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The “Stomach Bug” is cursing many households right now.  Here is our website article on how to manage vomiting and diarrhea symptoms, and directions on when to seek care.

Here is some great information from Immunologic (immunologic@substack.com) about this nasty infection:

Noroviruses are the most common cause of acute gastroenteritis (inflammation of the Gl tract). Norovirus outbreaks can occur throughout the year, but are most common during winter: which means, right now! Currently, norovirus test positivity rates are between 12 and 13%, with case rates especially high in the northeast. This is not quite as high as the rates this time last year, which peaked at around 15%.

While sometimes called “stomach flu”, norovirus is not remotely related to influenza viruses. Noroviruses are in the calicivirus family, which are non-enveloped viruses. Non-enveloped, or naked viruses like noroviruses tend to be more virulent than enveloped viruses. This is because they are more resistant to the elements and can withstand heat, humidity changes, and many disinfectants.

Most hand sanitizers are ineffective at inactivating non-enveloped viruses like noroviruses

Alcohol-based hand sanitizers work to inactivate viruses by a few mechanisms, based on the active ingredient: either ethanol or isopropanol (2 different alcohols).

Most commercial hand sanitizers range between 40-80% alcohol content. For effective inactivation of norovirus (and other non-enveloped viruses), you need 95% ethanol. As such, hand washing with soap and water is the preferred method for proper hygiene among the general public, especially if you’ve been in contact with fecal matter.

Detergents in soap form micelles (think of these like little fat cages) around pathogens which trap them and allow them to be washed away when rinsing with water.

What about cleaning surfaces?

Don’t panic – there are some chemicals that are effective for disinfecting surfaces that may be contaminated with norovirus:

Bleach (Sodium Hypochlorite): Bleach is your number one option and is the most effective disinfectants against norovirus. Bleach works by denaturing proteins and disrupting viral RNA, much more effectively than alcohol. A solution containing 5-25 tablespoons of household bleach per gallon of water is recommended. The exact concentration may vary based on the surface and situation.

Other options if bleach isn’t available:

1.    Hydrogen Peroxide: Hydrogen peroxide at a concentration of at least 3% can be effective against norovirus. It acts as an oxidizing agent, damaging essential components of the virus.

2.    Quaternary Ammonium Compounds: Also known as “quats,” these compounds can be found in household cleaning products and some types of disinfectant wipes. They can be effective against norovirus but often need to be used at higher concentrations. (Note: this includes benzalkonium chloride, which is not as effective as bleach and requires longer contact time and higher concentration).

3.    Alcohols at Higher Concentrations: While regular alcohol-based hand sanitizers are not very effective against norovirus, higher concentrations of alcohol in certain disinfectants (95%) can have some efficacy. However, their use is more limited compared to other options like bleach.

If you aren’t sure what you have is effective, check the EPA list of antimicrobials for norovirus.

Norovirus is also extremely contagious.

Someone can get infected after being exposed to fewer than 20 viral particles. That’s why it spreads phenomenally easily through person-to-person contact, fecal-oral, contaminated surfaces, and food/water sources (such as shellfish harvested from contaminated areas.)

Another fun tidbit: you can shed virus in your stool for several weeks after symptoms disappear, and since it spreads so easily and the virus is so stable, it means that infections can rage in communities.

Illness caused by norovirus is fast and furious

Symptoms develop between 12 and 48 hours after exposure and are typically violent. They include nausea, acute-onset vomiting, watery, non-bloody diarrhea, and abdominal cramps. Fatigue, muscle aches, headache, and fever can also be present.

Now, for all you reading and thinking, jeez, what next?! There is some good news. Illness for most is usually mild, & symptoms last 1-3 days. However, norovirus can be particularly serious for young children and older adults.

How can you protect yourself and others if someone at home has norovirus?

Unfortunately, there is no vaccine for norovirus and treatment involves supportive care. But if someone at home has norovirus, it isn’t a guarantee that everyone else will get it. You can take steps to reduce the risk.

Hand hygiene, especially in any common areas and particularly in the bathroom and kitchen spaces. Soap and water is king here. This is especially important after using the toilet, after changing diapers (if applicable), and before eating, preparing, or handling food.

Food hygiene is essential. It goes without saying the sick individual should not be touching common food or prepping food for others in the house, and, if possible, should not be in the vicinity when food is being prepared. You should also not prepare foods for up to 3 days after your symptoms subside. However, additional measures can also be taken. Thoroughly wash fruits and vegetables before preparing and eating them, especially if eaten raw. Ensure seafood is washed and cooked thoroughly: norovirus can survive “searing” and quick “steaming” and temperatures up to 140F. Any foods that are potentially contaminated from the sick individual should be discarded. You can also consider wearing clean gloves while handling food or interacting with a sick individual.

Disinfect surfaces immediately. Any surfaces which have been in contact with vomit or fecal matter should be disinfected as soon as possible. Use a chlorine bleach solution with a concentration of 1000–5000 ppm (5–25 tablespoons of household bleach [5.25%] per gallon of water).

Thorough and prompt laundry. Anything: clothing, linens, etc., that may be contaminated should be washed. Minimize disturbance of potentially contaminated fabrics (remember: 20 viral particles can infect someone), wear gloves while handling and wash hands thoroughly after touching. Wash items in the washing machine with the highest cycle length and machine dry (for additional heat sterilization) afterward.

Caring for the sick individual. If the individual is actively vomiting, having diarrhea, and may not have the best hygiene for whatever reason, you can consider wearing a high quality mask around the house when you are in contact with them. This will reduce the likelihood of particles floating around that may contain virus. You can also consider wearing gloves if providing care for them, and always make sure to wash your hands extra thoroughly after interacting with them. You may also consider changing out of clothing you wore when in contact with them so you aren’t potentially carrying viral particles elsewhere around the house or out of the house.

Fever: A Quick Guide For Parents

Adapted from a post by Natasha Burgert, MD

One of the most common reasons parents are calling or coming to the office is FEVER. Fever can make a kid look and feel lousy, which is not fun for a parent to watch.

First, A Few Fever Facts

A fever is a temporary rise in body temperature due to illness. Most consider a fever to be 100.4F degrees or higher (regardless of your child’s “usual temperature”).

Fever is a symptom of illness, not a disease. With very specific exceptions, fever is a normal, healthy way for the body to fight common infections. Bacteria and viruses that attack our bodies love normal body temperature, but cannot successfully replicate in hotter conditions. Fever reflects a robust immune system’s defense against these pathogenic attackers. The bacteria and viruses are the enemy, not the fever they cause.

It’s not your imagination – Fevers are worse at night. Our body systems follow a circadian rhythm. During the day, our level of cortisol (a stress hormone) is typically higher, slightly suppressing the work of the infection-fighting cells in our blood. At night, when cortisol levels drop, the immune system ramps up. When our immune system is working harder, higher fevers and more symptoms of illness can result.

Top 10 Fever FAQs

1. What is the best way to take a child’s temperature?

For healthy babies under two months of age, it’s okay to use an armpit thermometer to quickly screen for a fever. A simple digital thermometer will work. If a baby’s armpit temp is 99F degrees or higher, then a rectal temperature must be done to confirm your baby’s temperature. (Here’s a how-to video from Mount Sinai.) If the rectal temperature is 100.4F degrees or higher, call your pediatrician immediately or go to your nearest emergency room.

• For kids over two months, an armpit thermometer remains a good option for screening. If the temperature is over 99F degrees, you can confirm a fever with a rectal or forehead (temporal artery) thermometer.
• After six months of age, ear thermometers become an option, but can have some variability in accuracy. You’ll have the best chance of getting a correct temp by gently pulling your child’s ear up and back, while aiming the tip of the ear probe between the opposite eye and ear. Check both ears, and assume the higher temperature is correct.
• Over the age of four years, an oral digital thermometer is thought to be the most accurate. Make sure your child has not consumed anything cold or hot for at least 15 minutes before taking a temperature. Ear and forehead thermometers are also great options for this age.
• In our office, we use a simple digital thermometer to get rectal temperatures on our infants and a professional grade temporal scan thermometer for older kids (for home use try the brands Braun and Exergen.)
• Warning: Forehead fever strips and pacifier thermometers are not very accurate, so save your money.

2. Is it true that the higher the fever, the more I should worry?

Although a high fever may indicate more serious illness in an adult, this is not the case for young kids. A young child’s immune system is always on high alert, and any sign of illness can result in a significant immune response.

Regardless of the actual numerical value, look for signs of serious illness in your child. Some kids appear fairly normal with really high temperatures, while others are sluggish and sad with a reasonably mild fever. Observe the amount of discomfort, level of activity and ability to maintain adequate hydration. Those symptoms are more important than the number itself.

3. When do I take my child to the doctor for a fever?

Over two months of age, most fever can be safely treated at home with fever reducing medication, hydration and patience. The fever caused by most viral illnesses of childhood are typically seen at the beginning of an illness, associated with other symptoms and last about 72 hours. But, there are few instances when pediatricians definitely want to see your child with fever.

It’s time to go to the doctor when: 

• your child is less than two months old and has a fever of 100.4F or greateryour child has had a fever for five consecutive days or longer (under age 2 if 3 or more days)
• your child is also showing other signs of pain or discomfort, like pain with urination, persistent headache/neck pain, bad sore throat or ear pain (note that sore throats that accompany congestion and cough are most likely viral, not strep).
• if you are concerned about dehydration or excessive fatigue

A pediatrician’s job is to examine kids when parents are concerned.  If you are worried, please portal us. We are here to help you determine when you need to bring them in.

4. What “number” on the thermometer means an ER visit?

Over the age of two months, there is no number on a thermometer that requires a trip to the emergency department. Nope, not even 105F degrees.

It’s never wrong to seek help when you’re worried about your child, but no one wants to sit in the ER needlessly for hours. If your child gets a high temp, grab the fever reducer (see FAQ #6) and try to lower the fever at home before jumping in the car.

Pediatricians are always going to be more worried about fever for multiple days in a row (more than five) than a kiddo with a brief 105F temperature. And, we are going to be more worried about a kid who is too sleepy, not drinking or in pain — no matter the number on the thermometer.

If there has been NO change in your child’s temperature after an hour of offering a weight-based dose of medication, reach out to us for advice. (*note that high fevers may not come down fully to normal range, especially at night- if a high fever comes down a few degrees, enough that your child is more comfortable and able to sleep, there is no need to worry. If, after an hour there has been no change in the temperature you can give a different fever reducer- i.e. acetaminophen if ibuprofen was given, and vice versa)

5. Isn’t it true that fever helps the body fight infection, so we shouldn’t use fever reducer? 

The goal of offering fever reducing medication is NOT to get a high temperature back to “normal.” Fever reducers, like acetaminophen and ibuprofen, are simply medications to make your child feel better and might decrease the risk of dehydration.

As an aside, if you are coming to the pediatrician’s office because your child has a fever and her or she is uncomfortable, please give your child a fever reducing medication BEFORE coming to the office. The doctor doesn’t have to “see the fever.” We believe you. Plus, a comfortable child is much easier to examine. And a good exam will often determine the cause of the fever, allowing for accurate treatment.

6. What’s the difference between ibuprofen and acetaminophen? Which one should I use?

Fever reducers do NOT treat infection or cure a fever. The goal of these medications is to simply make your child feel better.

Acetaminphen (Tylenol) helps with pain and fever. This medication may be given to infants over the age of two months, sooner if approved by your healthcare provider. It comes in liquid, chewable, pill and rectal versions (Feverall). Acetaminophen is effective for 4-6 hours, and should not be used more than 5 times in a 24 hour period.

Ibuprofen (Advil, Motrin) helps pain, fever and swelling. Ibuprofen can be given to infants over the age of six months and is taken by mouth. Ibuprofen is effective for 6-8 hours.

Medications should be dosed according to your child’s weight, not age. If you feel that your child needs medication, give the correct dose. Weight based dosing charts are available on our website at www.saugatuckpeds.com. Learn more about safely using these meds in FAQ #7.

Fever reducer tips: 

• It’s not uncommon during the course of an illness for the temperature to rise near the end of the dosing interval.
• These medications may take up to an hour to start working. In the meantime you can try a tepid bath/cool cloths to help (do NOT use alcohol rubs, these can be dangerous in children.)
• If your child has an upset stomach, choose acetaminophen.
•  If your child has swelling, throat pain choose ibuprofen. Either medication is generally appropriate for fever and pain reduction when used in appropriate doses for acute illness. Dose fever reducers by weight, not by age.
• Please note: Aspirin is not an option for fever reduction in children. There is link between between aspirin and a condition called Reye Syndrome. Please keep aspirin away from your childhood medications. If your child is under the care of older caregivers, like grandparents, please remind them of this concern.

7. Acetaminophen can hurt the liver, so isn’t giving ibuprofen a safer choice?

Generally speaking, fever reducing medications are considered safe if administered properly (correct age, dose, dosage device, and frequency). However, when any medication is not taken properly, intentionally or unintentionally, kids can get hurt.

Tips to decrease the risk of using medications:

•  Medications (which many children find delicious) need to be stored in a safe place to prevent overdosing. Avoid keeping medication out on the counter or in the bedroom during times your child is ill. Always store medication in a safe place where children can’t access.
•  Use the dosage device that came with the medication. Don’t use cereal spoons or measuring spoons from the kitchen.
• Do not buy multi-symptom formulations, such as many cold and cough products. These products increase the risk of accidental overdose because parents may unintentionally give a fever reducer and a multi-symptom medication containing fever reducer, at the same time.

8. When my child gets a fever, I heard it’s best to alternate acetaminophen and ibuprofen. Is this true?

Although the results of a few studies have suggested fever reduction was slightly betterwhen using both medications, the risk of making a mistake while alternating fever reducers is higher than the increased relief your child may experience by using this method.

However, if your child’s fever is not coming down to a level of comfort with one medication alone, both may be used. If you choose to alternate, medication can be given every three hours. For example, acetaminophen at noon, ibuprofen at 3 pm, acetaminophen at 6 pm, etc. Make a chart to mark down the time each medication was given, and share it with all caregivers. Again, alternating two fever reducers is not needed for most illnesses.

9. Isn’t it true that a high fever causes brain damage?

Fever does not cause brain damage. Period. Full stop. Every normal brain has a internal thermostat that will prevent a person’s temperature from getting high enough to cause brain damage.

Organ damage can occur when an external factor is affecting our temperature regulation system. For example, when an individual is not able to cool oneself (as in a closed car on a summer day) or in the case of rare brain injury that has resulted in damage to the internal thermostat. A healthy child with fever is not at risk of organ damage.

10. What about febrile seizures? Don’t I have to treat fevers to prevent them?

Febrile seizures are scary to watch and terrifying for parents. But despite popular opinion, aggressive fever control does NOT prevent febrile seizures from occurring.

The cause of febrile seizure is thought to be due to a combination of genetic and environmental factors, and are the result of a developing brain’s reaction to fever. Fever reducing medications do not prevent febrile seizures from occurring. Rather, the risk of febrile seizures are associated with a child’s age at the first event and a history of family members who also had these events.

Simple febrile seizures most commonly happen in young children between 12-18 months of age. These events last for a few minutes, resolve on their own and rarely cause long-term health problems. Children grow out of these events as their brain matures, typically by elementary school.

If your child is having a unexplained or first-time seizure, call 911 for help.

Respiratory illneses, including RSV, Influenza and COVID19 continue to spread rapidly in our area. With the holidays fast approaching, it is important to understand how to limit your family’s exposure to these illnesses as well as protect vulnerable friends, schoolmates and family members from your potentially sick child.

Prevention:

• Your best first line against infection is via immunization.  We have influenza and COVID19 vaccines readily available in the office (influenza for all ages 6 months+, COVID19 for ages 6 mo- 18 years.)
• RSV vaccines are unfortunately in very short supply for infants under 6 months of age.  However, expectant mothers can get a different vaccine that stimulates their body to create antibodies which cross the placenta and provide protection for your soon-to-be born infant.
• Masks work, especially if well-fit and filtered (an N95.) Try to mask in public for at least 4-5 days prior to events to avoid getting sick. 
• Washing hands frequently with soap and water, and wiping down frequently touched areas in the house such as doorknobs and counters helps minimize in house spread of illness.
• Ventilation and filtration- planes are pretty good at this, but remember to mask up in the airport and boarding areas at minimum. If your child is too young to mask, try a stroller with a rain shield when possible until you get settled in your seat.

Testing:

• COVID19 home tests can be negative early on- remember to test several times over 2-3 days if you have symptoms to increase the chances of detecting the virus (2 tests 48 hrs apart will catch 39% of asymptomatic infections and 92% of symptomatic infections. ANY line should be considered a positive (though the fainter, the less contagious you are.)
• If your child has fever, aches, chills, sore throat and cold symptoms they may have the flu- contact our office for evaluation and testing.
• RSV presents as any other common cold (congestion, sore throat, cough.) Testing is indicated only in small infants who may become unusually ill. If your older child has these symptoms, assume they have one of many respiratory viruses including RSV, and consider whether they should be around vulnerable people.

Contagiousness:

The most common questions we get are about WHEN your sick child can safely go to school/a birthday party/your family gathering.  Many illnesses are contagious for a day or two PRIOR to symptom onset- hard to do anything about that (but do alert anyone who may have been exposed to your sick child unknowingly.)

Here are some general guidelines for when your child can go back in public-

• COVID19- most contagious just prior to symptom onset and in first 5 days. Day 0 is the first day of symptoms- you child needs to be home/isolated from other family members if possible for days 1-5, and can return to school MASKED on days 6-10 if they are fever free for 24 hours and feeling better.  Two negative rapid covid tests 24 hrs apart indicate they are likely no longer contagious, but this is not required for return to school/activities or after 10 days (and they still should mask for days 5-10 in public.)

• Strep throat- when on antibiotics for at least 12 hours, AND fever free, feeling better and able to stay hydrated.

• RSV– typically lasts 1-2 weeks, with a peak around day 3-5 but congestion and cough can last for WEEKS. It is most contagious in the first week. If your child seems better, then has a new fever/earache/worsening cough we would want to reevaluate them. Your child can return to school when fever free for 24 hrs, able to hydrate, and generally feeling better (no hacking cough or streaming nose.) Avoid more vulnerable people for at least a week, ideally 2 weeks.

• Impetigo (scabbed/oozy/blistering skin rash from staph or strep)- can return  to school/daycare when on antibiotics for 12 hours and the rash is drying up/not spreading. Cover infected areas when possible. 

• Pink eye (conjunctivitis)- this is almost always viral, but many schools/daycares require (unnecessary) antibiotic eye drops to return. We generally only prescribe such drops if your child has persistent thick eye discharge. Conjunctivitis  is most contagious prior to symptom onset, and is generally highly contagious (bacterial or viral). Schools usually require that any thick discharge has cleared up prior to return.

• Influenza A&B- incubation period is about 1-4 days post exposure and is typically spreads via respiratory droplets (coughs, sneezes…) Symptoms (fever, body aches, cough, congestion and sore throat) are worst in the first week, and are usually milder if your child has been immunized.  Cough and fatigue can last up to 2 weeks, but your child can return to school once fever free for 24 hrs, able to stay hydrated, and their symptoms are minimal. Avoid vulnerable people for at least a week.

• The ”Stomach Flu” (not a real flu, but usually from another virus such as Norovirus)- spreads rapidly via exposure via direct contact with bodily fluids OR contact with infected surfaces (this is the time to pull out the bleach wipes!) Norovirus often begins suddenly with bad abdominal pain, vomiting and diarrhea. While the vomiting phase is usually over within 1-3 days, the diarrhea can last for up to 2 weeks.  Children can return to school/daycare when fever free for 24 hrs, they are able to stay hydrated, and can control their bowel movements (or in infants, diarrhea has slowed and is contained within a diaper.)

• Croup– caused by any number of upper respiratory viruses (usually parainfluenza) that cause throat inflammation and cough. The incubation period is generally 2-7 days post exposure, and it spreads via contact with respiratory secretions. Can return to school/daycare when fever free for 24 hrs, able to stay hydrated, and the cough/congestion is minimal (sense a trend here?)

• Hand Foot Mouth (HFM)- caused by Coxsackie virus, with an incubation period of 2-7 days. Spread by respiratory secretions and saliva/stools (wash hands well after diaper changes.) Children can return to school/daycare when fever free for 24 hrs, able to stay hydrated, and the rash is no longer spreading and lesions have scabbed.

• Poison Ivy– NOT CONTAGIOUS!!! It is spread by contact with urushiol oil from Poison Ivy leaves, and the rash doesn’t emerge for several days, long after the oil has been washed off or absorbed by the skin. Various areas of involvement emerge over several days, depending on the amount of oil absorbed by the skin. Itching won’t spread the rash, but can worsen it. Washes such as Zanfel help draw the oil out of the skin and minimize the reaction.

For more information on the treatment of coughs and colds, please visit our website.

GlaxoSmithKline (GSK) is discontinuing production of Flovent HFA (fluticasone propionate) and Flovent Diskus. Flovent HFA and Flovent Diskus are inhaled corticosteroid medicines used as a controller medicine to treat asthma (and sometimes off-label for a gastrointestinal illness called Eosinophilic Esophagitis or EoE.)

GSK notified the FDA of this decision on June 2, 2023. The last date the product will be available for ordering is Dec. 31, 2023. GSK believes a supply of these products will be gone by early 2024.

If you use Flovent HFA or Flovent Diskus, here are some steps you can take:

• Refill your current Flovent prescription as soon as possible.
• Your child will need to switch to another medication in 2024. Some brand name options may include ArmonAir Digihaler and Arnuity Ellipta. These are dry powder inhalers approved for ages 5 and older, but cannot be used with a mask/spacer. Qvar is a breath-activated device with similar issues, but can be adapted to use with a spacer/mask with some manipulation of the device (not ideal.)
• A generic fluticasone metered dose inhaler is available. However, some insurers are not covering the generic and others don’t consider it a preferred treatment, which can lead to higher copays and the need for prior authorizations that delay access.
• Asthmanex HFA is a similar, but not identical, inhaled corticosteroid (mometasone) that may also be substituted, but needs to be covered by insurance.

Bottom line, CONTACT YOUR INSURANCE NOW to find out what they will cover in place of Flovent in 2024.

Read more here.

Our office will be closed Thursday, November 23rd in honor of the Thanksgiving Holiday. One of our physicians will be on call for emergency sick issues. To reach our on call MD, call our office and follow the prompts.

We will reopen Friday morning for sick acute visits only until noon, We will also be in the office Saturday and Sunday morning for sick acute visits only.

To request an appointment, please log into your patient portal accountand fill out a SICK VISIT APPOINTMENT REQUEST, or call our office prior to 10 am to book a visit.