Baby,Baby

The vast majority of infants and toddlers seen in the ER have some combination of fever, cough, stuffy nose, rash, vomiting and diarrhea. When some variation of this cluster of symptoms occur in the late afternoon, evening or night, the pediatricians' offices give the same advice: "Go to the ER".

Preschool children are divided into 4 groups by age: 0-28 days, 1-3 months, 3 months to 2 years and 2-5 years. Specific diseases predominate in each group with special attention in the early groups.

In the first 4 weeks of life any fever above 100.4 F triggers an examination and tests to look for infections that are potentially life threatening. Blood, urine, cerebrospinal fluid from a lumbar puncture (spinal tap) and a chest x-ray are performed on the neonate. Antibiotics are given pending the results of cultures of these body fluids. Unfortunately the tests are painful to the infant and disturbing to the parents. Sedation may be given to the baby but the parents are left to pray and fret.

The second and third month of an infants life is also a time for concern if high fevers develop. The ER doctor has some discretion as to the extent of the fever work up. Up to age 2, a temperature of 40 degrees C or 103.8 F or above raises the suspicion of occult bacterium. This is when a source of bacteria on the skin, in the ears, mouth or throat, the lungs or in the urinary or digestive track gains access to the blood stream. Tests may include blood counts and cultures, catheterization of the bladder to obtain urine, a chest x-ray and a lumbar puncture. Sedation may be given to the child to relieve discomfort and expedite the procedures. Appropriate antibiotics are given while awaiting the culture results.

Toddlers have better developed immune systems and have received a full complement of vital immunizations. The fever work up is guided by the specific symptoms and the results of the physical exam. A recent practice in treating children with ear infection is gaining greater acceptance. A child with an inflamed ear drum and a low to moderate fever may be treated with watchful waiting. A prescription for an antibiotic is given but the parents are instructed to wait 48 hours before filling and starting to dose the child. If the symptoms of the ear infection cease, the antibiotics are not given. Studies have shown that 80% of ear infections in children are caused by viruses, not bacteria. This 48 hour waiting period may significant reduce the use of unnecessary antibiotics.

Febrile seizures are frightening to parents. The height of the fever is not predictive of which child will suffer a febrile seizure. Simple febrile seizures involve a generalized convulsion in a febrile child. The period of the convulsion should last less than 5 minutes. Only one child in five who has a febrile seizure will have a subsequent episode. Parents should be instructed in the correct dosages of acetaminophen (tylenol) and ibuprofen (motrin). The weight derived dose must be stressed. The overwhelming number of children that I see in the ER have been underdosed with antipyretics. It is also important to make the parents aware that fever is not a bad thing. An elevated body temperature occurs during an infectious illness as a response and an aid to the immune system fighting off the infection.

Vomiting and diarrhea are frequent causes of pediatric ER visits. If the only symptom is vomiting, the parents should not try to force fluids. After a few hours of stomach rest, an attempt should be made to offer small amounts of clear fluids. Diarrhea is significant if 10 or more watery stools occur in a 24 hour period. Oral rehydration with Pedialyte or some other oral rehydration formula should be attempted. Breast fed infants should continue to be offered breast milk. Dry mouth, decreased urine output, lethargy, and a depressed fontanel (soft spot in the middle of a baby's head) are all signs of dehydration.

Rashes in children are common and usually benign. Eczema, fungal infections and variations of heat or diaper rash are easily diagnosed. Swelling or crusting of a rash may indicate a bacterial skin infection. Many viruses trigger a nonspecific skin reaction. Rashes that occur while the child is taking antibiotics may represent an allergic reaction. Any rash that looks like purple spots or bumps should be evaluated quickly. Blood blisters also fall into this group of rashes that are likely to be a serious infection or disorder of the blood cells.

At the age of 4, I announced to anyone foolish enough to listen, that I wanted to be a doctor when I grew up. I was adamant that I would be a pediatrician. My own pediatrician was Dr Charles Berson. He was handsome, smart, dressed immaculately and actually spoke directly to me. In the days before routine immunizations for most of serious childhood diseases, the family doctor or pediatrician was the source of all medical knowledge. ER's were rudimentary at best. If you were a sick child, you saw your pediatrician. Now I am the off (and sometimes on) hour pediatrician. Despite the virtual elimination of measles, mumps, chicken pox, rubella, H influenza bacterial infections, whooping cough(pertussis) and diphtheria, parents seem less able to cope with the innumerable minor illness that afflict their children. My role as educator in addition to physician has become more important.

One of the reasons that I chose emergency medicine instead of pediatrics was that I easily relate to children but not to working in an office. Helping an ill or traumatized child, is very satisfying. I also get to play with some really cool equipment in the ER. Advances in sedation allow me to make it less traumatic for the child to undergo painful and frightening procedures in the ER. I guess I made the correct choice.