by Dr. Joan Connell

Editor’s Note: It is hard, especially as a first time parent, to know when to take your kids to the doctor. As parents become more experienced and their children get older, it gets easier, but not in every case.
Dr. Joan Connell was nice enough to lay out some guidelines and parameters for different medical conditions. Hopefully they will help the next time you face the dilemma: do we call for an appointment, head to the walk in or emergency room, or wait it out?

FEVER
This answer varies with age, health history, immunization status, and parent experience.
There is no absolute temperature in which children over two months old need to see a doctor. If a child is under two months of age, and their temperature is over 100.4, they need to be evaluated. Previously healthy children over two or three months old who have not been immunized and have a fever should also be seen by a physician.
In otherwise healthy kids who have been immunized and are over two or three months, I tell parents the reasons to bring children to a physician include: fever with a red rash that does not pale when you press on it (may be a rash suggestive of a serious bacterial infection), if they are struggling to breathe, or have a first time seizure. When children first get sick with that fever, they often appear lethargic or inconsolable.

At that point, try giving them some Tylenol or Motrin and something to drink. Reassess them in 45 – 60 minutes. If they are still looking sicker than a regular viral illness, they should see a doctor. This is where parent experience really comes into play. If this is the first child, it can be hard to determine, so we do expect more office visits from first time parents. Sometimes, when parents have four or five children, they rarely need to come to the clinic because they are so comfortable managing their children’s mild illnesses. I have to remind them to come in for their wellness visits!
In general, with most viral illnesses, the fever resolves within five to seven days. We typically like to hear from patients if their fevers are lasting longer than that, as there is an increased risk that the illness causing the fever may be more than a simple virus. Having said that, there are some viruses (for example influenza, enterovirus, and the virus that causes mononucleosis) that result in fevers that can last up to two weeks.

COUGHS AND RUNNY NOSES
If your child has what seems to be what many call “the common cold,” the runny/stuffy nose typically lasts 7-10 days and the cough up to two to three weeks, peaking in the first week and then hanging on for another couple weeks. Families worry about their young children developing sinus infections. This actually doesn’t happen very often in young children because children have relatively few sinus cavities. There is some variability regarding how to diagnose sinus infections. The American Academy of Pediatrics recommends clinical criteria to make the diagnosis, including symptoms of runny nose/congestion that worsens after seven days, or persists beyond 10 – 14 days. Frequent or persistent cough also can indicate asthma and/or allergies. For example, frequent, persistent nighttime coughs for no apparent reason can be a major clue for asthma. If that is occurring, particularly if there is personal or family history of asthma, allergies, or eczema, the child should be seen.

INFLUENZA
The symptoms for Influenza A this season seem to include more gastrointestinal concerns- a lot of nausea, some vomiting, and diarrhea. We are also noting more irritability. These symptoms are occurring in conjunction with the classic fever, cough, runny nose, headache, and sore throat symptoms.
The test for influenza is a simple rapid nasal swab test and results are available within a half hour. However, none of the tests are 100% accurate, so when there is a lot of influenza in the community, it can be reasonable to diagnose and treat based on patient’s symptoms. As for the influenza vaccine, even in years when it does not do a great job covering a particular strain, it is certainly worthwhile to vaccinate, as the vaccine covers numerous strains of influenza.

RASHES
As mentioned in the fever section, a red rash that does not pale when pressed that occurs with a fever is a reason see your doctor immediately. Rashes that make children feel uncomfortable (painful or itchy and not responsive to over the counter treatments) may require a visit to the clinic, particularly if the rash seems to be getting worse or is associated with other symptoms throughout the body.

STOMACH FLU
The stomach flu does not generally require a trip to the doctor, but if there is blood in the vomit or stool, signs of dehydration (less than three potties/wet diapers in a 24 hour period dry eyes, mouth), or you feel like things are getting worse instead of better with time, take your child to the doctor.

BUG BITES / STINGS
There are degrees of allergic reactions that range from local to systemic (whole body) regarding the extent of the affected area. It is not unusual for kids to get mosquito bites, with each subsequent bite getting more swollen as the season progresses. It is nothing to seek care for, just be aware that it can happen and to prevent bites by using mosquito spray that contains DEET. If a bite does occur, use hydrocortisone cream +/- diphenhydramine to relieve symptoms.
If a bug bite/sting causes problems swallowing or breathing, swelling in the face that may compromise vision, swallowing, or breathing, seek care immediately. If you have managed the bite/sting at home but are concerned that the reaction was more than just local swelling, it is a good idea to visit your doctor to discuss this, as your child may require an epinephrine pen for use with subsequent bites that may result in worse reactions. Bites that seem to worsen instead of improve after 2-3 days may actually be complicated by a bacterial infection. These may require medical treatment.

SUN EXPOSURE
A red, non-blistering sunburn can often be managed at home. If blistering occurs, especially over a large part of the body, and/or if there is a fever over 100, a child should be seen. Remember, it is possible to get heat stroke without getting sunburned. Of course, prevention is best. That means sunscreen, staying out of the sun during peak hours, and getting plenty of fluids.

HEAD INJURY
Seek care if things seem to be getting worse instead of better. For instance, if a child falls and initially seems okay, but then begins vomiting, and then seems to be excessively sleepy, a visit to a care provider is required. Parent experience can also be helpful here. The parent who has seen the three older siblings do okay after similar falls and reactions that experience to determine whether this fall and the subsequent effects is out of the “normal” range. Children who fall and appear to have fractured their skull, new onset of unequal pupils, or who seem confused should also be seen immediately by a care provider.

MENTAL HEALTH
This is an area where it is especially nice to have a medical ‘home’-a primary care provider who is well known by the patient. This home is often a great place to start when parents are concerned about mental health issues in their children, including anxiety, depression, ADHD, substance use, and significant parent-child conflict. Usually, by the time families come to see me, parents have read a lot online, tried five or six different things with their child that have not been successful, and they feel like they are out of options. Remember, life is complicated for kids today. Many children, and their parents, may benefit from counseling at some point. When counseling alone is not sufficient, medication may be useful in certain circumstances.

RESEARCHING ONLINE
Most patient families seeking care are very tech savvy, and I encourage them to go online to get more information. In general, it is nice when patients and their parents are more informed and know when to seek care. I would simply encourage families to remember that when their online research has led them to the doctor’s office, this is an opportunity for that physician to add their experience, training, and acquired expertise to optimize the ability to provide excellent care for that child.

Dr. Joan Connell is a Pediatrician at the UND Center for Family Medicine and the Asthma Clinic. She is President of NDAAP and the Associate Clerkship Director for UND School of Medicine.