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ISTOCKPHOTOS COURTESY OF PM PEDIATRICS

Other than swear words, did you have any words or phrases that you were just Not. Allowed. To. Say when you were growing up? At my house it was “shut up.” That was a big no-no. My parents felt like it was a demeaning, rude, and crass phrase that should not be uttered by any young mouths in their house, particularly my brother’s and mine, without significant punishment and revocation of privileges. The notable part of this is that while I clearly recall thinking at the time that it was THE MOST ridiculous rule ever created, to this day I rarely use that phrase, and neither do my own children. The heavy duty meaning laden in those 2 words is reserved for very few (yet serious) circumstances. (And yet oddly enough I’ve been known to fire up some varsity level swear words with very little provocation. Go figure.)

This does relate to what I want to get to today: reviewing and defining several words and phrases used casually and frequently by people who aren’t in the healthcare field, but whose meaning has sufficient gravitas for professionals who are, that deserve some time in the public forum. I even asked a bunch of colleagues for their input on this so that this list wouldn’t just be a tour through my own idiosyncrasies. Let’s get started then!

Irritable. As in “My baby is very irritable.”

In medicine, particularly pediatrics, the descriptor “irritable” is a term that is used to describe someone’s neurological status indicating that something is wrong with their brain, spinal fluid, or tissues covering the brain. As in meningitis. Or encephalitis. These children are completely inconsolable and not acting like themselves at all. If I see a patient who truly appears irritable then the chances are good that I’ll be performing a spinal tap (lumbar puncture) to obtain some cerebrospinal fluid to send to the lab for analysis, searching for meningitis or some other infection or abnormality that could explain the irritable behavior.

Acceptable alternatives: Fussy, Cranky.

Lethargy, in any form. As in “He has been lethargic since yesterday.”

Lethargy is also a neurological term that describes altered mental status, difficulty with arousal and staying awake, and persistent change in level of consciousness. This does NOT mean more sleepy than usual, very tired, extreme fatigue, or anything in this vein. It means that potentially a wide variety of testing should be done to determine if there has been a poison/drug exposure, serious infection, seizure activity, or some other medical problem that affects the central nervous system.

Acceptable alternatives: very sleepy, decreased activity.

Dehydration. As in “I know he’s dehydrated.” Or “She hasn’t had anything to eat or drink in days.”

Dehydration is defined as significant intravascular volume depletion, or low circulating volume of fluid within the blood vessels. There is a spectrum of dehydration, from mild to serious, and this is one of the instances where the “art” of medicine plays as much of a role as the science, but suffice it to say that most children who have urinated within the past 8-12 hours are not significantly dehydrated. They may indeed be a bit behind on their fluid intake than their norm, but when a child is able to produce tears with crying and has a wet tongue and mouth, then dehydration is unlikely.

Acceptable alternatives: Decreased intake by mouth, not eating or drinking as much.

Low grade fever. As in “She has a low grade fever, 99.3.”

As a general rule, you either have a fever, or you don’t. While there are different thresholds of what constitutes a fever for different age groups (newborns: anything over 38C or 100.4F for example), or for people with compromised immune systems, but if there’s a body temperature between 98.7F and 100F, that is not a fever of any sort. It just isn’t. In otherwise healthy people there’s no good data in the medical literature that “some people run low” and so therefore a temperature in the 99’s is a “fever for them.” In order to have a fever, the body temperature has to be elevated enough to cause the chain reactions of the inflammatory cascade in the body, and this doesn’t happen with a mild spike.

Acceptable alternatives: none. Simply report the number.

Wheezing/Can’t breathe. As in “I could hear him wheezing from across the room and he couldn’t breathe.”

Wheezing describes the turbulent air flow in the lower airways of the lungs caused by bronchospasm and inflammation. It is typically not a sound that can be heard without a stethoscope. A musical, noisy sound can sometimes be audible when standing next to someone in respiratory distress for a variety of reasons, but these sounds are either transmitted upper airway sounds, or coarse sounds from larger airways, or even a tight cough, but they aren’t wheezing per se.

There’s also a big difference between “difficulty breathing” and “can’t breathe.” If someone can’t breathe that means they cannot ventilate themselves at all and their respiratory rate may be zero. They may have an airway obstruction or may have a respiratory arrest. I’m not being flippant here: the difference has major clinical ramifications- both regarding necessity of urgency of treatment as well as type of treatment. If someone is able to cough or talk or cry or make noise, they should not be described as “can’t breathe.”

Acceptable alternatives: Short of breath, difficulty breathing, noisy breathing.

What do you think of those 5 words/phrases? Are they part of your clinical vocabulary? I know that there are more like this. Perhaps I’ll write a second edition of this post to help further clarify, but please know that what I’m not telling you to do is to “shut up,” (!!!) but rather be in the know about the inside scoop on hot button words and phrases in medicine, so that should you come face to face with an acute care situation, you’ll know how best to describe the scenario to get precisely the right response and care from the clinicians you encounter. Sometimes, as in much of life, it’s all about word choice.

Christina Johns, MD, MEd is the Senior Medical Advisor at PM Pediatrics and author of the blog, Dear Dr. Christina. As a parent, pediatrician and pediatric emergency physician with a master’s in education, she shares her own expertise, plus the wealth of knowledge from our highly skilled staff, with patients and families everywhere.

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PM Pediatrics is the specialized urgent care just for kids from cradle through college. Open every day until midnight, the practice’s kid-friendly themed offices are staffed by Pediatric Emergency Specialists and feature on-site digital X-ray and lab. PM Pediatrics treats a broad array of illnesses and injuries – from earaches, fevers, infections and abdominal pain to dehydration, asthma, fractures and wounds requiring stitches. The result is the highest quality after-hours pediatric care, delivered with comfort and convenience to both patients and their parents. To learn more about PM Pediatrics’ services and locations, visit pmpediatrics.com.

Progression of Illness

ISTOCKPHOTOS COURTESY OF PM PEDIATRICS

Since I’ve started this digital gig, I’ve had the opportunity to read a lot of healthcare patient feedback: reviews of doctors, physician assistants, and nurse practitioners, commentary on urgent care offices and hospitals, and opinions on nurses and reception staff. Lots of people report on things like cleanliness of surroundings and wait times and throughput. There are a fair number of comments about staff attitudes and “tone”. But I’m not going to talk about those aspects in particular today. Believe it or not, many of those topics I’ve just named are fairly straightforward to address: people can be given feedback to pay more attention to their behavior and to improve communication skills, and the facilities issues are mostly easily rectified. Billing disputes are typically solved after varying degrees of investigation.

I also read occasional comments about “missed diagnoses” in the acute care setting.

Every now and again I’ll read a frustrated review from someone who sought medical care one day and was given a diagnosis, only to obtain a different one the next from another physician. Or an upset parent who got the news that his child had an ear infection a day after they were seen elsewhere and told that the ears looked clear. These situations require a more complex dissection, and each and every one of them must be reviewed and analyzed in detail to search for any discrepancy of standard of medical care. And they do happen, as we all know. Medicine is far from perfect. I’m sure that the term frustration doesn’t even BEGIN to describe how this must feel on the patient/family side of things. I can vouch for this personally.

What I DO want to highlight in these few paragraphs is the concept of “progression of illness” and how that causes a lot of tough breaks and is at the heart of many negative reviews and bad feelings about various healthcare encounters, though I’m not sure it should be. I know it sounds obvious to state that “things change,” but clinical scenarios do. Diseases evolve, big and small. It’s really true that on a Tuesday night a child’s ears could look clear as day and by Wednesday they are red and fluid-filled. Or that the lungs sound great on Friday but by Sunday morning there’s an audible pneumonia. So progression of illness is the term we use when a disease takes its typical course. Kind of like a timeline. And on that timeline there’s an early, middle and late phase. The hard part about snapshot diagnostics, when clinicians only see patients once and briefly at that, is that if you catch someone on the early phase of a disease timeline, there’s a chance that an accurate diagnosis will be missed. Thankfully this doesn’t happen all that often.

There are several reasons to be careful about pulling the definitive diagnostic trigger too soon in the early phase of an illness.

For example, in the case of possible infection, incorrectly calling it “bacterial” and thus prescribing antibiotics too early can actually do more harm than good if the infection turns out to be a simple self-resolving virus. It won’t help a person get better any quicker, can potentially have some unpleasant side effects, and fosters the growth of antibiotic resistant superbugs. A little bit of “expectant observation” often allows for better accuracy, even if it means taking time out of busy schedules for another healthcare check. I understand the potential financial impact of this, which must be weighed into the equation, but I still stand behind the belief that doing the right thing medically should take precedence.

Another example is the decision whether or not to give intravenous (IV) fluids to a child with the stomach flu. Nearly everyone who gets the stomach flu has some degree of dehydration, and I’ve seen situations where an IV is expected yet not necessarily indicated. Dehydration is a spectrum, and it’s nearly always better to use the stomach to rehydrate if at all possible, meaning to hydrate by drinking in frequent small sips or sucking on an ice cube. This can be slower and often takes more work than rapidly infusing some saline into someone’s veins, but in the end it avoids a needle-stick and helps keep the intestines at work. The tricky part in this scenario is being able to guarantee that a person will be successful at rehydrating by mouth: it’s impossible to predict. Sometimes that queasy feeling subsides sooner rather than later and tolerating fluids goes better, but sometimes not. Regardless of direction, there has been progression of illness, and as a result of that progression, a different therapeutic direction may need to be taken. No one’s fault, it just is.

I bring up the topic of progression of illness today because it’s what I ask myself every time I read a review or post or commentary or survey response that includes details about a delayed or missed diagnosis. “Could this have been simply part of the progression of illness?” is a worthwhile question, and I hope by bringing it up today it’s a question that you’ll ask too as you come across reviews and posts in the digital space.

What can YOU do?

Ask your provider the question about progression of illness. Know what to expect in general, recognizing that every situation is slightly different.
Establish a plan of action at your first medical visit for what to do if things seem to be worsening. Are there specific signs to watch out for?
Know what else your clinician is thinking about in regards to your specific case. What other diagnoses are on the list? How will the determination be made, and does it matter (i.e. will it affect treatment)?
Don’t be afraid to call your provider if you have questions after your visit. He/she may tell you to come back in for evaluation or may be able to direct you right at home. Speaking from experience, we always want to help to provide the best care possible.

I’m not trying to make excuses for medical care that doesn’t measure up, or make light of the fact that it is often difficult, usually time-intensive, and frequently expensive to have more than one medical visit for an acute issue, but what I am trying to say is that progression of illness is always at play and sometimes the clinical care dictates some step by step management with observation and evolution in between. Being mindful of this amidst the plethora of commentary by understandably stressed and concerned people when considering various healthcare environments is important in the spirit of fostering the most positive clinician-patient relationships possible.

And THAT, I know, is good for everyone’s health.

Fever-Reducing Tips

A pediatric emergency doctor's list of things that will, won't, and might help lower your child's fever

Istock PHOTO COURTESY PM PEDIATRICS

Who applies a damp cloth to the forehead during a fever? You? Your mom?

Whenever I was sick with a fever growing up I always felt like I was undertreated by my parents because they never put a cool, damp washcloth on my forehead when I got a fever. This was unbelievable to me at the time. And they wouldn’t let me bundle up in a really warm blanket when I had the chills. They just gave me a fever-reducer medicine and had me take a lukewarm bath without much fuss. I was occasionally offered a 7-UP. I was jealous of kids with doting parents who had all sorts of different remedies to get rid of the high temperature. Yet now, after all these years of medical training and practice, I think my mom and dad did a-ok with their fever management. There’s a lot of literature out there suggesting different herbs and other therapies to help bring down a fever, and most of these are harmless. Many have no actual research or evidence to support that they actually work, but they probably don’t hurt either. I had a great time reading all the different suggestions, and after it all I thought that it might be worth thinking about reducing fever itself in more detail.

Lots of people debate what IS and ISN’T a fever, and that’s its own discussion, but not for this post. Why don’t we say for the sake of this document that we are calling fever a body temperature greater than 38C, which is 100.4F. We can split hairs about what constitutes a fever another time.

So let’s review what helps a fever; what might or might not help, and what definitely DOESN’T help bring down a fever. 3 categories, along with a few nuanced details that I think are important to know.

WHAT DOES HELP LOWER A FEVER:

Fever reducing medicines
Undressing
Not overbundling babies
Cool compresses
Time

WHAT MIGHT HELP LOWER A FEVER:

Lukewarm baths
All those herbal remedies, who knows
Hydration

WHAT WON’T HELP LOWER A FEVER:

Lots of blankets
Cold baths
Aspirin (NOT FOR CHILDREN)
Alcohol baths

Everybody knows about acetaminophen (Tylenol and others, abbreviated “APAP”) and ibuprofen (Advil, Motrin and others, abbreviated “IBU”). These are the mainstays of fever-reducing medicines, and can be used in babies. APAP can be used in children over 3 months old and IBU can be used in children over 6 months old. If your less than 3 month old has a fever, please call your pediatrician right away for guidance on a game plan that may involve some labwork. Fever in this age group can indicate a serious infection, and we don’t take it lightly. But in older children, reducing the fever with these medicines won’t necessarily make the underlying cause of the fever go away faster, but it will make a kid feel more comfortable and do a better job hydrating during the illness. Fluid losses increase during the febrile state, so added hydration on top of what is normal is critical.

Examples of ibuprofen and acetaminophen

Recall that nearly all medicines in children are dosed based on a child’s weight in kilograms, so knowing a relatively accurate weight on your child is important in this scenario.

Read the labels closely because APAP and IBU are dosed differently. And in the spirit of accuracy, please use a syringe to measure in cc’s or ml’s, not teaspoons. APAP can be given every 4-6 hours and IBU should be given every 6-8 hours, so there are some potential areas for confusion. There was a time when alternating the 2 medicines every 4-6 hours was popular (so give APAP, then 4-6 hours later IBU, then 4-6 hours later back to APAP, etc), but many clinicians have given up on this since it became a potential source of harm for some children if the caregiver had trouble keeping it all straight. So now the general consensus is to stick with one medicine at a time so there’s no confusion. One medicine that we are NOT going to use at all is aspirin. Aspirin is a dangerous and toxic medicine for children younger than 18 years old as it is associated with the neurologically devastating Reye’s syndrome. Don’t even. Not one dose.

That’s really it on the medicines for fever. So what about all the rest of it? As far as clothes and layers and blankets go, a balance needs to be struck between roasting and freezing. In the febrile state, the body’s “set point” is elevated, so the temptation is to add more layers because a person with a fever often feels cold. And everyone thinks that little babies need to be bundled up in 25 layers even when they don’t have a fever. But the last thing we want to do is ADD to an already high temperature, so many people do the opposite and remove everything. Then shivering starts, which unfortunately is the body’s natural attempt to raise the temperature as well. So somewhere in between lies the right amount of lightly layered skin covering that will neither cause the child to shiver nor will directly increase the body temperature. This sometimes requires a little experimentation, since everyone is different.

Let’s move on to baths, washcloths and compresses.

Same as above, the goal is to cool the body without causing shivering so that the internal temperature set point comes down. Using common sense, that means a cold bath or ice bath is NOT a good idea. Additionally, I’m not aware of a single soul on earth who thinks it’s comfortable, and this whole post is about bringing down a fever to increase comfort, right? So avoid the cold baths. A lukewarm bath or compress, however, can be effective at helping the body cool down without overcooling enough to cause shivering. If a bath sounds perfectly awful to the sick person, using cool (not cold) or lukewarm compresses in the areas where the body typically loses heat can work well. These areas include the head, armpits, groin and feet.

Alcohol baths seem to be a popular folk remedy, and I’m giving it its own short paragraph because I want to be clear that we shouldn’t do this. Not only can alcohol be extremely irritating to the skin, especially sensitive young skin, it can be toxic if ingested so it’s really best to avoid this method as a fever-reducing therapy.

As I mentioned, the most fun part of creating this blog was reading the multitude of available content about how well basil and apple cider vinegar and other substances can help get rid of fever. I couldn’t find any science-based, peer reviewed evidence to support these compounds, but the words “draw out the fever” and “beneficial medicinal activity” sure were used a lot with no further elaboration of detail. Several websites extol the virtues of essential oils—like peppermint and ginger—claiming that they help dissipate heat by warming the circulatory system and cause sweating. Not sure about this one, folks. Any sweating helps dissipate heat for sure, but I cannot find any data that shows that essential oils do this directly. A few sources recommended spearmint and eucalyptus oil rubbed on the feet to help “resolve the body’s warmth.” This should definitely help with stinky feet, but not clear if it will reduce fever.

Before my runaway train of woo snarkiness really leaves the station, I’ll simply say that most of these herbal remedies are harmless if used sparingly. Just don’t get your hopes up that they will definitely work. And, as one of my pharmacy sources pointed out, the concerning component of these herbal remedies is that some of them can have real interactions with therapeutic medicines (like ginger with blood clotting medicines), so please talk to your doctor if you or your child takes daily medicines and you want to try an herbal remedy. Safety, first.

I want to close by reminding everyone that it’s important to seek medical care right away if you notice:

Fever and difficulty breathing
Fever and mental status/sustained behavioral changes
Fever and rapidly-evolving purple rash

Fever makes many people feel terrible, weak, and tired. Try a few interventions from Category A and definitely the hydration part of Category B, and hopefully you will achieve at least enough fever control to make you or your little one feel a little less terrible during the inevitable illnesses that we all encounter along life’s way.

Keep in touch – let me know what worked for you! Speedy Recovery.

Christina Johns, MD, MEd is the Senior Medical Advisor at PM Pediatrics. As a parent, pediatrician and pediatric emergency physician with a master’s in education, she shares her own expertise, plus the wealth of knowledge from our highly skilled staff, with patients and families everywhere.

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