that is because many products contained pseudoephedrine, which is now stocked behind pharmacy counters in accordance with the Combat Methamphetamine Act. Pseudoephedrine is the best-studied decongestant in adults, but NO decongestant has been well studied in children. Often doses have been extrapolated from adult data. We also know that adult studies report common side effects including an increase in blood pressure, increase in heart rate, and restlessness. Other decongestants (including phenylephrine, which has replaced pseudoephedrine in many products), have not been widely studied, and where studied, have shown limited benefit.

Our favorite cold/cough preparations are listed below, but if you have found something helpful for your child in the past, feel free to continue using it at the manufacturer’s recommended dosing, or call our office for additional guidance. Remember these medicines will not make the cold go away; they only help to make your child feel better until the dosing wears off. In general, upper respiratory infections/colds last 10-14 days from onset of symptoms until completely resolved.As a parent you must weigh the potential benefits and risks, and use these medications only when your child is experiencing significant enough symptoms to warrant TEMPORARY relief. Nothing replaces rest, fluids, TLC and time.

Do not give cold/cough medicines to infants less than 6 months of age. Mechanical alternatives such as suctioning the nose and throat with a bulb suction syringe, loosening mucus with saline solution (Ocean nasal spray, NaSal nose drops, etc.), and using a cool mist humidifier/vaporizer will help infants breath more easily while congested.

In general, it is best to give medicines only for the specific symptoms that a child is experiencing. Remember these products treat symptoms only. They will not make your child’s cold resolve faster, but they may help to make him/her more comfortable in the meantime. Do not use a multi-symptom product with a combination of acetaminophen and cold/cough products, because combo products often result in inadequate doses of acetaminophen. Please refer to the Tylenol/Motrin dosage chart for those doses. To ensure the correct dose, make sure you have a working thermometer at home (with fresh batteries).

During the cold/flu season your child may experience back-to-back colds/illnesses. Choose your medicines wisely. You can help your child through an illness by encouraging plenty of fluids and rest; avoiding airway irritants like cigarette smoke, scented candles, fireplaces and potpourri; and by providing extra TLC. Good hand-washing will help keep your child from picking up viruses which can live on surfaces for an extended period of time. You can help prevent the spread of germs in your own home by cleaning commonly handled surfaces such as doorknobs, light switches, and the remote control, with Lysol or another antiseptic cleanser.

Colic in Infants

Crying is a normal part of an infant’s day. During the first two weeks of life, an infant usually is crying because he is hungry. After three weeks of life, infants may cry for about three hours a day. When your baby cries at this age, it may be that he is hungry, needs his diaper changed, or just wants to be held. Also check his eyes to look for scratches and his fingers, toes, and penis to check for a tourniquet (sometimes a piece of thread can wrap itself around his skin tightly to cut off circulation). Call your doctor if the crying is associated with skin color changes, fever (a rectal temperature over 100.4 degrees Fahrenheit), or a bulging fontanelle (the baby’s soft spot).

Colic describes a subset of babies who cry more than others. The classic definition of colic is infant crying that lasts for more than 3 hrs per day, more than 3 days per week, and lasts longer than 3 weeks. Some parents describe these periods of crying as “sudden”, an “attack”, and “intense.” The babies may have flushed cheeks, distended stomachs, flexed legs, clenched fists, or arched backs. The infants are often inconsolable, often unrelenting until they pass stool or flatus. These attacks often have early morning and/or evening peaks.

Theories abound regarding the causes of colic. Some experts in child development suggest that colicky babies are just at one end of a spectrum of normal infant temperaments. Infant crying is a necessary and healthy way for your baby to discharge the excitement accumulated from a day of external stimulation before nightfall.

Other studies support the theory that infants’ colic is derived from their immature gastrointestinal systems. Infants may not have fully developed their ability to break down lactose and other carbohydrates, leading to a buildup of gas. Compared to other babies, colicky infants also were shown to have a higher level of motilin, a gastrointestinal hormone that makes their system hyperactive, contributing to cramps. Still others think that colicky infants are expressing hunger during a growth spurt. Mother’s breastmilk has the least amount of fat in the evening (prove it to yourself by expressing milk at a different time each day, you’ll see that the cream level is lower at night). Infants may be crying for more frequent feedings because they may need more fat at night to support a growth spurt. Try to pump some breastmilk after the baby’s morning feed and top the infant off at night with this more creamy milk to see if the increased fat intake alleviates the colic.

Others believe that a small group of colicky babies are really suffering from milk protein allergy or gastroesophageal reflux. These babies may also have loose stools and more frequent spitup.

You should never feel inadequate as a parent of a colicky baby-if anything, pat yourself on the back for the hard work of caring for a challenging infant! Over 90% of infants recover from colic by the age of three months without any intervention. In the meantime, there are some strategies to try. It may take some experimenting to find which one works for your baby–only 30% of the techniques work with any given infant.

Child development suggests that parents try to match the baby’s environment to “fit” the baby’s temperament. Some light or motion sensitive babies may benefit from swaddling and a darkened room to calm themselves at the end of the day. Babies who seem sensitive to sounds may enjoy lying in a carseat on the washing machine or the sounds of a fan or TV on white noise. Other infants thrive on music, rocking, and the voices of loved ones nearby.

Some remedies that address the infant’s gastrointestinal immaturity relate to feeding. Feeding the baby more vertically with frequent burping may help. Breast-feeding mothers should avoid caffeine. Herbal remedies can be used once the infant is two weeks old. Fennel, chamomile, or balm-mint tea (2 oz at room temperature, without sugar or honey) have long been used to help colicky infants. Teas should only be used once or twice a day, so that the infant’s milk consumption does not decrease. A teaspoon of 0.1% fennel seed emulsion oil up to 3 times per day was shown to help colicky infants in a recent study.

Antispasmodics such as dicyclomine are dangerous for infants and should not be used. Although simethicone (Infant Mylicon Drops 0.3 mL up to three times/dy) drops are safe to use in infants over 2 wks old and can be helpful for gassy babies, they have not been shown to significantly help colicky babies.

Since milk protein allergy does cause colic in some babies, it may be worth a one week trial of a hypoallergenic infant diet. This could be a hypoallergenic, pre-digested formula such as Nutramigen or Alimentum. For a breast-feeding baby, the mother would eliminate milk/dairy/soy/egg/wheat/nuts from her diet. If after one week there is no change, the infant should go back to his previous formula ( and the mother to a regular diet).

And most importantly, make sure that you get some rest as a parent. Let someone else carry her for a few hours so you can enjoy dinner or even get some sleep. You will both be recharged after the temporary separation. Colicky infants (and their exhausted parents) eventually recover from this period, almost all by three months old. Compared to their peers, colicky babies do not have any increased future risk of allergies, asthma, or sleep problems. So both of you will sleep at last!

Constipation

There are several causes of constipation. There might not be enough fluid and fiber in the diet and the stool gets progressively drier, harder, and more difficult to pass. It is also thought that some children have gastrointestinal tracts that move at a more leisurely pace. There are families with more of a tendency to constipation, and one supposes that they have “slower” GI tracts. Yet another cause of constipation is a large S curve at the lower left abdomen. This is where the left descending colon joins the sigmoid and leads to the rectum.

The rectum has a complicated anatomy. There are many stretch receptors that detect the presence and quality of stool. Then there are two sets of circular muscle groups called sphincters that have to open. One of these sphincters is under voluntary control and is what you use to “hold it back” until the time is right. Toilet training requires that smooth contraction of the sensors and sphincters.

Many children have an occasional bout of constipation. This often happens during vacations when everyone is eating on the go, not eating as much fiber, or not drinking enough water. Toddlers tend to like dairy products. If most of the diet is milk and cheese, their stool can become hard and dry as the milk is digested. Increasing fluids and giving children more fruits and fiber cereals will offset the constipation. When the child needs a little help, there are several over-the-counter laxatives you can use, but you should not use these laxatives on a long-term basis. If you do not get good results within 2-3 days, you must contact Ramsdell Pediatrics. If there is fever, vomiting, or abdominal pain, do not give any laxatives, and contact Ramsdell Pediatrics immediately.

Some Treatments for Constipation include:

Glycerin Suppositories: These provide gentle rectal stimulation which helps promote a bowel movement and also act as a lubricant when formed stool moves through the rectum and anus. Usually, a child will have a bowel movement within 2 hours after inserting a suppository into the rectum. This is usually the first treatment choice for acute constipation in infants and small children. They make sizes for infants and children, so make sure you choose the correct size for comfort.

Miralax: For children who have been holding back stool – a vicious cycle can build in which the stool becomes harder and more painful to pass. A new over-the-counter medication called Miralax acts to “bulk” up and soften the stool . It comes as a powder that can be mixed with food or liquids.
Milk of Magnesia: 1/2 to 1 tsp twice daily for up to three days for children over age 2. This should only be given for children who suffer from occasional constipation and should not be given for more than 3 days.
Fletcher’s Castoria: this is a root beer flavored liquid that can be given to children ages 2 and over for occasional constipation. 1/2 to 1 tsp twice daily for up to three days.

Mineral Oil: A long-time standard treatment for chronic constipation is mineral oil. Mineral oil is given on a daily basis to soften and lubricate the stool so it is better able to slip through the sigmoid colon. The standard protocol is to give the child mineral oil once or twice a day for one month. The dose is 1-4 ml/kg/day. The low range of this dose translates into 1 tsp of mineral oil a day for every 10 pounds of a child’s weight. Example: if your child weighs 30 pounds, he or she could take 3 tsps daily, 1.5 tsp in the morning and 1.5 at night. Mineral oil will absorb fat-soluble vitamins such as A, D and E. If someone took mineral oil three times a day with every meal he or she would slowly develop vitamin deficiencies. When given twice a day (morning and bedtime), it’s not a problem. Nonetheless, you can give the child a multivitamin around dinnertime.

Mineral oil on a daily basis will start giving your child a “slippery stool.” If it gets too slippery and your child is having oily diarrhea, it means you’ve given too much and it’s time to cut back. Once the child starts having easy, painless stools for a couple of weeks, start lowering the dose of mineral oil over a couple of weeks. Then, stop it altogether. Most child use mineral oil for about a two-month period. They might use it from time to time thereafter for recurrences. Chilling it in the refrigerator and immediately giving something sweet and tart (like a sip from a juice box) makes it more palatable. There are some flavored forms of mineral oil, such as Kondremul, which has a marshmallow taste.
Warm Water with Lemon: this is a natural remedy that has helped with digestion and elimination. Take 8 ounces of warm water and squeeze the juice of 1/2 lemon. Drink in morning. For children ages one and older.

Herbal Remedies: Alfalfa, Black Walnut, Chickweed, Flaxseed, Hibiscus, Senna, and Yellow Dock are western herbs that have been used to treat constipation in children. Herbal remedies should never be used without consulting an experienced practitioner and should not be used for more than 10 days.

Homeopathic Remedies: Calcarea carbonica, Causticum, Lycopodium, Natrum muriaticum, Nux vomica, and Silica are homeopathic remedies used to treat constipation in children. Consult an experienced practitioner prior to use.

  • High Fiber Diet (use common sense for choking hazards and puree for children at risk for choking!!!)
  • Fruit cocktails and canned peaches or pears if fresh fruits aren’t available.
  • Crackling Oat Bran cereal (served by the handful as a snack, tastes like miniature oatmeal cookies)
  • Corn Bran cereal (also served as a snack – pretty crunchy and tasty)
  • Bran and Corn Chex cereal (also tasty)
  • Homemade oatmeal cookies (use the higher fiber types of oatmeal)
  • Popcorn (for older kids)
  • Corn on the cob (or frozen corn given at dinner as a side dish)
  • Dried apricots, prunes, and raisins
  • Cantaloupe
  • Blueberries, raspberries, and blackberries
  • Fig Newtons or any snack made with figs or dates (minus the pit!)
  • Fruit Rollups made from dried apricots
  • Add bran or flax seed to recipes when making cookies, cakes, muffins, pancakes, waffles.
  • Make cupcakes with frosting using bran muffin mix or a combination of carrot/bran cake mix.
  • Add pureed celery to meatballs, meat loaf, or tomato sauce, where your child won’t notice it)
  • Branola Bread
  • Fruit punches made with chamomile tea (example: Celestial Seasonings Sunburst C tea)
Diarrhea

Most children experience several episodes of diarrhea. Most will be mild and self-limited. However, depending on the pathogen and severity of infection, some will take days or even weeks to completely resolve. This is because every intestinal cell that had been attacked by the virus has to be replaced by a new cell. Recovery occurs as the intestinal lining is restored and usually takes at least 8 days.

During this time when the intestinal lining is injured by the virus, nutrients might be not completely absorbed. Cow’s milk and apple juice can be incompletely digested in the small intestine and reach the colon. These undigested sugars can aggravate the diarrhea and make it more irritating to the skin. Infants often get a red, raw diaper rash.

It is of utmost importance to replace lost fluids, otherwise a child can get progressively weaker and start to experience electrolyte disturbances. If a child has one or two loose stools, the parents can offer more fluid, however, if more stools ensue, it is important to start Pedialyte, kaolyte or other electrolyte solution.

Electrolyte solutions such as Pedialyte were developed in the 1960’s and are formulated to replace the ongoing water and electrolytes. As a rule of thumb, if a child takes 2 ounces of electrolyte solution for each watery stool, he or she will remain in balance.

Diarrhea Without Vomiting

The goal is to replace fluids by mouth in an amount which is roughly equivalent to that which they are losing in diarrhea. It is fine to continue nursing and/or offering formula during mild cases of diarrhea. However, if there are multiple episodes of diarrhea (with or without vomiting) and electrolyte solution is best. Avoid things that cause loose stools on a good day (such as apple juice and cider) and avoid dairy products, as diarrhea will cause temporary lactose intolerance in most children. (The lactase enzyme which digests lactose sugar in milk/dairy is in the very center of the intestinal tract. With multiple episodes of diarrhea, the lactase gets washed away and may require a few days of being well to replenish itself.) Gatorade, sodas, and koolaid have electrolytes in them, but sometimes contain too much sugar or high fructose corn syrup. They are not the best choices for fluid replacement in a child with multiple episodes of diarrhea.

If your child is tolerating fluids, you can use carbohydrates such as pretzels, crackers, toast, and noodles to “soak up the fluid”. Other foods that can help are bananas, decaffeinated teas, rice/rice cakes, and applesauce (the pectin helps to stop diarrhea). In general keep your child’s diet boring and bland for a few days, even when their hunger returns. Reintroducing their favorites such as hot dogs and pizza too early may make symptoms reappear.

What if it seems like everything I give goes right through my child?

This may appear to be the case, but is really not what is happening. Remember when you first brought your child home as an infant? Every time you fed him/her, he soiled his diaper. This is because the body has a “gastro-colic” reflex and no tone to the anal sphincter when you are very young. Every time you introduce something into the stomach, the colon starts moving things along and the rectal sphincter relaxes to expel whatever happens to be down there. If things are moving rapidly through the intestinal tract (as in the case of a viral illness), the contents do not sit in the colon/rectum long enough for the body to reabsorb any excess water. This is why it looks like the fluids you are giving by mouth are coming out the other end. Be persistent! Keep pushing the fluids and the body will eventually recover.

What do I give an infant with vomiting/diarrhea?

In general, children under 12 months of age should receive fluid replacement in the form of Pedialyte or one of the other electrolyte replacement solutions on the market. These products have the correct amount of sugar/salt to make sure the baby’s “chemistries” don’t get out of whack. As above, start with small amounts. If your child is not vomiting, keep offering fluids as tolerated and monitor hydration status as above. If you are breastfeeding, continue to do so with small, frequent feedings. If you are bottle feeding, offer no other foods but Pedialyte (absorbed through the stomach, and the body doesn’t have to do any work to digest, so it gives the intestinal tract a “rest”) for the first 24 hours.
Once there has been no vomiting for 2 hours, you can begin to introduce fluids. Start small and work your way up: 1 teaspoon every 15 minutes for the first 2 hours, then 1 ounce at a time as long as there is no vomiting. If vomiting returns, wait 2 hours before trying to give the electrolyte solution again.

FYI: Ice water is very harsh on an irritable stomach. If children have an upset stomach, giving ice water tends to make them vomit more.
Then switch to a non-milk based or lactose-free formula for a few days. It is often a good idea to do 24 hours of Pedialyte only, followed by 12-24 hours of Pedialyte and lactose-free/soy formula, followed by full strength (mixed according to the directions on the can) lactose-free/soy formula for a few days. If your child is eating solids, you can reintroduce bland/boring things once you know they are tolerating full strength formula.

When should I be concerned?

Seek medical attention if your child appears dehydrated, symptoms persist longer than expected (vomiting continues longer than 12 hours, and/or diarrhea persists longer than 3 days), your child appears very ill/listless, or diarrhea is accompanied by severe abdominal pain/cramps and/or has mucus or blood in it. If there is a fever, or if there have been no tears when crying, or less than one urine (wet diaper) in 12 hours, it’s time to contact Ramsdell Pediatrics.

Copyright © 2005 by Children’s Wellness Center. All rights reserved. Reproduction for commercial use strictly prohibited.

What if your child doesn’t like Pedialyte or kaolyte:

Try one of the flavored forms of Pedialyte, (particularly apple). Electrolyte solutions are also available as popsicles and Jello.

Make a sugar based solution: Mix 1/2 tsp of salt (2.5mL) with 8 teaspoons of sugar and one quart of water. This contains the right proportion of sodium, glucose but doesn’t contain potassium. The child will also need to have bananas, carrots, or another potassium containing food. Tip: Make this solution, add a banana and quarter cup of orange juice and put in a blender.

Make a soup based solution: Use a proportion of 1/3 tsp of salt to each quart of water (This will make up for some evaporation of the water during cooking). Add a piece of chicken or other meat preferably with a bone. Add carrots and rice or potatoes and start cooking. You can also add some frozen squash. The resulting chicken/rice/carrot soup will help replace sodium, potassium, water but also contain trace elements like calcium, magnesium and phosporus.

It’s good to give a child rice during diarrhea. The structure of rice acts like a cotton mop by absorbing bacterial byproducts. Potatoes, carrots, and squash also help firm up the stools. When a child is starting to improve, giving high fiber foods like oatmeal and small amounts of lentils and beans help normalize the GI tract.

Yogurt contains the beneficial bacteria lacto-bacillius. It populates the intestinal tract with ‘friendly’ bacteria that crowds out the more pathogenic germs. It is recommended that parents start giving children yogurt (or commercially available pro-biotic) at the beginning of diarrhea, or when ever they are taking an antibiotic.

When a child needs to go to the ER or be hospitalized:

Severe diarrhea with inability to keep up with ongoing losses. Each winter, many infants are hospitalized for IV fluids because of the Rota virus, which gives a particularly watery diarrhea.

GREEN VOMITING – this can be a sign of a medical emergency, intussusception, in which the stressed intestinal tract becomes obstructed in a telescoping like motion.

BLOODY STOOLS – this can be a sign of pathogenic e.coli that can cause complications with blood clotting and kidney function.

PAIN WITH MOTION or PAIN IN THE RIGHT LOWER ABDOMEN – this can be a sign of appendicitis. After intestinal viruses, the lymph nodes of the intestinal tract become slightly enlarged. Children have relatively larger lymph nodes than adults and they are more crowded in the vicinity of the appendix. Appendicitis is notoriously hard to diagnose is younger children. One of the early symptoms is pain with movement. Another symptom is pain in the middle of the night. The pain of appendicitis typically starts around the belly button and then moves to the right lower quadrant. However, if can have an atypical pattern. The appendix can be slightly deflected and the pain if it is inflamed can be referred to another area of the abdomen.

IF YOU THINK YOUR CHILD IS ACTING SICKER: Parents have very good intuition. If your child is acting weak, this can mean that dehydration or an electrolyte imbalance is setting in. A few hours of IV hydration can make a tremendous difference. Diarrhea can be serious. It continues to claim countless lives in third world countries and war zones. I remember reading in a medical journal that in 1900, 20% of the children in New York City died of diarrhea. This was before IV therapy was available and people knew about the need to replace electrolytes as well as fluid.

Ear Infections

Ear infections are one of the most common illnesses of early childhood. The medical name for ear infection is otitis media, meaning inflammation of the middle ear.

How Do Ear Infections Occur?

There is a passageway called the eustachian tube, which connects the middle ear with the back of the throat and nose (the nasopharynx). The middle ear is usually filled with air, and the eustachian tube serves to equalize the pressure. It’s your eustachian tube that causes the “popping” sensation when you go up in an airplane or climb a mountain.

When a child gets an infection of the nose or throat (upper respiratory infection), sometimes the lining of the eustachian tube, or its outlet, can become blocked. An airlock develops in the middle ear. The child may tug at his ears as they have a sensation of fullness. As the pressure builds, the child experiences pain, in much the same way people can feeling twinging or sudden sharp pains when flying on an airplane.

Why Antibiotics Are Often Not Needed:

Many ear infections are due to respiratory viruses. There is clear fluid within the middle ear and the pain is due to pressure. The fluid will resolve spontaneously and the viral infection is cleared by the immune system. Antibiotics will have no effect and can cause potential problems like diarrhea and allergic reactions. When antibiotics are widely used, strains of “resistant” bacteria, which are immune to the antibiotic can evolve, making it more difficult for antibiotics to work when they’re really needed.

Why Antibiotics Are Sometimes Needed:

Bacteria in the back of the throat can become trapped in the eustachian tube and extend into the middle ear. The germs set off an inflammatory response. The child develops a fever and usually experiences more pain, especially at night as the child lies on the affected side. When the doctor looks at the child’s ear drum, there is more inflammation and sometimes a bulging abcess. This type of ear infection is treated with antibiotics.

After the child starts antibiotics, it will still take a few days for the pressure and inflammation to subside. If symptoms persist more than two days, the child should be rechecked. Sometimes, the antibiotic has to be changed because the middle ear fluid is harboring bacteria that are “resistant” to Amoxacillin, the medicine usually used as first line therapy.

Bacterial ear infections are potentially serious. They can cause hearing loss by damaging the delicate middle ear structures. Also, because of the middle ear’s proximity to the brain and cerebral blood vessels, a severe, untreated ear infection could lead to meningitis (infection of the lining of the brain). In the days before antibiotics, children could develop mastoiditis, an infection of the mastoid bone which is right behind the ear.

Alleviating Pain:

To help alleviate pain, ibuprophen (motrin or advil) or acetomenophen (tylenol) can be used. Ibuprophen has more of an impact, so try to give it before the child goes to sleep. You can repeat it six hours later. You can alternate ibuprophen and acetominophen every 3-4 hours for severe pain. An antihistamine like benadryl can help a child fall asleep.

Some Old Fashioned Tricks for Ear Pain:

Place a few drops of icy cold water in the affected ear.
Another trick, place a small heating pad on the mother’s or father’s chest, and letting the child sleep upright on your chest with the affected ear lying on the pad.

To Make a Small Heating Pad:

Put a cup of uncooked rice in a thick sock, sprinkle some salt in with the rice to help ‘hold the heat’, tie the top, and place the sock in a microwave oven for about 60 seconds. It makes a nice heating pad. Placing it against the parent’s chest assures that it’s not too hot.

E. Pytlak, MD (10/2006)

Fever in Childhood

Fever represents the immune system “turning itself on”. As it recognizes the arrival of a challenge – usually a viral illness – and signals the production of antibodies and activated T cells against the pathogen. As the ‘orchestra” warms up, the fever will rise. One of the substances released, interferon, blocks the ability of viruses to spread, but also makes a person feel ‘weak’. Other substances, called “acute phase reactants” have an effect on the intestinal tract. Young children often throw up while older children and adults report nausea or a total lack of appetite.Different viral infections have different fever patterns. Most rhinoviruses will give a low grade fever, while adenovirus and influenza are famous for high spikes. The height of a fever can also vary with how large a dose of viral particles the person was initially exposed to. Also, if a person had an illness within the previous month, exposure to another fever causing illness will cause an exaggerated fever response. There are many other factors as well. Some families always seem to have high grade fevers.

Special note: Fever is newborns (infants less than 2 months old) are treated differently than older children. Because the infant’s immune system is immature, a low grade fever could signal a serious infection such as a kidney infection or a systemic infection like group B strep. All infants with a rectal temperature over 100.5 need to be taken to the hospital immediately so they can have the necessary tests to rule out bacteremia (bacterial infection of the blood stream). Also, because bacteria in the blood stream of newborns can more easily pass into the spinal fluid, a spinal tap is needed to ascertain that the child is not in the process of developing meningitis.

Most parents are afraid when their child has a fever, especially when the child is young and can’t describe what hurts. Moderate and low grade fevers (< 102) are extremely common after six months of age. The child has started to crawl and explore more – putting more things into his or her mouth. Also, after the immediate newborn period, the infant usually has more contact with people – attending family gatherings, music classes, or day care.

Many fevers will start with a high burst in the late afternoon or evening. Parents will often remember thinking that the child acted a “little tired”, “whiny” or maybe threw up before the onset of the fever. As a rule of thumb, if a child acted “OK” in the morning and spiked a fever in the afternoon, there is no need to rush to the doctor or hospital right away because this usually the arrival of a respiratory virus. The child might describe a sore throat, runny nose, or watery stool.

If however, a child has had a low grade fever and cough/cold for several days and then spikes a high fever, there is more of a possibility of a secondary bacterial infection.

If the fever has been high grade (103+) or persistent, the pediatrician will want to see the child to check for serious bacterial infections or autoimmune conditions.

Why treat a fever:

If a child is cheerful, or not having pain, it is not necessary to treat a fever. Fever can allow the immune system to work more efficiently. Some pediatricians think that it’s better to let the illness “burn itself” out. In many cultures, its thought that intensifying the fever speeds recovery.
However in children who are not able to express themselves, when a fever is over 103, it is thought that there can be some “vasodilatation” of blood vessels that can give a low grade headache. Bringing the fever down to the 102 range takes away this form of headache. Many children act happy and talkative when they have a fever – some five years old will even describe vivid dreams that border on hallucinations. It is not necessary to lower fevers if the child is not having pain.

Many viruses make a child have a scratchy throat or throbbing headache. Giving acetominophen or ibuprophen can erradicate or minimize the pain.

Besides giving fever reducers, other ways to lower a temperature is stroking the child’s forehead with a wet hand, or putting cool compresses around the wrists and/or ankles. To illustrate this, put a wet cold piece of cloth on the pulse point of your wrist.

An old “fever reducing” technique from the Caribbean is giving a child lemon grass tea and wrapping them in a blanket to help “sweat” out the fever. An old Italian remedy is putting rubbing alcohol on a baby’s socks and putting the socks on. (Never put rubbing alcohol near a child’s face – they could inhale it).

How to take a temperature:

For young infants, take a rectal temperature. Place the baby on its abdomen or on its back with knees to chest. Insert a thermometer gently into the anus about 1/4 of an inch. Squeeze the buttocks together to keep the thermometer in place instead of holding it in your hand. . You can remove it in about 30 seconds or when you hear a digital thermometer beep.

Axillary temperatures can be used for toddlers and older children. Put a standard thermometer under the child’s arm so it touches both layers of skin. Hold it for one minute. Add one degree Fahrenheit to the result; i.e, a 101.5 axillary is a 102.5F

Tympanic thermometers tend to read slightly high if the child is crying. Sometimes the parents will get a 103 or 104 reading when the child is actually 102. Also, there can be an underestimation if there is lots of wax in the ears, or the child is moving.

Acetaminophen (Tylenol) and Ibuprofen (Advil/Motrin) Dosing.

Sleep Issues

Babies don’t start to develop a diurnal cycle until about a month of age. By four months, most babies will be able to stretch for 5-7 hours. After their long stretch, they’ll wake to feed, and then continue waking up about every 2 hours until morning.
One month old babies usually sleep about 16 hours a day. By one year, most children are sleeping about 13 hours will two naps consolidating into one. Some babies seem to want to start their ‘big sleep’ around 7-8, while others aren’t ready for the long stretch sleep cycle till later. Common signals that a baby is ready for bed is unprovoked crying/whinniness. Some babies will even droop their head or rub their eyes.

Some babies are champion sleepers, and start consolidating their sleep cycles about 2 months of age. Breastfed “good” sleepers might go 8-9 hours straight, while a bottle bed baby might go as long as 12 hours without crying. On the other end of the spectrum are the extremely light sleepers. There are babies who wake every 2-3 hours throughout the night for months, and toddlers who still don’t stay asleep through the night.

It is thought that the long-distance sleepers rise in and out of sleep cycles through the night, but are able to return back into a deep sleep without waking up their parents. The light sleepers, can’t soothe themselves, and cry out when they come out of a sleep cycle.

It is recommended that parents start encouraging “self soothing” techniques between the age of 2 and 4 months. When the baby is fed, dry and content, start the routine. Dim a few lights in the living room, and start a lullaby. As the baby is watching you, smile and close your eyes. The baby might mimic you and close his/her eyes briefly. Then put the baby on your shoulder, leaning on a burp pad, and hum to the baby as you walk him/her to the crib/bassinet. Place the burp pad in the crib and gently place the baby on top of it, on his/her back, briefly stroke his/her forehead and say “good night…….” Then walk away. As the baby starts fussing, wait a few moments, and go back in and do an abbreviated version of the lullaby, stroke or pat him/her. If the baby is hysterical, you can lift him/her and repeat the lullaby – then lying in the crib scenaria. You are trying to teach the baby that whenever he/she hears this lullaby, being placed into the crib will soon follow. The base of this technique is that if a baby self-soothes him/herself to sleep, he/she will be able to get back to sleep when they naturally wake up in between sleep cycles as the night goes on.

Despite this technique, many babies still are insomniac. It is thought they are the ‘super light sleepers’. In these situations, one of the parents can lie sideways on a mat on the floor with the baby being held in the fetal position facing away. The baby will feel your heart beat and breathing. Pretend you are snoring. Hopefully the baby will be lulled into a sense of being in the womb and will fall back asleep. Try not to automatically nurse or feed the baby, unless five or six hours have elapsed, or if this is the second ‘wake up’ that night.

There are lots of factors in what is a good bedtime for a baby. 7 pm might be too early for some families if the mother works outside the home,or it might be perfect if the older kids need help with homework. There are also lots of cultural differences with infant sleep. Many mothers will have the baby on a schedule with regular naps in their crib. Twins are often put on a regular schedule, while babies with older siblings often sleep “on the go” strolling back and forth to school. In many cultures, babies snooze in a sling, basket or papoose, and don’t have a crib, let alone their own room.

Infant insomnia might not be a problem for some parents, but for many it can cause a wide array of sleep deprivation problems. Besides stress and exhaustion, it can cause contributes to car accidents, marital strife, and maternal depression.Here are some excellent comprehensive books for sleep help:

  • Healthy Sleep Habits, Happy Child – by Marc Weissbluth, Marc Weisbluth 2003
  • Happiest Baby on the Block: The New Way to Calm Crying and Help Your Newborn Baby Sleep Longer – by Harvey Karp 2003
  • The Happiest Toddler on the Block: The New Way to Stop the Daily Battle of Wills and Raise a Secure and Well-Behaved One to Four-Year-Old – by Harvey Karp, Paula Spencer 2005
  • Secrets of the Baby Whisperer for Toddlers – by Tracy Hogg, Melinda Blau 2003
  • Secrets of the Baby Whisperer: How to Calm, Connect, and Communicate with Your Baby – by Tracy Hogg, Melinda Blau 2005

article reprinted courtesy of E. Pytlak, MD

Strep Throat

Strep throat is bacterial sore throat. It is due to the group A strep bacteria and although it can affect people of all ages, it is especially common in grammar school children. Many people are exposed to strep and never get sick because of .factors in saliva that prevent the bacteria from adhering to surface of their throats. Other people have acquired a high level of immunity and even though they are exposed, antibodies quickly inactivate the bacteria. During the 1930s, the New York City Board of Health did throat cultures on large groups of school children. They found that in some classrooms, up to 30% of the children who were well enough to be in school had group A strep in their throat. Many of them were asymtomatic carriers. Others were in the recovery phase, or few would be incubating it, and on the verge of being symptomatic.
Prior to the development of antibiotics, if a child came down with a strep throat, he/she could be out of school for a couple of day, or a couple of weeks. When a child had serious strep throat – they would be burning with fever for days. The parents would give them soups, juices, and various gargles such as salt water, peroxide, vinegar, to help fight the germ. Doctors would sometimes paint the child’s tonsils with medicines like gentian violet.

Parents used to dread scarlet fever. This is a more virulent form of strep in which the bacteria contains miscroscopic packets of toxin that cause fever, and/or a rash. There are several different serotypes of strep and some are more pathogenic and contagious than others. When one of these strains gets introduced into a classroom, or birthday party, the kids tend to be sicker and have a high fever. Fortunately, antibiotics are available and the infection can be stopped before overwhelming infection occurs. Strep used to be a significant killer . One of Abraham Lincoln’s sons died of strep during the Civil War. Jim Henson, the creator of the Muppets, died of septic shock strep which had extended into a pneumonia. However, even when exposed to more virulent strains of strep, many children won’t get sick.

Besides its ability to cause severe infection, strep can also cause the auto-immune disease Rheumatic Fever. This is a form of arthritis and fever due to antibodies against strep that cross-react with collagen. The antibodies can damage the heart, especially the valves. Many children who had recovered from strep would go on to have weakened hearts, like the character Beth in Litle Women. In the days before antibiotics, some young adults who had had rheumatic fever were unable to climb stairs and would die at an early age of complications of heart failure.
Sometimes it’s difficult to distinguish between strep and viral sore throats. Some characteristics of strep are:

  • Fever that rises to 102 or persists
  • Worsening of the sore throat (viral sore throats often are worse at the beginning and then lessen)
  • Pain that’s worse with swallowing (viral sore throats can hurt more with coughing)
  • Bad breath
  • Some children will have a headache or vague abdominal pain whenever they have strep

People who have had strep will often recognize the feeling.

Co-existing viral infections and strep:

While a child has a cold, if they are co-exposed to a child with strep, they can have both a viral and bacterial infection. During viral infection, the tonsils become slightly puffed up. If strep is able to attach and grow along the mucous membranes, a secondary bacterial tonsillitis, otitis, or sinusitis can arise. That’s why doctors become concerned if a child had a cough/cold and low grade fever that starts spiking after several days.

Ways to Prevent Strep:

Because a certain number of strep bacteria have to adhere to and grow along the throat, saliva is the first defense against strep. They don’t know why young grammar school children have a particularly higher incidence of strep, but saliva factors must play a role. Salt is a deterrent for strep, as is garlic. Sugar can be a facilitator. Cavities are promoted by a less virulent strain of strep, group C. Foods that are protective against tooth decay , such as apples and cheese, can perhaps have a protective effect against strep.
Have your child rinse his/her mouth with water after having something sweet. Put water instead of a juice box in the lunch box. (Sharing food in the lunch room is a possible vector for strep, and the child shouldn’t go back to the classroom with ‘sweet’ saliva..
Put an piece of apple, cheedar cheese or a few pretzels in his/her lunch box.
There is a mouth wash and toothpaste, Biotene, that has ingredients that protect against strep. It is usually used for adults with impaired saliva production, but is also good for children with recurrent strep.

E. Pytlak, MD (11/2006)