Part two: Urgent Care Centers Versus Our Office

What if your child is ill, and you want him to be seen quickly, and you know he does not need an ER visit? Your choices are between us and an urgent care center.

We have been working hard to make our office more parent-friendly. Thus, all our locations have walk-in hours from 8-12 and 2-4 each day, if you want to just come in with an acute mild illness (e.g. coughs and colds, fever, mild injuries), and wait for the next available opening. We tend to process these quickly although there are times – for example, during flu season – when there can be back-ups. As always, we continue to offer sick appointments as well if you want to be more likely to have your child seen on time, or have a more complicated problem (e.g. headaches, ongoing abdominal pain). We also offer evening hours and weekend (Saturday and Sunday) appointments.

The undeniable advantage of going to an Urgent Care instead of us is that it is usually right near-by, with a short drive, and can be quicker than seeing us. What could be simpler than going in for a quick strep test to see if your child needs medicine?

The answer has to do with the quality of care you might receive. Most Urgent Care Centers are staffed by practitioners who have trained primarily in adult medicine. (There ae some exceptions to this. KidMed in Stafford uses providers with pediatric backgrounds, and the Inova Urgent Care locations in Manassas and Springfield do as well, at least for part of the day). They are less comfortable taking care of children, and as such often practice ‘defensive medicine’ to make sure they are not missing something, as they have less confidence in their clinical skills.

As an example, I will describe a very common scenario. You take your child to an Urgent Care for a sore throat. There, a rapid strep test is done (perhaps reasonable, but not all sore throats require testing, if the doctor can be pretty sure it is not strep).   Then because of a bad cough (which, by the way, makes strep much less likely), a chest-X-ray is ordered to see if there is pneumonia. Now, pneumonia which can only be seen on X-ray, and is not suspected on a physical examination, is almost always viral, and will not respond to antibiotics, so the x-ray, even if positive, should not change treatment. We therefore almost never order X-rays on patients we see in the office. When both of those come back negative at the Urgent Care, indicating a viral illness, an unnecessary antibiotic is often prescribed anyway, ‘just in case.’ Many times, the antibiotic is Zithromax, rather than the less expensive but otherwise identical generic azithromycin. I will also point out that, while azithromycin can be useful in adults, in pediatrics there are almost no common conditions for which it would be the first choice, even if an antibiotic were indicated.

Thus, if you do go to an Urgent Care, and they want to order an X-ray or blood test, I recommend you at least ask what they hope to find that would affect treatment. And, if they do order an antibiotic, ask them what they think they are treating. In our office, in the case described above, your child would be seen, diagnosed as having a virus without unnecessary testing, and sent home without an antibiotic but with information about what to do while you wait for your child to improve naturally on their own over the next few days.

Bottom line, although urgent care centers have their place, I advise that, when possible, you bring your child to our office to be seen instead. You will be seen by someone who has access to your child’s medical history and knows pediatrics. While it may not be quite as convenient as an urgent care center, I strongly believe that it is in your child’s best interests as well, and that is why I recommend it.

EMERGENCY ROOMS, URGENT CARE CENTERS, AND OUR OFFICE

There are different places you can take your child to for health care, and in this two-part article I will explore them in greater detail.

Part one: The ER

I will start with the ER first. Hopefully, your child will never need one. However, I understand that there is nothing as worrisome to a parent as having a sick or injured child, and the temptation to use one in these circumstances can be great. How do you decide whether or not your child needs an ER? I have a simple rule to help you decide:

IF YOU DON’T FEEL YOU NEED TO CALL 911, YOU DON’T NEED TO RUSH TO THE ER.

Of course, no rule is 100%, and you still need to use your judgment, but this is highly reliable. This does not mean your child can avoid going to the ER; what it means is that you have time to look into the question further before making a decision. To help you decide, I suggest that you call our office. We have triage nurses available 24/7 who work under the supervision of the doctors, and who are trained to answer these questions, with set protocols. A doctor from the practice is always available (again, 24/7) as back-up if they feel we are needed. If the recommendation, following talking with us, is to go to the ER, you can feel comfortable that that’s the way to go.

Another source of reliable information is our webpage, which has useful links on pediatric conditions. Lastly, for those of you who have smart phones (which seems to be everybody but me), the app Pediatric SymptomMD ($2.99) is a very reliable resource on pediatric care that is meant specifically for parents.

There is a surprisingly long list of things which do not usually require ER visits, even after discussion. This includes: fevers, even if high; lacerations which stop bleeding on their own; head injuries where a child is not unconscious, even if there is large swelling; finger and toe injuries even if they look broken; vomiting if not yellow-green, even with abdominal pain; and croup. Call us; if we feel you should take your child to the ER, we will tell you so, but otherwise we can make arrangements to be seen in our office, if needed, in a more efficient manner.

Why do we try to avoid the ER? For one thing, we feel that it should really be just for emergencies. Every patient who shows up in an ER who does not need to be there is potentially taking time away from someone who truly does have an emergency. A second factor, quite honestly, is the cost. If you have a plan with co-pays, you will pay significantly more for the ER visit than being seen elsewhere. And for those of you with high deductibles, the average cost of an ER visit starts at around $1000 and can go much higher.

Please visit next week to read part two: Urgent Care Centers Versus Our Office

To Treat or Not to Treat (with antibiotics )

“Primum non nocere”, Latin translation from the original Greek “do no harm” as in the Hippocratic Oath as recited by all medical students.

Perhaps while you were growing up (much as I did) you heard statements such as:

  • “you’re sick, then go to the Doctor to get an antibiotic”
  • “I love Dr. (insert name here). I just call him/her up and he/she phones in an antibiotic for me. You have to see him/her”
  • “Just swing by the local Urgent Care they will write a prescription for you”

In essence, taking an antibiotic meant getting healthy.

However, in my quest to provide quality care, more often than not I have learned that NOT prescribing antibiotics is the only way to truly follow the Hippocratic oath and do no harm!

 

Why not prescribe antibiotics just in case?

Antibiotic resistance – the CDC sees antibiotic resistance as amongst the greatest public health threats today, leading to an estimated 2 million infections and 23,000 deaths per year in the United States (1). Taking an antibiotic when it is not needed, the wrong antibiotic, the wrong dose, and/or the wrong duration can all increase the likelihood of bacteria developing resistance and becoming ineffective.

Antibiotics upset the balance of good and bad bacteria in your intestinal tract. Antibiotic associated diarrhea is its mildest of forms. Clostridium difficile is its most severe (profuse, often bloody diarrhea with abdominal cramping).

There also is the potential to develop an allergic reaction to your prescribed antibiotic, hives being the mildest form. However, these reactions can progress to a more severe allergic reaction leading to an emergency room visit or even hospitalization.

There are ongoing studies being done on antibiotics and their effects on our microbiome (the genes in the trillion or so symbiotic helpful microbial cells harbored by each person ) and ultimately our overall health

Based on this, I challenge you not to ask your physician why is my child not getting an antibiotic, but why ARE they getting an antibiotic. Don’t get me wrong – there are often times where the benefit outweighs the risk. The development of antibiotics by Alexander Fleming in 1928 was nothing short of a miracle. Having a treatment for Group A strep throat and thus preventing rheumatic fever, treatment for bacterial pneumonia, severe ear infections ( notice the use of severe, as often mild ear infections will resolve on own ), persistent or severe sinus infections ( again, mild ones often will resolve on their own ) has prevented significant morbidity and mortality.

To this end, All Pediatrics has undertaken a quality improvement project with the Virginia AAP and the CDC to improve antibiotic prescribing practices.

There is compelling evidence, as stated above, that often there is no benefit to the use of antibiotics and there are real risks. I sure do wish there was more I can offer as a pediatrician to ease the symptoms of a troubling cough that keeps your child up at night. It would be very rewarding. However, I will take peace in knowing that I have given sound advice that will keep your child from being harmed.

  1. http://www.cdc.gov/drugresistance/threat-report-2013/index.html

Winter Illness Part 2

Along with holiday cheer, snow and cold weather comes Influenza (flu) and Respiratory Syncytial Virus (RSV), two common winter illnesses that can be very serious for children. Below is Part II of my primer on winter illnesses.

Influenza (flu):   This illness presents with the sudden onset of fever (often with chills), headache, diffuse body aches, lethargy and non-productive cough. During the course of the first few days, upper respiratory symptoms worsen and evolve into lots of congestion, productive cough and sore throat. Think of flu as a common cold magnified 100%. Symptoms such as conjunctivitis (pink eye), abdominal pain, nausea, vomiting and diarrhea are uncommon with influenza. The illness is highly contagious and primarily spread by respiratory secretions….infected people sneezing and coughing. Annually, 10-40% of healthy children getting flu. The peak incidence in the United States is anytime between November to March but most commonly between January and March. Influenza is largely diagnosed clinically. The tests commercially available are not reliable and I would trust a pediatrician’s exam and clinical opinion much more than a test in most cases.   Children less than 24 months have a higher risk for complications from influenza including hospitalization and death. The CDC data from the 2016-17 season note a total of 101 flu associated deaths in children with the majority of those occurring in unvaccinated children. Treatment of flu is usually symptomatic only. Tamiflu, an antiviral medication which decreases the replication of the influenza virus is not a cure but has been shown to decrease the duration of the illness by several days. It is not recommended for the healthy pediatric patient older than 2 years old and side effects such as nausea and vomiting are very common.

After years of seeing lots of children with influenza, there are a few symptoms that I have found to be most concerning to parents of children of all ages.

#1 fever – it is high! The highest fever I have ever seen with any infectious disease is with influenza. It was 106.3 and I was more affected by the number than the 3 year old sitting on the exam table. While the child surprisingly didn’t look that ill with the fever, she definitely seemed like she felt better when it was brought down. Parents should be prepared for high fever of 103+ that can persist for 3-6 days and remember that most children do look listless with fever.   The child may also have a pounding heart rate and they are often breathing fast which are normal body responses to higher temperatures.  Hallucinations can also sometimes occur. The important thing to do immediately is get the fever down, not rush to the ER or call 911. Fever in and of itself is not a medical emergency. Take off some clothes or blankets, apply cool compresses, give fever reducer and monitor closely for the child to seem overall more comfortable when the fever lowers.   I recommend parents call their pediatrician if the fever is greater than 104, persists longer than 72 hours or if the child is ill appearing regardless of fever.   As long as the fever comes down and the child seems happier or states they feel better, this can be done during regular business hours.

#2 Markedly decreased activity – Children ill with the flu literally just want to do nothing for 7-10 days. This is understandably very disturbing to parents of children of all ages, especially because most children are innately very active. Many parents use the word “lethargic” which is defined medically as an “abnormal state of drowsiness due to disease or drugs”.   A lethargic child is somewhat unarousable, much sicker appearing and most likely not able to use or even be interested in a smart phone or I-pad ( I suppose a good crude way to test degree of illness in 2018). I try to frame this concerning behavior in a positive light when I counsel parents. It is good the child is comfortable enough to rest as this is what is needed to improve and fight off the illness. Regardless of the amount of daytime sleep/rest, parents should see periodic episodes during the course of the day when a child perks up, asks for Elmo or checks Instagram and generally seems more like him/herself, even if 20 minutes later they are back on the couch asleep.

#3 Body aches and pains – When I examine a child and I feel like they are uncomfortable with me even laying my stethoscope on their chests, I always worry about flu. Children with flu often seem like every ounce of their body hurts …maybe another reason why activity is so diminished. In addition to diffuse generalized body aches, increased muscle breakdown due to the virus can occur in large muscles such as the thighs and calves and affect a child’s desire to walk. (think of how you might feel after an intense leg work-out). In this case, increased intake of fluids is essential to help.

With regard to influenza, here are my top pieces of advice:

  1. Get your child vaccinated. There is no reason to not try to protect your child from this illness.
  2. If you child is less than 2 years old or has a chronic medical problem such as diabetes or asthma, and you believe they may have influenza, see a doctor sooner rather than later for an evaluation. This recommendation is the same whether or not he/she received the flu vaccine. Based on your doctor’s evaluation, Tamiflu may be recommended as treatment and is most effective is used within the first 48-72 hours of illness.
  3. Control the fever, push lots of liquids and be prepared for lots of rest. Remember to watch for periods of time daily where your child perks up and is looking to watch their favorite movie or eat their favorite snack.
  4. Do not use aspirin to control fever in a child, especially if you think they have influenza. Instead use Acetaminophen or Ibuprofen.
  5. Check in with your doctor for advice and recommendations on whether or not to be seen. If the fever has persisted beyond 3-4 days and/or the child looks more ill than usual. An evaluation may be warranted to rule out any secondary bacterial infection such as an ear infection or pneumonia.

 

Respiratory Syncytial Virus (RSV):   This is one of the most common diseases of early childhood. Most children are infected in the first year of life and nearly all are infected by the second year of life. Again, a very bad common cold with lower respiratory tract or wheezing 20-30% of the time. The lower tract symptoms are called bronchiolitis – inflammation of the bronchioles or small airways in the lungs. RSV is one of many viruses that can cause bronchiolitis. This inflammation results in wheezing as well as what parents sometimes describe as “rattling” in the chest or “chest congestion”. If your hand is on your child’s chest, you can feel a vibration like sensation when they breathe. This usually clears with coughing or crying. It is also usually causes increased respiratory rate or very fast breathing almost like panting. Other symptoms include fever and copious amounts of congestion. Infection is spread by contact with this congestion – sneezing, coughing, contaminated surfaces such as hands or daycare toys.   Secondary complications such as ear infections can occur and the cough/wheezing associated with RSV can take 4-6 weeks to completely resolve.

The most frustrating aspect of these diseases for both pediatricians and parents is the lack of treatment other than time and close monitoring. Even in situations where patients are in respiratory distress requiring hospitalization and supplemental oxygen, they are provided symptomatic care only in a safe controlled setting and VERY closely monitored.  There are no medications to make this virus go away. In the past, doctors prescribed Albuterol – a medicine that opens the airways that is used for people with asthma. Many studies have now shown this does not help with viral induced wheezing/bronchiolitis and it is not currently recommended. Given this often unsettling and nerve-racking watch and wait approach, my top pieces of advice for RSV are as follows:

  1. Synagis is a monthly immunization against RSV that may be recommended for some patients. Ask your doctor about Synagis if your child was born at less than 28 weeks gestation and will be less than 6 months of age going into the RSV season (November through March) or if they have a chronic medical condition.
  2. Physicians talk about “happy wheezers” – a child that is breathing fast but happy and smiling despite it all. As in flu, how a child appears is so important in judging severity of illness. If your child is breathing fast but happy, be less concerned. However, if you child is breathing fast and very fussy and despite doing all the things you know to do that normally calm him/her down, he/she is still fussy, worry more and call your pediatrician.
  3. Most children that are in respiratory distress will not eat. Not my appetite is down because I am sick and want to eat less but I am hungry but cannot physically eat and breathe at the same time.
  4. Look at your child’s chest to help differentiate between upper airway congestion (heard easily without a stethoscope) and lower airway wheezing (heard only with a stethoscope unless very severe). If you see the outline of the ribcage and all the ribs with breathing and the child’s abdomen is moving up and down very fast, this is more likely to be lower airway wheezing and the child should be evaluated.
  5. As with flu, if a fever persists greater than 3-4 days and/or the child looks more ill than usual, an evaluation may be warranted to rule out any secondary bacterial infection such as an ear infection or pneumonia.

 

I hope the information provided was both interesting and helpful for those families reading. Please remember to teach your child to cover your cough and practice lots of hand washing. Wishing all a Happy New Year and a healthy 2018!

A PERSONAL LOOK AT VACCINES

One reason why parents can be reluctant to immunize is that vaccines have been so effective that parents do not have experience with most of the diseases we can protect against. They therefore do not know the devastation the illnesses can cause, leading to a natural tendency to not worry about them.

I have been doing pediatrics for over 40 years now, and have seen most of these diseases, and will offer my perspective here.

Flu is a major cause of death and hospitalization in the US each year. The vaccine is not perfect, but it is useful. I still hospitalize a few children each year in whom this could have been avoided if they were vaccinated.

I used to hospitalize several children each year for vomiting and diarrhea due to rotavirus; I have not had this happen since I started giving the vaccine.

I have seen a parent who had polio as a child and survived, only to develop progressive muscle weakness due to post-polio syndrome as an adult. I have seen a child with autism, due to her mother having German measles (rubella) during the pregnancy.

I have seen children with devastating brain damage following meningitis from HIB and pneumococcal bacteria, both preventable conditions nowadays.

I did part of my medical training in England during a pertussis epidemic. I have seen wards filled with children with pertussis.

I have seen a beautiful child who had measles when younger, and apparently did fine, only to develop a late complication, SSPE, many years later. She developed uncontrollable seizures, and gradually lost the ability to use her muscles.

Chicken pox is felt to be a relatively harmless condition. My daughter caught the disease before the vaccine came out; she subsequently had shingles as a late complication, in her 20’s. Before the vaccine was developed, over 100 children would die from chicken pox in the US each year. I have seen two children, previously healthy, die suddenly from this disease. In one, it went to her brain, causing encephalitis, and she literally seized to death. In the other, the child developed a condition called purpura fulminans, and bled to death within hours.

Over my career, I have seen heart-breaking outcomes from vaccine preventable diseases. I never want to see these again. Please vaccinate your children.