The Family Guide to Preventing and Treating 100 Infectious Illnesses

Introduction: Is It Catching?

When your children get sick, it’s usually for one simple reason: they’ve caught something. Bacteria and viruses cause colds, coughs, flu, ear infections, strep throat, and chicken pox—in short, all the common childhood illnesses that we parents have to cope with. The more you learn about causes and prevention, the easier coping will be.

By the 1950s, many scientists, doctors, and governments thought that, because of antibiotics and vaccines, we no longer had to worry about infectious diseases. The public shared in this wildly mistaken belief, and it’s no wonder. Here’s what the United States Surgeon General, William Stewart, had to say on the subject in 1969: The war against infectious diseases has been won.

He was right only in the sense that, for people living in developed countries at that time, death or illness from infectious disease was rare. But for the rest of the world the threat of infectious disease has been constant. These diseases have never ceased to be the leading cause of death in poor countries, particularly for young children.

Since the 1980s, AIDS, herpes, chlamydia, and Lyme disease have all appeared, and measles, syphilis, and TB returned to threaten the health of North Americans.

It is now clear that our expectations that medical science could eliminate all infectious disease revealed a poor understanding of both the true nature of these diseases and the interdependent relationship between humans and the microbe.

Because we do not, and never will, live in a sterile environment free of all bacteria and viruses, we must always be vigilant to maintain a truce in the natural, never-ending conflict for dominance between humans and our microbial enemies.

Epidemics are not new. They are really large-scale conflicts between species—a natural and continual phenomenon. But epidemics, like wars, may skip a few generations, and we may then mistakenly believe that we have reached a state of world peace and freedom from disease.

Unfortunately, epidemics will always be with us. Despite this, we have made vast improvements in our knowledge of diseases and how to treat, control, and prevent them. For example, the bubonic plague of 1346 killed 20 million people in Europe in just over two years. This was 60 percent of the population at the time. AIDS, on the other hand, has killed two million people worldwide in 12 years, a tiny percentage of the world’s five billion people. The bacteria that caused plague in the fourteenth century was not discovered for another 550 years, when the French scientist Alexandre Yersin identified it and named it after himself: Yersinia pestis. In contrast, scientists identified HIV, the virus that causes AIDS, within two years after the epidemic began.

We need to be alert to both emerging and ancient diseases. The germs that cause diseases we consider new, such as Lyme disease and AIDS, are not new. They have lived in animals or isolated human populations for millions of years. The spread of Lyme, new strains of TB, and AIDS is a sign that these emerging germs thrive and spread when human agriculture and urbanization disturbs nature. Then trade, travel, crowding, and complacency of modern society allow them to spread further. For example, when land development brought deer and human populations together, the result was Lyme disease.

You may think that diseases that occur far away are no threat to us here in North America. But they are. Worldwide epidemics can happen at any time because of the growth of the world’s population and rapid international travel. Another problem concerning public health and infectious disease specialists is the development of drug-resistant germs and disease-carrying insects that are resistant to pesticides. This development means that more diseases are likely to appear, but no one knows when, where, or how.

The United States measles epidemic of 1989 to 1991 was deeply concerning to me as a public health nurse. Philadelphia, which contains several large teaching hospitals and many medical schools, was one of the hardest-hit cities. I worked then as the infection-control nurse at the Children’s Hospital of Philadelphia, which considers itself to be one of the finest pediatric hospitals in the country. The hospital sits adjacent to the community of West Philadelphia, a medically underserved area with one of the highest infant mortality rates in the country. Before the epidemic reached the city, it ravaged similar communities in California, Chicago, and Dallas. The city health department reported that fewer than one-third of the two-year-olds in West Philadelphia were immunized against measles. Yet neither the administrators nor the infectious disease physicians in the hospital, although well aware of this alarming situation in the surrounding community, made any effort to speak out about the need for a mass immunization drive to protect these vulnerable youngsters.

Nine children died from measles in Philadelphia in the winter of 1991. One was a young girl with a weakened immune system who caught measles while a patient at Children’s Hospital after a baby who was sick with measles was put in her hospital room. It struck me that something is terribly wrong when a completely preventable disease can kill children in a city filled with prestigious medical centers.

I believe that information is the best weapon against disease. I decided that I wanted to give the information known by the infectious disease specialists directly to the people who need it: parents and individuals who want to take responsibility and become informed about what the infectious disease risks are and what they should do to protect themselves. Nobody wants to get sick. If we have the resources and understand how to stay healthy, most people will act to protect their own and their children’s health. The proof is the decrease in smoking over the last 20 years that occurred once doctors understood and explained the health dangers of smoking to the public.

Often parents and others don’t get the information they need from their doctors or the media. Medical journals and texts are not comprehensible to the general public. Government agencies put out many fine pamphlets, but unless you go to public health units or clinics you won’t receive them. You also need to write to various organizations for their health literature. This book consolidates much of that information for you in a straightforward manner.

I’ve noticed that when outbreaks of a disease do occur, the details you need are often not presented fully and clearly in most newspaper or television coverage or by local public health officials. If you are ever in a situation where there is an outbreak or epidemic of a frightening disease, try not to become hysterical or contribute to hysteria in the community. It is never helpful.

If you do not receive what you consider to be adequate information from your local public health sources, call the Centers for Disease Control and Prevention (CDC) in Atlanta. I call often with questions. This government resource is available to the public, has the most recent information, and will mail or fax it to you free of charge. The CDC must be notified when there is a case of an unusual disease. If you don’t think your local officials are following through adequately, do it yourself. If you live in Canada, call the Laboratory Centre for Disease Control in Ottawa (for phone numbers, see page 380).

All parents want to keep their children healthy. You can rely on this book to give you the medical facts and advice on nursing care. But you must rely on your own skills, knowledge, and common sense, and you must take responsibility. I can’t overemphasize this. Too many of us think that the experts know and care more about our own health than we do or that it is up to the government to make sure our children are immunized. The government and health care system must give us the ingredients we need to keep ourselves and our children healthy. But it’s our job to put all those ingredients together. We have to bring our children to the doctor on schedule for shots, take prescribed medicines correctly when we have an infection, and arrange for adequate care for our own sick children. The ultimate responsibility for our own health rests with each of us.

Part I 

Understanding and Treating Infectious Illness

Chapter 1 Understanding Infectious Illness

A never-ending war pits human beings against the germs that try to invade and infect us. The immune system protects us against microbial enemies, but sometimes this defense fails. That’s when we get sick.

Germs—either bacteria, viruses, fungi, protozoa, or parasites—are the culprits responsible for the infections that cause most sickness. Viruses are the number one enemy, followed by bacteria. Doctors need to find out what kind of germ is making us

How Germs Are Spread

If we want to prevent infectious illness, we must stop germs from spreading. Infectious illness is spread when germs leave an infected person and enter the uninfected person. This occurs by several routes: through the air (sneezes, coughs), by direct contact (holding hands with an infected person) or indirect contact (touching doorknobs, faucets), by eating infected food, and through sexual transmission. Children usually catch infections through the air and by direct or indirect contact.

Germs cannot get through intact skin. Skin is the most important way our immune system keeps out germs. Germs can enter the body through broken skin and the mucous membranes (eyes, nose, mouth, genitals, urethra, and anus) and directly into the blood through cuts, injuries, incisions, or needles.

Handwashing is the best way to stop the spread of infections. Germs are deposited on your hands after sneezing, coughing, blowing your nose, or using the toilet. If you don’t wash your hands, these germs will be passed on to the next person or item that you touch. That is why nurses and doctors are taught always to wash their hands after taking care of patients.

Other conditions that favor the spread of infections include large numbers of people in a small space (crowded housing, bus, or dormitory), being of a young age with lots of personal contact (nursery school or child care), poor hygiene, lack of washing and bathing facilities, untreated public water supply, and recirculated air (as on airplanes).

To prevent an infectious illness, we must try to control the three elements that are needed for its spread: (1) a source—an infected person, (2) a means of spread, and (3) a susceptible host—an uninfected person. We can eliminate the source if we keep sick children away from healthy children. We can minimize the spread by washing hands and cleaning germ-filled surfaces. Finally, we can reduce our susceptibility to infection by immunizations; a balanced, nutritious diet; adequate rest; and a healthy environment.

How the Immune System Works

The immune system is an intricate combination of organs and cells organized to defend us against attacks by foreign invaders. It works best in people who are well-nourished, well-rested, and not under a lot of stress. Some people are also born with stronger immune systems than others.

If germs succeed in gaining entry, the organs and cells of the immune system are triggered to respond and destroy the invader. Certain white blood cells, called lymphocytes, are the key operatives. White blood cells grow, develop, and move throughout the body through the organs of the immune system. These organs include the bone marrow, thymus gland (located behind the breastbone), lymph nodes, spleen, tonsils, adenoids, appendix, Peyer’s patches in the small intestine, and blood and lymphatic vessels.

There are two kinds of lymphocytes: B cells, which mature in the bone marrow, and T cells, so named because they mature in the thymus gland. B cells and T cells produce antibodies that attack and destroy the invading bacteria and viruses.

Other large white blood cells, called phagocytes, are also part of the immune response. These cells surround the harmful invaders and swallow them. The immune response of the person fighting the invaders produces the symptoms that tell us we are sick: fever, chills, loss of appetite, tiredness, inflammation, and rashes.

Treating Infections

We treat infections with germ-destroying drugs called antimicrobials, the most common of which are antibiotics. We use antibiotics to treat bacterial infections, such as strep throat or middle-ear infection. Antibiotics do not work against viral infections such as colds, chicken pox, or flu.

Antivirals treat viral infections. Because viruses are parasites that exist within living cells, it is difficult to make a drug that will kill the virus without killing the human host cell as well. That’s why we have developed only a few antiviral medicines. They are mainly used to treat very sick hospitalized patients or people with deficient immune systems. Mostly, we rely on our immune systems to fight viral infections.

Antifungals treat fungal or yeast infections such as athlete’s foot, ringworm, thrush, and vaginal yeast infections.

Fever

Fever is an elevation of body temperature above the normal range. We always have a temperature, but we have a fever only when we are sick. The normal range depends on when and how our temperature is taken. We say a normal oral temperature is 98.6°F or 37.0°C, but this can vary. Right after activity, a child’s normal temperature will be 99.0°F (37.2°C). Rectal temperatures are 0.5° to 1°F (0.3° to 0.6°C) higher, and under the arm temperatures are 0.5° to 1°F (0.3° to 0.6°C) lower.

Normal body temperature is lower in the morning and higher in the late afternoon and evening.

What Causes Fever?

The thermal regulatory center in the brain controls body temperature. The brain’s temperature setting rises during an infection, resulting in a fever because white blood cells release certain proteins during the immune response. These proteins trigger the brain to release a chemical called a prostaglandin, which causes our nerve cells to produce a sensation of coldness. This is why we feel chills when we are developing a fever. In response to this coldness, the brain increases the body’s temperature. The increased temperature speeds up the activities of the immune system against the invading germs. Thus, fevers help fight infection.

What Do We Do about Fevers?

We take medicines called antipyretics to bring high fevers down. Aspirin and acetaminophen are antipyretics that reduce fever by slowing the production of prostaglandins.

Because fevers help to fight infections, we give acetaminophen or aspirin only for fevers over 101°F (38.3°C) (to learn how to treat fevers, see pages 15–20).

Chapter 2 Home Nursing Care

Observing for Symptoms

Be observant. Nurses are skilled in noticing and recording small changes in how a patient looks. Often these small changes are a signal that something is wrong. If we catch warning signs early and seek medical attention, complications can usually be avoided. This is your goal. It is important to notice changes in breathing patterns or skin color and to watch for any signs of pain or rash.

■ Breathing patterns. Is breathing faster than usual? Is it shallow or deep? Are there wheezing, grunting, rattling, crackling, or high-pitched sounds? Does your child make very loud, harsh noises when breathing in (stridor)? Can you see the areas between the ribs move in and out during breathing (retractions)?

■ Color changes. Skin color tells how well oxygen is reaching all parts of the body. Blood receiving enough oxygen is very red, and well-oxygenated skin is pink. If a child has problems breathing and begins to look dusky, pale, or bluish, there is poor air exchange taking place in the lungs. This can be caused by an infection in the lungs, such as pneumonia. When blood is not well oxygenated, you will notice color changes. On dark-complexioned children these changes are most noticeable on nail beds and lips. Color changes are serious and require a doctor’s attention.

■ Pain. Pain is a good indication that something is wrong. Pain in the ear is usually a sign of an ear infection (page 139). Small children with ear infections will pull, rub, or tug at their ears. Children who complain of pain in their throats when they swallow may be suffering from a bacterial throat infection such as strep throat (page 327). Pain during urination is often a sign of a urinary tract infection. A belly ache (abdominal pain) can have many causes. Pain is not always a sign of infection. Injuries or bites also cause pain. Listen when your child complains of pain, and take these complaints seriously. If the pain doesn’t go away after a few hours or it’s very severe, call the doctor and describe where the pain is located, when it began, if it is constant or comes and goes, and, if possible, the nature of the pain—whether it is aching, sharp, dull, severe, or mild. A doctor should examine anyone with severe or unusual pain.

■ Rash. Rashes have many causes. A viral infection will often result in a rash. Reactions to medicines, allergic reactions, and insect bites can also bring about a rash. It is important to observe the details of any rash you notice, such as

■  When and where on the body did the rash appear?

■  How did it spread?

■  Is it itchy?

■  What color is it?

■  What does it feel like—is it bumpy or smooth?

■  What shape is it—round raised bumps or flat marks, run together or separate?

■  How big are the marks or bumps—pinpoint or larger?

■  How many spots are there?

■  Does the rash come and go?

■  Does it change in the sunlight?

Try to be as detailed as possible when describing a rash to your doctor. Many infections cause rashes, and the rashes usually have distinct characteristics and change as the infection progresses. A good history and description of the rash will help the doctor in making a correct diagnosis.

Caring for Babies Younger Than Three Months Old

A newborn baby seems so helpless and fragile. It’s normal to worry. No doubt you’ve received lots of advice from your doctor, friends, books, and magazines on how to care for, feed, and nurture your baby. This section will give you specific information on how to protect newborns from infections, how to tell if your baby is sick, when to call the doctor, and what may happen if your baby is hospitalized.

A newborn baby has a limited ability to fight germs. For nine months, the baby develops in the sterile environment of the womb. Before birth a baby is protected from germs by the placenta, which acts as a barrier to many germs, and by the mother’s immune system, which provides antibodies that cross the placenta and enter the baby’s bloodstream. At birth a baby’s immune system is not yet capable of providing protection from germs. To make up for this, nature has provided protection in two ways. First, the baby is protected by maternal immunity. All the mother’s antibodies that streamed into the unborn baby’s bloodstream before birth will give immunity to all the infections to which the mother is immune. This protection gradually wanes because after birth the baby’s own manufactured blood slowly replaces the fetal blood present at birth. By six months, maternal immunity is very low.

The other line of defense is mother’s breast milk. Through nursing, the baby receives protective antibodies against many infections. At six to nine months, as you wean your baby, the baby’s own immune system is able to take over and fight invading germs. Protecting your baby from infections is one of the most important of the many advantages breast milk has over formula.

How to Protect Newborns from Infections

We need to protect our susceptible newborns from exposure to germs. You may have noticed nurses in the hospital nursery wearing gowns and washing their hands. I consider the hospital’s premature nursery an area where we must protect the babies from catching anything from the staff or visitors. Visitors with colds are not allowed, hand washing for staff and visitors is the rule, and employees with colds or exposures to infections are either transferred to other areas of the hospital or sent home.

You don’t need to set up a system quite like this at home with a healthy newborn, but be careful for the first four weeks. Try to keep anyone with chicken pox, sore throats, and cold sores away from the baby. Don’t allow visitors with colds, flu, or serious coughs. Your friends will not be offended if you explain to them that this rule is made for the baby’s protection. If household members get sick, they should avoid holding or caring for the baby if possible. Don’t put your baby to bed in the same room with a sick child. Get everyone into the habit of washing their hands before picking up the baby.

But what if one or both parents become sick? Try to find a friend, family member, or trusted sitter to help out for a few days. Depending on the situation, you might take your baby to the friend’s house while you stay home and recuperate. Use your own judgment and common sense. What illness do you have? Is it contagious? Who is available to help? How sick are you? How healthy is the baby? How old is the baby? Is the baby breast-fed? If the baby is breast-fed and your illness is mild, try to continue breast-feeding. Your baby will be partially protected by your antibodies, and the advantages of breast-feeding outweigh the disadvantages of exposing the baby to your infection. However, if you are quite ill and receiving medicine, you may have to stop breast-feeding and arrange for someone else to care for your baby while you recover. Talk it over with your doctor, the baby’s doctor, and your family.

Be practical. For example, try to keep your baby away from crowds, buses, and malls for the first three or four weeks. If you must go somewhere and have no one to leave the baby with, go. But try not to do it too often at first.

On the other hand, don’t become fanatical. Wearing face masks is not necessary because they do not keep cold viruses from getting through. They scare babies and serve no other useful purpose at home. Hand washing and a clean environment are all that’s needed.

How to Tell If Your Newborn Is Sick

Sometimes it’s hard to tell when a newborn is sick. They don’t have the obvious symptoms like coughs and fevers that are seen in older babies and children. Changes in eating, sleeping, or behavior are often the first signs that something is amiss. Whoever takes care of the baby usually notices the changes first. Most of the time, whatever is ailing your baby will be mild and nothing to worry about, and your baby will recover quickly and completely without any medical intervention.

Serious illness is rare. If you know what’s serious and what is not, you won’t panic at every little thing. You’ll also be alert to real danger signs and get your baby medical attention when it’s needed. You’ll be prepared and informed, which will give you a feeling of control that should help reduce your anxiety.

When to Call the Doctor

Call your doctor if your baby shows any of these warning signs:

■ Listlessness: less alert than usual, not as interested in the surroundings, floppier than usual, unusually sleepy, or difficult to wake

■ Poor feeding: not interested in nursing, refusing the bottle, taking less than usual

■ Increased irritability: constant or high-pitched crying, tenseness, impossible to quiet or calm

■ Vomiting: vomiting that projects away from the baby (called projectile vomiting) or vomiting all or most of the feeding (spitting up a small amount of breastmilk or formula after feeding is not vomiting but normal)

■ Diarrhea: loose, watery, unformed, often foul-smelling, usually green-colored stools passed more than two or three times a day (formed soft stools, even if very frequent, are not diarrhea)

■ Rectal temperature above 100.4°F (38.0°C)

■ Convulsion: uncontrollable shaking arms or legs or other muscles.

■ Difficulty breathing: very rapid breathing; more than 40 breaths per minute, working hard to get air in and out; rattling, crackling, or high-pitched sounds in the chest; ribs visible when the baby breathes in.

■ Color changes: dusky or bluish rather than pink color, usually most noticeable around the lips, nail beds, hands, or feet.

■ Bulging or fullness of the soft spot in the front of the baby’s scalp (anterior fontanelle): This area usually has a four-sided shape. When it’s bulging, you can’t feel the bony edges because of increased pressure in the fluid around the brain and it can be a sign of meningitis (see page 237).

Be sure you know how to reach your baby’s doctor in an emergency and where to take the baby if your doctor is unavailable. When you call the doctor or go to the emergency room, try to give as complete a medical history as possible. Don’t panic if you can’t remember all these details. Anything you remember will be helpful.

Try to be able to tell the doctor:

■ What time you first noticed the symptoms.

■ The exact temperature and how and when you took it (see Caring for Toddlers and Children with Fever on page 15).

■ The color and consistency of the stools—are they watery or formed?

■ The approximate amount and how often the baby vomited.

■ When the baby last bad a wet diaper.

■ How the baby nursed or how much formula the baby took.

■ The baby’s color and breathing—is the baby’s breathing faster than normal?

■ Whether the baby has been around anyone who is sick or who became sick within two days after seeing your baby (if your baby has been around a sick person, try to obtain information on the type of illness or infection).

If you’re worried that your baby is sick, be firm and insist on being taken seriously. The most competent doctors and nurses are those who listen carefully to a parent’s description of the baby’s condition and to what they think is wrong. Most doctors and nurses I have worked with do their best to take good care of their patients and fully inform parents.

Ask questions whenever you don’t understand what the doctor is telling you. If you run into someone who won’t help, don’t worry about being considered a pest. Remember, doctors and nurses are there to care for your baby. Insist on full explanations of your baby’s condition and of any medical procedures or tests that are being done.

When Your Baby May Be Hospitalized

Infants under three months old with a fever above 101°F (38.3°C) have a twenty-times greater risk of having a serious infection than older children. Although a fever this high is rare, if it does happen, your baby must be seen by a doctor within six hours. If your baby appears sick, hospitalization may be necessary until it can be determined what is causing the fever. If your baby looks fairly well, tests will be done, but hospitalization may not be required.

The tests usually done are blood counts, blood cultures, urine cultures, urinalysis, and lumbar puncture (LP, or spinal tap). Blood counts show whether there is a higher or lower than normal amount of both white and red blood cells. Abnormal values can indicate infections. Blood cultures are done by drawing the blood in a special sterile manner to see if the baby has bacteria growing in the blood. Lumbar puncture involves getting a sample of the fluid surrounding the spinal cord with a small needle. This sample is tested for bacterial meningitis (page 237), an infection caused by bacteria in the fluid around the spinal cord. It is treated with antibiotics.

While in the emergency room, some pediatricians give the baby an injection of antibiotics, a decision that depends on the judgment of the particular doctor and the policies in the emergency room. Do not give your baby any medication unless instructed to do so by the doctor or emergency room. Keep the baby warm and comfortable. Don’t panic. Offer, but don’t force, nursing or a bottle.

If admitted to the hospital, your baby will probably be given antibiotics intravenously, or through the vein (called IV antibiotics), until the blood and spinal fluid culture results are known, which takes from 24 to 48 hours. If no infection is found, IV antibiotics will be stopped. If doctors detect that a bacterial infection is the cause of your baby’s fever, IV antibiotics will be continued for five or more days and will not be stopped until repeat blood cultures show that the infection has cleared.

Caring for Toddlers and Children with Fever

Don’t worry about temperatures below 101°F (38.3°C). This is called a low-grade fever. It may be a sign of a mild infection, but your child does not need medication. However, if this low-grade fever lasts for several days, you should call the doctor and have your child seen. Call the doctor for a child’s fever higher than 101°F (38.3°C).

If your infant is younger than three months of age, any fever over 100.4°F (38.0°C) requires medical evaluation. (For complete details on caring for your sick baby, see page 12.)

Fevers are not harmful. They are important defense mechanisms and help the child’s immune system fight an infection. The degree, or height, of a fever does not tell you how serious the illness is. Severe infections can cause low fevers, and mild infections can cause high fevers. The child’s behavior is a more important sign in determining the seriousness of an illness (see the discussion of warning signs on page 13).

Buy an oral and rectal thermometer, and make sure you learn how to take an accurate temperature. If you find a thermometer that measures in both Fahrenheit and Celsius, get it. In the hospital, temperatures are taken in Celsius. If you find it hard to read a mercury thermometer, buy a digital readout thermometer. They are just as accurate, and they are quicker and easier to use than mercury thermometers. You’ll probably find them worth the extra few dollars in price. Many hospitals now use ear lobe thermometers. These are available in some pharmacies and through mail-order catalogs for about $75 to $100. The thermometer is inserted just inside the ear and gives a temperature reading in just one second.

A rectal thermometer is used for infants and young children who cannot hold an oral thermometer in their mouths. It has a stubby, rounded bulb so that it will not damage the baby’s rectum. Don’t use an oral thermometer to take a rectal temperature.

It’s best to have a mercury thermometer on hand, too, in case the battery runs out on your digital one. In a mercury thermometer, the mercury in the bulb heats up and rises up the glass tube to a point that shows the person’s temperature. An arrow marks the normal temperature of 98.6°F (37°C).

You may find it difficult at first to take a baby’s temperature, but it’s really not that hard, and it’s important to learn. Practice shaking down and reading the thermometer so that you’ll have confidence when you need to take your child’s temperature.

After every use, clean your thermometer well. Just wipe it clean using lukewarm soapy water and rinse well with cold water. Hot water will break a mercury thermometer. Or you can wipe the thermometer off with alcohol, and rinse it with cold water to get rid of the alcohol taste.

When to Take a Temperature

Check your child’s temperature if you notice any of these signs:

■ Sweating, or flushed face or skin

■ Skin that feels hot to the touch

■ Cold symptoms

■ Rapid breathing

■ Unusual sleepiness

■ Vomiting

■ Diarrhea

■ Poor appetite

RECTAL TEMPERATURE READINGS

How to take a rectal temperature with a mercury thermometer:

1.  Shake the thermometer down by holding the glass end, not the bulb end, and flicking your wrist until the silver line is below the 96°F (35.5°C) mark.

2.  Dip the bulb end in petroleum jelly.

3.  Place an infant on his tummy and spread the buttocks to see the anal opening. Place an older baby or toddler on her back and hold the legs up in the diaper-changing position so that she does not try to crawl away or stand up.

4.  Gently insert the thermometer no more than 1 inch (2.5 cm) into the opening, that is, below the 94°F (34°C) mark.

5.  Place your hand in the small of your baby’s back to keep him from moving.

6.  Keep the thermometer safely in place with your other hand by holding it between two fingers. Rest this hand gently against the baby’s buttocks.

7.  Keep the thermometer in place for two minutes. One minute is the minimum, but two is more accurate.

8.  Gently remove the thermometer. To read the temperature, twirl it around at eye level in good light until you can see the silver line of mercury inside. Where this line stops is your baby’s temperature. Record it.

How to take a rectal temperature with a digital thermometer:

1.  Read the instructions that came with the thermometer.

2.  Use a non-petroleum-based lubricant.

3.  Insert and hold the thermometer in the same manner as you did for the glass mercury model.

4.  Turn the thermometer on according to the manufacturer’s directions.

5.  Remove the thermometer when the beep or signal tells you it has a reading. This usually takes 60 seconds. Record the temperature.

ORAL TEMPERATURES

Oral temperatures are taken for children over five or six years old. You can use either a mercury or a digital thermometer.

How to take an oral temperature with a mercury thermometer:

1.  Shake the thermometer down by holding the glass end, not the bulb end, and flicking your wrist until the silver line is below the 96°F (35.5°C) mark.

2.  Don’t give hot or cold liquids for five minutes before taking an oral temperature.

3.  Ask your child to open his mouth, then place the bulb end gently under the tongue.

4.  Tell your child to close his mouth around the thermometer, to remain still, and not to bite or talk.

5.  The thermometer should remain in place for two to three minutes.

6.  Never leave a child alone with a mercury thermometer in his mouth. If your child starts to play and the thermometer breaks, he can be cut by the broken glass and poisoned by swallowing mercury.

7.  After three minutes, remove the thermometer yourself, then twirl it around at eye level in good light until you can see the silver line of mercury inside. Where this line stops is your child’s temperature. Record it.

How to take an oral temperature with a digital thermometer:

1.  Press the button to begin as directed in the manufacturer’s instructions.

2.  Follow steps 2 through 4 for taking a reading with a mercury thermometer.

3.  Remove the thermometer when it beeps. Read and record the temperature.

AXILLARY (ARMPIT) TEMPERATURE

The axillary method of taking a temperature does not give as accurate a reading as the rectal or the oral method. Take an axillary temperature in the following situations:

■ When an older child is vomiting and you can’t take an oral temperature

■ When a baby or toddler has frequent diarrhea and you don’t want to irritate the rectal area any more with a thermometer

■ When a baby requires a reading several times a day, such as during hospitalization of a very ill baby, to avoid damaging the anal opening

■ When children are attending a child-care center where rectal temperature taking is not recommended for safety reasons

You can use either an oral or a rectal thermometer to take an axillary temperature reading.

How to take an axillary temperature:

1.  If using a mercury thermometer, shake the thermometer down by holding the glass end, not the bulb end, and flicking your wrist until the silver line is below the 96°F (35.5°C) mark. If using a digital thermometer, press the button to begin as directed in the manufacturer’s instructions.

2.  Place the thermometer under the bare, dry armpit and have your child hold his arm tightly against his body. You can sit him on your lap and place your arms around him. Lay your baby on her tummy and place the thermometer under her arm.

3.  After five minutes, remove the thermometer, then twirl it around at eye level in good light until you can see the silver line of mercury inside. If using a digital thermometer, remove the thermometer when it beeps. Read and record the temperature.

How to Treat a Fever

We treat high fevers in children with acetaminophen (Tylenol, Tempra). Don’t give aspirin to anyone under 18 years old, because it has been associated with Reye’s syndrome in children who have the flu (page 153) or chicken pox (page 100). Reye’s syndrome is a very rare but serious condition affecting the brain and liver.

Infants younger than three months old with fevers higher than 100.4°F (38.0°C) must see a doctor (see page 14)· For infants over three months old and children, give acetaminophen for fevers higher than 101°F (38.3°C). Lowering the fever will make your child more comfortable and will also lessen the risk of febrile seizures. These seizures tend to run in families and occur in less than three percent of normal children between ages six months and six years with high fevers. They last less than 15 minutes and do not cause brain damage or epilepsy. The seizure may be the first sign of fever.

Give the medicine every four hours if needed. The dose depends on the age of the child so follow package directions carefully. Give your baby liquid medicine by dropper. Syrup or chewable tablets are available for toddlers and young children.

Please be careful when giving medicine to children. Check carefully that you give the correct dose at the correct times and only when needed. Some children like the taste of the chewable tablets and think they are candy. This is dangerous. Clearly explain the difference between medicine and candy to your children. Always keep medications in a childproof container out of sight and reach of children.

How to keep a child with a fever comfortable:

■ Sponge him down with lukewarm (not cold) water. This is important if the fever is over 103°F (39.4°C). Lay your undressed child on a towel, then sponge him off for about 15 to 20 minutes with another towel soaked in lukewarm water.

■ Dress your baby in only a diaper and shirt, or lightweight pajamas. Light clothing helps heat to escape through the skin.

■ Make sure that your child is drinking enough liquids to avoid dehydration. Small sips of clear fluids are best when a child feels sick: apple juice, water, frozen treats, ice chips, herbal tea, powdered soft drink mix, caffeine-free soda, or clear soup.

Don’t:

■ Rub a child with alcohol because the fumes can be dangerous.

■ Immerse a child in cold water. This will reduce the body temperature too quickly.

■ Overdress the child.

Fevers and rashes are symptoms of many common, mild childhood infections, including chicken pox and roseola. The fever may last more than two days, but if the child does not develop any of the symptoms or warning signs listed below you may not need to take him to the doctor. Such a child can be safely cared for at home with the help of telephone evaluation and advice from your doctor or emergency room. In the busy clinic where I worked in Manhattan, we practiced telephone triage. This means doctors and nurses evaluate the symptoms and give advice over the phone. Only the children with worrisome symptoms are advised to come in. This is safe, saves time and money, and avoids unnecessary exposure of other children to contagious diseases. Be alert for any signs of complications. If any of the warning signs occur, call your doctor and obtain prompt medical evaluation.

WHEN TO CALL THE DOCTOR FOR FEVER

Any infant younger than three months old with a rectal temperature higher than 100.4°F (38°C) must see a doctor within six hours. For older infants and children call the doctor if the fever goes above 102°F (39°C), lasts longer than three days or increases after two days, or if any of the warning signs of complications develop.

Here are the warning signs to watch for. Call immediately for these:

■ Unusual irritability, screaming, impossible to console, tense or stiff arms and legs

■ Extreme drowsiness—child difficult to wake

■ Confusion, delirium, or hallucinations

■ Difficulty breathing—wheezing, crackling sounds in the chest, high-pitched sounds during breathing or if you can see the area between your child’s ribs move in and out during breathing, called retractions.

■ Neck pain, stiff neck, or holding the neck in an unusual way

■ Seizures—shaking arms or legs

■ Sunken or bulging soft spots—especially in front

■ Vomiting after every attempt to give fluids

■ Dry lips, tongue, and mouth

■ No wet diaper or urination in 12 hours

Call and arrange an appointment within 24 hours for these:

• Abdominal pain

• Sore throat or difficulty swallowing

• Ear pain or pulling, tugging, or rubbing at the ear

Caring for Family Members with Upper Respiratory Infections (Colds, Coughs, Sore Throats)

More than 200 different cold viruses are lurking out there, ready to strike. They attack our upper respiratory tract (nose and throat) and cause infections that we call the common cold.

Colds

As you probably well know, colds are the most frequent childhood illness. Young children, who haven’t yet had a chance to build up immunity to cold viruses, average eight to ten colds a year. Their parents average 2 to 4 colds a year. (See page 120 for more information on specific cold viruses and cold prevention.)

Doctors may refer to a cold as an upper respiratory infection, or URI for short. Symptoms are runny or stuffed-up nose; sneezing; sore, scratchy throat; cough; low fever (sometimes); headache; and runny eyes. Generally, these are not serious infections, but are annoying and can cause a few days of misery. Lower respiratory tract infections, on the other hand, are more serious but less common. Pneumonia (page 269) and bronchiolitis result when viruses or bacteria attack the lower respiratory tract (bronchial tubes and lungs). Adults and children with chronic lung and heart conditions are more likely to get infections in their lower respiratory tract.

The three basics to remember when caring for family members with colds are to provide rest, fluids, and humidity.

Rest helps the immune system fight the infection. Encourage naps and quiet indoor play.

Fluids are most important. Clear fluids replace the water lost through sweating and help thin out the sticky mucus, loosen thick secretions, and ease scratchy throats. Try hot water or weak tea with lemon and honey, hot cider, or clear broth. Do not give honey to children less than one year. Avoid too much milk when a child is congested, as milk products do not help thin out congested airways.

Humidity loosens nasal congestion. The best way to provide humidity is with a cool-mist vaporizer, available at pharmacies for less than 20 dollars. Cool mist is safer than a warm-water humidifier.

Salt water nose drops, or saline drops, help a baby or toddler clear mucus from the nose. These are available at pharmacies, or you can make a saline solution at home by mixing ½ teaspoon (2.5 ml) of salt to 8 ounces of warm water. After placing two to three drops in each nostril, use a soft rubber suction bulb, also available at pharmacies, to help your baby clear the discharge. This is especially important before feedings and before bedtime. Be sure to clean the bulb well after using. Teach your older child to blow his nose after applying saline nose drops.

Wipe runny noses frequently with disposable tissues. Applying petroleum jelly lightly to this area will help prevent irritation. Some parents also find that tissues containing lotion help prevent reddened, irritated little noses.

COLD MEDICINES

Acetaminophen (Tylenol, Tempra), used to lower fevers, also helps to relieve headaches and body aches. Make sure you give the correct dose for the age and weight of your child. (See How to Treat a Fever on page 18.)

You don’t need other medications. They usually do more harm than good and cost too much money besides. At a government hearing on health care held in April 1992, it was pointed out that much of the billion-dollar cold medication industry may be based more on hype than health care. (Quote from Rep. Ted Weiss, Manhattan Democrat who was chairman of the Government Operations Subcommittee on Health, hearing in Washington, April 18, 1992.)

Antihistamines, an ingredient in most cold remedies, do not help the common cold. They are useful for treating allergies because allergic reactions cause a release of histamines that leads to runny noses and watery eyes. Cold symptoms are the result of your immune system’s attack against the invading virus and are not caused by the release of histamines. Antihistamines can have dangerous side effects, especially in children, such as drowsiness and impaired mental performance.

The other ingredients found in cold medications are decongestants, cough remedies, and acetaminophen, usually in combinations. It is much less expensive to purchase acetaminophen on its own. The combinations often counteract each other and can have dangerous side effects. For example, decongestants that make a child excited are usually combined with antihistamines that cause drowsiness. Cough suppressants are combined with substances called expectorants, which make a cough more productive.

Adult cold medicines often have alcohol as a major ingredient. It’s just as easy to pour yourself a drink.

We recover from colds on our own. Try not to waste your money or take chances using expensive over-the-counter cold remedies. Instead, concentrate on rest, fluids, and humidity.

Normally, as our immune system successfully fights an infection, we improve after a few days. If instead, your child with a cold gradually gets sicker, or improves and then seems to get worse, something more serious than a simple cold may be going on. This is a sign to take your child to the doctor.

WHEN TO CALL THE DOCTOR

Call your doctor right away if your child has any of these warning signs:

■ High fever—102°F (39°C)—that stays up after the fever medication has been given or any fever that lasts more than four days

■ Difficulty breathing, very rapid breathing, shortness of breath, wheezing, or stridor, which often sounds like rattling or crackling noises in the chest or high-pitched sounds when breathing in

■ Pain or tenderness around the eyes or in the face

■ Increased irritability

■ Increased listlessness—hard to wake

■ Blue or dusky color around mouth, in nail beds, or anywhere on the skin

■ Red, raw, irritated skin under the nostrils

■ Red or watery eyes or thick discharge from the eyes

■ Ear pain, or tugging, rubbing, or pulling at ears

■ Symptoms that get worse instead of better

Coughs

Coughing is a protective reflex. We cough when the lining of our respiratory tracts becomes irritated, either by infection, polluted air, or smoke. It is important to determine the cause of the cough and treat the cause, not the cough.

When viruses attack the throat, they damage the cells, causing inflammation in the lining of the throat. The inflammation thickens the mucus in the throat and lungs which is irritating so we cough it up. The cough can be either productive or unproductive. A productive or useful cough expels secretions in the throat and lungs. A dry, hacking, or unproductive cough doesn’t bring anything up and only serves to exhaust the cougher.

The secretions brought up by a productive cough are called sputum, mucus, or phlegm. If the thick secretions aren’t coughed up, the lungs become congested and complications such as difficulty breathing or even pneumonia may result. You can tell the difference between the two kinds of coughs just by observing closely. If you hear congestion in the chest during a coughing spell, or you see material being brought up, this is a productive cough.

COUGH REMEDIES

These are used either to loosen secretions to make a cough more productive or to suppress a dry or useless cough.

An expectorant is a cough remedy that thins the thick secretions in the throat and airways leading to the lungs, thereby making it easier to cough them up. It also increases the amount of fluid in the respiratory tract, which has a soothing effect. Drinking lots of warm, clear fluids is the best way to thin, loosen, and liquefy thick, sticky secretions.

It is usually not necessary to buy expensive over-the-counter preparations. Most cough remedies contain the expectorant guaifenesin, which is not particularly effective. These home remedies for coughs act as expectorants, work better, and cost less:

■ Humidify the air with a cool-mist vaporizer. Breathing in moist air soothes the irritated respiratory tract and also helps thin the secretions so that you can cough them up.

■ Drink warm clear fluids such as clear chicken or beef broth, weak tea with honey and lemon, and apple cider. Do not give honey to children less than one year.

■ Suck on cough drops to soothe the throat, ease the cough, and provide fluids and sugar—good for older children and adults.

Cough suppressants, called antitussives, suppress the center in our brain that controls the cough reflex. If a cough is dry because the secretions are so thick that it is difficult to cough them up, don’t use cough suppressants. Suppressing this kind of cough can be dangerous because thick secretions in the lungs may lead to congestion, difficulty breathing, or pneumonia. Loosen thick congestion that’s hard to cough up by humidifying the air and drinking lots of warm clear fluids to thin the secretions. However, if your child ends a cold with a dry, hacking, cough that seems to go on forever, a cough suppressant is helpful.

You may be familiar with the over-the-counter cough medicines. Cough remedies marketed as specially formulated for children usually contain dextromethorphan (DM), an effective cough suppressant. Try a cough remedy containing DM for a school-age child who has a persistent dry cough or a cough that prevents sleep, interferes with eating or other activities, or causes vomiting. Make sure you buy one that contains only DM, not a combination suppressant and expectorant. DM may cause sleepiness, so it’s best to give it at bedtime.

Doctors may prescribe cough syrups with codeine for adults who are left with dry hacking coughs after a bout of influenza (page 153) or other respiratory viruses. Do not give these to children because there can be serious side effects such as respiratory depression.

WHEN TO CALL THE DOCTOR

Call your doctor for a cough with any of these warning signs:

■ Difficulty breathing, rattling or cracking in chest, shortness of breath

■ Color changes, usually noticeable around lips or nail beds

■ Fever that lasts more than two days

■ Blood in coughed-up secretions

■ Wheezing or croupy cough (barking-seal cough)

■ Persistent vomiting caused by cough

■ Cough spasms that cause choking, passing out, or bluish color in lips

■ Chest pain

■ Cough that lasts more than one week after cold symptoms are gone

Sore throats

The scratchy, sore throat that often accompanies a cold is caused by the damage done to the throat cells by the cold virus. It is not a bacterial infection, so you don’t need antibiotics to treat a sore throat with a cold. Strep throat, however, is a bacterial infection (see page 327).

Children old enough to gargle and adults with a scratchy sore throat can try

■ Gargling with warm salt water—½ teaspoon (2.5 ml) of salt in 8 ounces (250 ml) of warm water is the same salt concentration in body tissues and soothes the throat.

■ Sucking on hard candies, throat lozenges, or cough drops to provide fluids and sugar, which gives needed calories.

Young children can drink warm fluids that are easy to swallow and feel good, and eat soft, easy-to-swallow foods such as cooked noodles, soft-boiled eggs, applesauce, and bananas.

WHEN TO CALL THE DOCTOR

Any of the following signs may signal the onset of epiglottitis, a medical emergency. A child with these symptoms needs medical care immediately:

■ Sudden, severe pain in throat

■ Refusing to swallow

■ Uncontrolled drooling in a child past infancy

■ Difficulty breathing, or especially harsh sounds when the child breathes in

See croup, page 130.

These signs may signal a bacterial infection such as strep throat. Report these symptoms to your doctor:

■ Swollen and tender lymph glands in the neck

■ Fever that lasts more than two days

■ Pain with swallowing

Caring for Family Members with Diarrhea or Vomiting

Diarrhea and vomiting sometimes occur together. They cause fluid loss and, if severe, can result in dehydration. Dehydration results when the stool and vomit contain large amounts of fluid so that the child loses more water than he takes in. When the body loses too much fluid blood cannot circulate well and the child goes into shock. Therefore, replacing lost fluids is your main goal.

Signs of Dehydration

■ Decreased urination

■ No wet diaper in six hours

■ Deep yellow or brownish urine

■ No tears

■ Dry mouth

■ Sunken eyes

■ Irritability

■ Listlessness

■ Sunken soft spot (fontanelle) in the baby’s scalp

■ Rapid, weak pulse

■