Wednesday 14 November 2018

Dr Brian Higgins: How to differentiate between sick, and 'sick sick' in the back-to-school season

The new term often heralds the start of a winter of coughs and runny noses. But when is it time to see the doctor? GP Brian Higgins explains

Dr Brian Higgins
Dr Brian Higgins
Dr Brian Higgins
Young children are vulnerable but also incredibly resilient - however, trust your parental instinct and seek medical advice if you are worried
Dr Brian higgins

This week, we send our young off to school like young soldiers going to war. After a carefree summer ceasefire from illnesses, we are returning to the trenches of coughs, colds and flus. Childhood illnesses can often be distressing and as children can get sick very quickly, it is often difficult to differentiate between sick, and 'sick sick'.

Young children are, of course, vulnerable but in ways incredibly resilient. Seemingly made of a combination of rubber and magic, children have a phenomenal ability to heal and recover. It is actually quite important that kids are allowed to get sick. Exposure to the legions of viral infections that roam our crèches and schools are important dogfights to prepare a young, developing immune system to its future challenges. In fact, children who are kept "too clean" and aren't exposed to potential allergens and illnesses often have higher rates of allergy, referred to as the 'hygiene hypothesis'.

Often it is my patients who got sick most frequently in playschool and crèche that are the most bulletproof when entering the big leagues of primary school. It is entirely normal for young children to have six viral infections per year. But it is important to be aware of what should be a considered a "normal" childhood illness as opposed to what should alert a parent to seek medical help.

1. Coughs

A child can cough for up to eight weeks after a viral infection. If they are eating, playing, laughing and generally being their banter-merchant selves, feel free to ignore almost all coughs for at least two months, even if a parent-in-law says "Jesus, would you get that child seen to?"

Almost all coughs in children are viral. Symptoms of a runny nose, sore ears, blanching (disappears under a glass) red rash or a sore throat are likely viral and need nothing more than paracetamol and patience.

When to seek help:

* Coughs that last longer than eight weeks

* Coughs that are worse in the night may be an indicator of asthma, especially if chronic and there is a family history of asthma or the child has had food allergies and/or eczema.

* Shortness of breath

* Noisy, raspy breathing at rest

* Coughing fits that make breathing difficult

2. Runny noses

Runny noses are very common in children and the sleeve of a school jumper can be a disturbing sight by mid-October. Both clear or quite thick discharges are normal. Parents commonly worry about green nasal discharge, believing that an antibiotic is required, however this is rarely the case, especially if the child is otherwise well.

When to seek help:

* Chronically runny noses with sneezing, as there may be an underlying allergy

* A one-sided runny nose, especially with a bloody discharge, may be a sign of something hiding up there

* If there is any chance of a battery being lodged up there, that is an emergency

3. Tummy Bugs

Generally, vomiting and diarrhoea are self-limiting and highly-contagious viral illnesses. A virus is transferred to the mouth, irritates the stomach and the bowel. The irritated stomach will try to empty if expanded, causing a vomit, and the irritated bowel will try to clear the infection, resulting in watery diarrhoea.

Children are small and can get dehydrated quite quickly. While vomiting usually lasts 24 to 48 hours, it is important to encourage the intake of fluids. The rule is 'small volumes frequently'. This can be hard, especially if the child is thirsty, but ingesting a large volume at once will result in a vomit. Don't worry about eating. As long as the child is getting fluids and carbohydrate (sugar), they will be fine for a day or two.

Diarrhoea may last for 10 days to two weeks. Children can lose considerable amounts of fluids and essential salts during this period, so it is vital to replace them with rehydration drinks such as Dioralyte. If the child is otherwise well, alert and in good form, don't worry if the diarrhoea lasts a few more days than you would expect. However, it may be wise to keep them home from school to prevent the spread.

When to seek help:

* If your child is unable to tolerate any oral fluids without vomiting

* Diarrhoea that is blood-stained or lasting longer than two weeks

* Vomiting with a high temperature without diarrhoea

* If a child is generally deteriorating, especially if listless or won't engage

4. Tummy pain

Children get abdominal pain for many reasons, very few of which need blood tests or further investigations.

Tummy pain with any viral infection is very common, glands (lymph nodes) in the stomach can swell, just like glands in the neck, and can cause considerable pain. Constipation is probably the most common cause of abdominal pain in school-age children.

Another common problem is known as functional abdominal pain. Adults can have difficulty in dealing with stressful emotions and children are no different. The gut has an impressive nervous system of its own and children who are having stress in their lives can experience quite severe stomach pain. Bullying and social stress should always be considered if there is no concurrent illness, constipation or other medical symptoms.

We all worry about appendicitis - usually this presents in a very typical fashion. The child will become unwell quite quickly with a temperature and pain around the belly button. There may be some vomiting and the pain will move to the lower right-hand side. Movement will be sore - even driving over bumps in the road will cause pain while in the car.

When to seek help:

* Signs of appendicitis

* If your child is losing weight

* Tummy pain lasting more than two weeks

* Change in stools, especially if greasy or blood-stained

* Constipation that does not resolve with increased intake of fluids and dietary fibre

5. Rashes

Rashes are common. Many viral illnesses will cause what is known as a viral exanthem, a pale red or brown rash that may appear and last a few days.

There are other specific rashes that are common in children such as slapped cheek syndrome, hand, foot and mouth disease, chicken pox, and unfortunately there is now an outbreak of measles.

You should always be cautious to have the child assessed if they are unwell. When making an appointment with the doctor, please let the admin staff know that the child has a rash and may be infectious.

When to seek help:

* If the child is unwell and you are concerned

* Any rash that does not disappear under a glass tumbler

* If the child is not vaccinated

* If the child is wheezing or having difficulty breathing

6. Ear Pain

Seeing a child distressed with an ear pain is so upsetting. They can be extremely painful but they are usually due to a cold and are not sinister.

The middle ear has a pressure valve that connects to the nasal cavity called the Eustachian tube. With a cold, this can often get inflamed and blocked, leading to severe pain from a build-up of pressure. Occasionally, when this happens the middle ear can then fill with fluid and the stagnant fluid may become infected.

However, most ear pains will settle with an anti-inflammatory, such as ibuprofen, that will open the pressure valve and release the trapped air.

When to seek help:

* If there is a high temperature

* Ear pain not relieved by paracetamol and ibuprofen

* A discharge from the ear

* Ear pain lasting for longer than four days

For the vast majority of the time, childhood illnesses are self-limiting and best dealt with in the home with some simple analgesia, TLC and rest. What is difficult as a parent is knowing when to seek help and when to not.

Above is meant to be a simple, reliable guideline for specific illnesses but here is some advice that I often give my patients that they can reliably follow to know when their children need to see me.

When to seek help:

* Any temperature above 39°C

* Any temperature that does not reduce after paracetamol and ibuprofen

* A temperature lasting longer than five days

* Any sick child younger six months

* A sore throat with no runny nose, no cough and a high temperature

* Any illness that causes difficulty breathing

* Last and often most importantly, a strong parental instinct that something is really wrong

For more information, undertheweather.ie is a fantastic resource

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