Fever in Children: When to go to the ER

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Guest: Dr. Keith T. Borg - Emergency Medicine Physician

Host: Dr. Linda Austin – Psychiatrist

Announcer: Welcome to an MUSC Health Podcast.

Dr. Linda Austin: I am Dr. Linda Austin. I am interviewing Dr. Keith Borg, who is an emergency room doctor here at the Medical University of South Carolina Associate Professor of emergency medicine at MUSC. Dr. Borg, one of the toughest questions that people grapple with especially taking care of children is when to take a child to the emergency room. Let’s start by talking about fever. Some fevers obviously can be a real signal of danger, most are not. What kind of general advice would you give to a parent?

Dr. Keith T. Borg: Sure you are exactly right. It is a really a tough question and it is tough for doctors to know too. We tend to look at the other things that are going on as well, if the child, otherwise, eating, going to bathroom normally, what’s their appetite like and other things like cough or rash going on. In constellations of the symptoms, described things that are concerning to us like pneumonia or meningitis with the headache and fever and neck stiffness, and those are things that we really look for. An isolated fever, if a child is well, tends not to be in a significant illness, but there is no way to know for sure sometimes.

Dr. Linda Austin: So, what would be the first step be then if a child looks kind of hot and red and their forehead feels hot, what would you suggest to the parents?

Dr. Keith T. Borg: Certainly taking a temperature and getting an accurate temperature and overall temperature would be a great first step to know, and if the temperature is greater than 104 F or 38 degrees Celsius. Knowing the temperature is a great first place to start and then examining your child, looking all over them, asking about their symptoms, and how old they are, what kind of history you can get and then relaying that information to your pediatrician and getting some information from them if you can depending on the time a day, and if they are available, it is a great place to start.

Dr. Linda Austin: Now, if a parent who has no medical background or training is examining their child, what are some of the things they could look for.?

Dr. Keith T. Borg: The first will be the breathing and look at their breathing pattern, they breathe fast or slow and difficulty breathing. Next would certainly be their mental status, they are awake, alert, responding normal like they were to you. Next would be any pain anywhere in joints, in the belly or any place like that. Finally skin and rash, is the skin nice and perfusing well. If you look at the palm, is it pink backup after you press on it really fast and certainly in less than three or four seconds.

Dr. Linda Austin: How about looking in the throat? Do you think an average parent could look at the throat and tell if it looks little bit red or not?

Dr. Keith T. Borg: Sure you can do it, It is even hard, therefore, doctors to be honest on examination to look at the throat and tell whether strep or not. So, it is certainly worth looking, but it is difficult to know that for sure.

Dr. Linda Austin: So, the first step in is to call a pediatrician. I would imagine that most parents who have a child who has a pediatrician would prefer to take their child within 24 hours to see that doctor if necessary, but let us imagine it is 7 o? clock or 8 o?clock at night and that it isn’t really possible, what are some of the warning signs or symptoms that a parent might think about in order to decide to bring the child to the emergency department and not wait until morning?

Dr. Keith T. Borg: Certainly, if your child is not behaving normally. if they are not alert, awake, interactive. Children, just like adults, when they are having fever don’t feel good and they don’t really want to eat or drink, but if they are not behaving themselves, if they are acting odd, if they are having difficulty breathing those are all things that we really want to see them for right away. The bottom line is if you are concerned as a parent that your child is ill something and wrong, we are happy to take a look at it.

Dr. Linda Austin: Now, from your point of view as the recipient physician there in the emergency department, what are the diagnoses associated with fever that your worry most about?

Dr. Keith T. Borg: What we worry most about is certainly meningitis. It is also part of thing we see the least of. The thing we see the most in term of patient is viral illnesses. We see certainly a lot of that, and that’s all very minor and tends to get well, although causes patients certainly discomfort and cause parents lot of discomfort. Kids are sleepless, they don’t want to eat and drink, they miss school, and they can’t go to daycare. So, it is a significant problem for families and for patients.

Dr. Linda Austin: Let’s talk about meningitis. What are some of the early signs and symptoms of meningitis?

Dr. Keith T. Borg: Certainly, fever is one of the first, headache and neck stiffness are the two others that are certainly seen. You can get, what is called, the petechial rash, which is a dark violet rash that starts looking very small 1 mm to 2 mm size and then spreads in large patches. It is very progressive, which means it happens very fast. Kids tend to get fever and they can get very, very sick within 8-10 hours.

Dr. Linda Austin :So then certainly that child should go directly to the emergency room.

Dr. Keith T. Borg: Absolutely.

Dr. Linda Austin: Is there any thing remarkable about the headache? Is that a particularly severe headache?

Dr. Keith T. Borg: It is a severe headache and the child will complain a lot and say that it is the worst headache they have ever had. It is not a minor irritating kind of thing. It is very bad.

Dr. Linda Austin: It is immediate

Dr. Keith T. Borg: Absolutely

Dr. Linda Austin: Attention. What other illnesses associated with fever do you worry a lot about?

Dr. Keith T. Borg: The two others that we see commonly besides viral illnesses are pneumonia, which certainly has breathing as a component of that with cough and breathing fast and difficulty breathing, and then certainly, in young girls, urinary tract infections are common as well.

Dr. Linda Austin: How about earache? As a parent I know that when your child does has an earache, it can certainly be a very traumatic presentation. It can be very painful for a child, is it necessary to bring that child to the emergency room?

Dr. Keith T. Borg: Not necessarily. It is probably complaint with the minor earache and low-grade fever that can be followed by pediatrician, but depending on height of the fever and the age of the child, certainly. Any child who has a fever, less than two months of age, should certainly come to the ER, no matter what time of day, to be examined. It depends on?

Dr. Linda Austin: Or see their pediatrician.

Dr. Keith T. Borg: Actually if the child is less than two months of age, they should come to the ER pretty much right away to get looked up. Very little children don’t do a get a good job of telling us where and how they are sick. They don’t have complete immune systems. So, those children get, we call a full septic workup. They all get blood workup; they all get urine examined, and most of them get spinal fluid examined as well because they don’t have a developed immune system to let us know by exam where they are sick and what’s going on.

Dr. Linda Austin: What do you do for a child with an earache in the emergency department?

Dr. Keith T. Borg: The first thing is we examine ears and look for signs of an inner ear infection and recommendations if changed on those, and we are not treating with antibiotics merely when ear infection is more. People who have recognized that most of the things causing those and certainly now with the moderate vaccinations are viral and the antibiotics aren’t helping, and we are not doing 06:19. So, recommendations are actually for the first two days of fever now not to treat, I mean we are certainly doing more of that than ever before. Parents like antibiotics. There is a perception among both doctors and parents, the antibiotics help but based on lot of research data and certainly practicing for years and years, it is really not necessary in lot of cases.

Dr. Linda Austin: Dr. Borg, thank you so much for talking with us today.

Dr. Keith T. Borg: Thank you.

Announcer: If you have any questions about the services or programs offered at the Medical University of South Carolina or if you would like to schedule an appointment with one of our physicians, please call MUSC Health Connection at (843) 792-1414.

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