Fisher Pediatrics
4037 South Arbor Lane, Suite D
New Palestine, IN 46163
Phone: 317 861 7125
Fax: 317 861 7141
Monday 8-5
Tuesday 8-5
Wednesday 8-5
Thursday 8-5
Friday 8-5
Most Saturdays 8-10
We are open August 9th from 8:30 - 10:30
We will be getting flu vaccines in August. We will be offering them to parents as well again this year, if you are interested, please send us your name, date of birth, and insurance information on your child's Patient Fusion portal account.
William J. Fisher, MD
Caitlynn Worden, PNP
Fever
For over 20 years, the most common after hours call I get is, “At what temperature do I have to go to the ER?” If we are talking about children over 2 months, who have a fever due to an illness, and not fever from sun/heat exposure, the answer is there is no specific temperature that means you need to go to the ER! It all depends on the child. If your child is drinking well, breathing well, alert, will sometimes smile, is strong enough to fuss at you when you try to do things with them, then they are almost always better off seeing us the next morning, regardless of temperature. If your child is lethargic, dehydrated, has a change in mental alertness, or has labored/difficult breathing, they should be in the ER, regardless of temperature.
First and foremost, fevers are not a bad thing! A fever is when your temperature is 100.4 or higher. A fever is our body’s natural way of fighting an infection. It is natural for a fever to cause low energy and decreased appetite. There are times when you should let the fever continue and times when you should treat it. Studies show that not treating the fever during a viral illness may decrease the length your child is ill. If your child is waking up appropriately, drinking fluids, and is not super fussy/uncomfortable you can let the fever continue. If your child is fussy, not wanting to drink fluids, etc. then you can give ibuprofen (if they are over 6 months of age) or tylenol. We prefer ibuprofen because it generally works better and it lasts longer, and is much safer in an accidental overdose. We do not encourage parents to rotate fever reducing medications because this can get confusing when you’re doing this all day long and through the night.
How high a fever gets is not the concerning part of a fever, a child can have a 105 temperature and as long as they are drinking fluids and waking up appropriately then it is ok and normal. A high fever does not cause seizures. Febrile seizures tend to happen as the fever is starting to go up, usually before the family even knows their child has a fever.
If your child is less than 2 months of age and has a temperature of 100.4 or higher, and it is after office hours, you need to go to Riley’s ER or Peyton Manning’s ER. If the fever is during office hours, you need to call us right away. A fever in a child less than 2 months of age is an emergency. The most accurate way to check a temperature in an infant is a rectal temperature.
The best way to take your child’s temperature is under the arm or under the tongue if old enough to do so. If your child is less than 1 year of age and their temperature is above 100.3, we encourage you to check their temperature rectally (only if you are comfortable doing so). If you take an underarm temperature you will add one degree to that reading and that is your child’s approximate temperature. Please avoid forehead and pacifier thermometers as these are not as accurate.
You should make an appointment if your child’s fever lasts longer than five days or the fever comes back after going away for over 24 hours. During flu season, it is best to make an appointment in the first few days of fever, because the flu medication is more effective early!
One last piece of advice - once you know your child has a fever at night, stop taking it! Taking it over and over will increase you and your child’s anxiety and will not change how you will treat them, because remember, you are treating your child, not the degree!
And if you have any questions or concerns, please reach out to us, it is what we are here for!
Caitlyn Worden, PNP
Dr. Fisher, MD
Vomiting & Diarrhea
Gastroenteritis - aliases “the stomach flu” “the 24 hour bug”
These viruses can be tough on kids because of their stubbornness to drink when they are nauseated. They also tend to have symptoms much longer than adults.
The illness usually starts with 1-3 days of vomiting, followed by diarrhea a day or two later.
The diarrhea phase can go up to 10 days in infants and toddlers. Fever is not always present, but when it is, it tends to be 102 or lower.
Your first goal is to make sure your child stays hydrated. For infants continue breastfeeding or formula feeding, but if they refuse you can use pedialyte as an option. If toddlers fight hydration, you can give them five ml of fluids every five minutes to keep them hydrated. If you need to, you can use a medicine syringe and give it to them between their cheeks and gums. Be persistent! Once they realize you are more stubborn than they are, they will usually give up and start drinking. For toddlers and older, you can use water, pedialyte, sports drinks (low sugar versions are best). Food is optional, but great if your child will eat. They don’t have to do the “BRAT” diet, just avoid lactose (cow’s milk, cheese, yogurt, ice cream) while they are having the diarrhea phase. Avoid straight fruit juice as well because the concentrated sugar can cause more diarrhea.
Warning signs include:
Green like a tree vomit (unless they just had spinach or another green food). Green vomit can be a sign of obstruction and you should go to the ER. This is very rare (I haven’t seen it in over 20 years). Yellow/Lime vomit is fine. Yellow vomit is not bile. Bile is dark green and a sign you should go to the ER. Yellow vomit is just stomach acid.
Black/red stool (green and dark brown stool is fine)
No tears when crying and/or a dry, sticky mouth.
Less than 4 urines in a 24 hour period for older kids, and less than 6 urines in a 24 hour period for toddlers and babies.
If your child has any of these signs, they should go to an ER immediately. If you are not sure, call our office so we can assess your child immediately.
If the vomiting goes longer than 2-3 days, or the diarrhea is approaching 10 days we definitely should see your child.
Do not use anti-diarrhea medications. These medicines can make your child sick longer and are not safe. You want the poop coming out ASAP, there is no good reason to hold the germs making you sick inside your stomach longer!
Diaper Rash
Diaper Rash
Diaper rashes are very common in infants and young toddlers - what can you do to help when this inevitably occurs? Be sure to change your child as soon as you can after they have urinated or had a bowel movement. The next easiest and most effective thing you can do is air time! After you have cleaned your child, either during a diaper change or after the bath, allow them to go without a diaper for 10-15 minutes. You will want to do this before reapplying diaper cream and as often as you can throughout the day. When the diaper rash is mild, it is fine to continue using the wipes you likely have at home (Pampers, Huggies, Kirkland, etc), however if it is continuing to get worse we recommend the brand Water Wipes or a soft washcloth with water. The other brands likely contain a bit of alcohol and/or fragrances in them which can be very irritating to a diaper rash. Another tip is to temporarily switch to Pampers diapers if you don't currently use them. They have been shown to wick away moisture better than many other brands.
Now which diaper cream to choose?
There are two main types of diaper rash. The most common is a red raw rash on the buttocks, close to the “crack” that looks like a burn into the skin. That is because it is! When the urine and stool mix, the enzymes that digest your food can also digest your skin. For this type of rash, you want a barrier that will shield the skin from the stool and urine. There are so many on the store shelves it can be overwhelming to decide. The key is to find a diaper cream with 40% zinc oxide, and then put it on as thick as possible! You should not be able to see the skin afterward. If you need to get the zinc oxide off, a little bit of cooking oil on a soft towel will wipe it right off.
The second type of rash is a yeast (candida) rash. That type of rash focuses on the genitals instead of the buttocks, and goes up off the skin, instead of burning down into the skin. That rash can be very red as well, but sometimes it will have small red dots forming at the edge of the rash. Those are called satellite lesions, and they are telling you where the rash is going next. For those rashes, we recommend clotrimazole cream three times a day. It usually takes a week to see improvement with a yeast rash.
What if this doesn’t work?
If it has been 2-3 days of doing the above recommendations and the diaper rash is still worsening, you should make an appointment so we can examine your child. Sometimes diaper rashes need a prescription strength cream or other remedies. Also, if the rash is having discharge, or is very painful to the touch, we should see your child right away.
Caitlynn Worden, PNP
William Fisher, MD
Constipation
(school age)
Constipation (preschool through middle school)
Constipation is very common for school age children. It often presents as recurrent abdominal pain, usually close to the belly button, and often worse after meals, especially dinner. Most kids who are constipated say they poop every day. The problem is often they are only pooping small balls, and the whole system is backed up. Parents usually assume that eating more fiber and drinking more fluids will help, and it might, but one of the main causes of constipation in school age kids is not pooping when their body tells them to poop. They are very picky when it comes to toilets, and most will not poop at school, stores, movie theaters, etc. It is very important to teach them to poop when their body says they need to. When they don’t the stool gets drier and leads to constipation. Often constipation presents in the office as “diarrhea”. How is that possible you ask? Good question! They can get so constipated that their colon gets stretched out, which causes it to lose strength and sensation, so fresh, new poop will leak around the edges of old poop and eventually it will even leak out into their underwear. Often teachers and parents think the child has control over this - they don’t. It happens without them being aware of it, and they will even get so used to the smell of their own stool that they will not notice the smell either. This is called “encopresis” which is really just chronic, bad, constipation. All of this drama leads to stooling being a very negative experience for young kids, and what would an average young kid do if they know they don’t like something? You guessed it - avoid it. So they start holding in stool because they know how miserable stooling makes them feel. Adults are completely different, in the same situation, we would use our adult logic to poop the second we notice we can, but kids don’t think like us.
How can we help? Miralax is truly a miracle laxative. It has changed how we treat constipation and encopresis entirely. The goal 1) to make the poop so urgent the child can’t decide to hold it until they get home to use their favorite toilet, and 2) to have them pooping so easily for 2-3 months that they stop being afraid of stooling and their colon has a chance to snap back into shape. For most kids we start with 2 caps of adult miralax a day, with the goal of 1-4 loose soft happy stools per day. Once they get very watery, we back it down to 1 cap a day for the next 2-3 months. The biggest mistake families make is stopping the miralax too fast due to their child having a few days of normal poops. The problem is their intestines haven’t snapped back into shape yet, so a few days later they are back where they started. During the 3 months of miralax, sometimes the dose has to go up or down. I use the rule of 2 for that. If your child is on it and starts to get constipated again, double the dose. If you are on 1 cap, go to 2 caps. If a child is having watery stools and too many stools, instead of stopping the miralax, cut the dose in ½, so if you are on 1 cap then go down to ½ a cap a day. This up and down by multiplying or dividing by 2 works very well.
School tip - I encourage all my patients on this regimen to put a pair of shorts and underwear in a ziploc bag in their backpack. That way if they have an accident at school, they can quickly put the smelly clothes in the ziploc, and use the clean clothes. Once the ziploc is zipped, smell will not be an issue. Also, make sure the teacher knows what is going on, so that bathroom access is immediate.
There are websites that talk about the horrors of miralax, these are not credible in any way and I encourage you to avoid them; there is zero science behind anything the opinions on those sites. Miralax is the safest medicine I use, and is so safe, that when we used to “clean out” kids in the hospital, we would use 24 caps of miralax over a 24 hour period in school age children. The only side effect - diarrhea.
"Cold" Treatments
0 - 12 months
For babies, we recommend only nasal saline drops. A few drops can be put in each nose hole, then wait 30 seconds, and then suck out with a nasal aspirator/bulb. Only suction your baby if they are struggling to drink or breath, don't do it just because you don't like them having congestion. Too much nasal suctioning can cause nose bleeds. Running a humidifier in the room can help as well. All other over the counter medications for babies with colds are a scam and should be avoided.
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1 year - 11 years
Kids 1 year and older can do 5 ml of honey every 6 hours for cough, which has been shown to work better than over the counter medications. Kids over 2 can try Vics vapor rub, either on the chest, or on the soles of the feet with socks on. All other cold medications are a scam and should be avoided.
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12 years and up
Older kids can do over the counter pseudoephedrine if their congestion is making school or sports difficulty, but it is important to get the real pseudoephedrine from the pharmacist (without prescription). This medicine can increase pulse and blood pressure, and makes it impossible to sleep, so definitely avoid it at nighttime. The "Sudafed" in the aisle is a scam.
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Here is my article about cold medications in case you are interested:
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When your child is sick with a cold or flu what medicines should you get? When patients ask me, for nearly 20 years I have had the same response, “None, in general they don’t work and are a scam.” It is hard to find evidence that over-the-counter cold medications do anything but take away money that could be used for more important things that families and children desperately need, but since every parent wants their child to feel better, they are very hard to resist.
Recently the Food and Drug Administration (FDA) passed an unanimous vote on 9/12/23 that stated the most common decongestant, phenylephrine, is ineffective. I was thrilled when I saw this, but we have known this for 20 years, so I am not sure why it took that long to hopefully save people a lot of money. How much money do you ask? Americans spent 1.76 BILLION dollars on over-the-counter cold medicines with phenylephrine last year - all for nothing. The other decongestant does work but, since you can use it to make illegal drugs, is sold only by the pharmacist without a prescription to adults. That medicine is called pseudoephedrine. It works well, but makes it nearly impossible to sleep and is not safe with people with blood pressure problems or heart conditions, but for many adult sized teens it is a helpful medicine to take in the morning to get through a day of school without blowing their noses all day!
What about cough suppressants? First, remember that coughing itself isn’t necessarily a bad thing. It is your body's reflex to protect itself by “getting things up” and not drowning in snot, but yes, sometimes it can get out of hand and make kids really miserable. Dextromethorphan is the most common “cough medicine” and drumroll - there is no evidence it works either. What is worse for parents with teenagers, is that at high doses dextromethorphan will cause a buzz, hallucinations, intoxication, and a feeling of having an out of body experience. Unfortunately, teens have figured this out, and have been abusing the non-effective cough medicine for recreational purposes, which can be very dangerous.
So, what should you do? First, now that you know cold medications don’t work, you can feel guilt free not buying them when your loved one is sick. You can definitely try 5 ml of honey every 6 hours for cough (for kids over 1 year old), which has some evidence for helping. You can run a humidifier in the room, which can make the coughing more comfortable. Definitely don’t forget ibuprofen for aches, pains, and irritability. Lastly, make sure to get your covid and flu vaccines to decrease the number of total illnesses your child has per year. If your child has a wheezy or croupy cough, or it is getting progressively worse or the cough is accompanied by a fever after the fifth day of illness, definitely go see your doctor!
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Hand, Foot, and Mouth Disease
Hand, foot, and mouth disease (HFMD) is caused by a virus and is spread through respiratory droplets (coughing, sneezing), touching a contaminated surface, or fecal-oral route. Your child will likely get tiny blisters on the palms of their hands, soles of their feet, around their mouth, and inside their mouth. These tiny, blister-like lesions can also go all over the body and are commonly found in the diaper area as well. Usually the blisters are not painful, although sometimes the kids feel a little arthritis in the wrists or ankles. Some kids with HFM have fever, but others do not. The fever (over 100.3) is often early in the illness and is not dangerous. As always, if the fever goes longer than 5 days you need to let us know and likely be seen. Kids can get HFM up to six times, so eventually they will become immune, but it can take several infections!
With it being a virus there is no medicine to help get your child over the illness, so we treat symptoms to keep your child comfortable. We recommend giving ibuprofen every 6-8 hours as needed due to the blisters in the mouth being painful. Be sure to keep your child hydrated through frequent sips of fluids - water or a low sugar electrolyte drink. If your child is not urinating once every 6 hours (every 4 hours for infants) or not making tears, please call us right away. Popsicles and ice cream can alleviate some of the pain for your child if they are not wanting to eat or drink. Don’t worry about perfect nutrition during HFM; the main goal is hydration! The rash should never drain pus or turn yellow/crusty, so if it does, let us know to check to make sure it hasn’t become infected with a secondary bacterial infection.
The illness lasts 7-10 days, however you are generally not contagious once you have not had a new lesion develop within the last 24 hours. Lastly, adults can also get HFMD, but it is rare. Sometimes weeks after the HFM has gone away, the child (or the parent) will lose some of their fingernails or toenails. This is always alarming to families, but is absolutely normal and the nails will grow in normally over the next 6-12 months. As always, if you have any further questions or concerns, please reach out to us!
William Fisher, MD
Caitlynn Worden, PNP
Croup
Croup
Croup is a 7-10 day illness caused by a cold virus, but also can be caused by Covid, flu, and RSV. Patients with croup have congestion and cough similar to a traditional “cold” but they have much worse coughing at night and in the early morning. This is caused by nightly swelling in the neck, which peaks on night three, with the barky cough usually gone by day five. The cough is described as “barky” but it sounds more like a seal’s honk than a dog’s bark. Children with croup also make a sound called “stridor” which is a deep horn sound with inspiration. Stridor is louder with deeper inspirations, which are more common during coughing or crying. These symptoms are worse for younger kids, because their airways are more narrow, which makes the symptoms more pronounced.
Most children with croup need to be seen for accurate diagnosis and to look for other complications like pneumonia or ear infections. To treat croup we use oral or injectable steroids. Steroids help the swelling in the neck, but do nothing for congestion, fever, or the length of the illness. If you get a fever after day five, please call me - that could be a sign of a late ear infection (20% risk with croup). Honey for kids older than 1 year old is helpful, 5 ml every 6 hours. Also, running a humidifier in the room can be a benefit. If your child starts having stridor with every breath, please call us during the daytime, or go to the ER during after hours. Some stridor during crying, coughing, and laughing is probably okay as long as breathing at rest is normal. Please use nasal saline and humidity for congestion. Vics is also a reasonable strategy, which can either be placed on the chest or on the feet, covered with socks.
Please call if fever persists longer than 5 days, starts after day 5, or congestion continues past day 10 to 14 of the illness. Other reasons to call and be seen are difficulty talking, drinking, or if your child looks like they are working to hard to breath.
Children with croup can go back to daycare after their fever has resolved for over at least one night, and their cough is improving!
Hives
Hives/Angioedema
Hives, also called urticaria, can be alarming to parents because the rash comes on so fast and can cover a large part of the child’s body, but hives are very common and very safe.
How can you tell if your rash is hives?
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The rash comes on fast or abruptly.
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The rash moves and comes and goes. Every few hours it will usually look different!
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It still feels smooth. It may be raised, but the skin itself still feels smooth.
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It blanches. When you push firmly with your finger into the red area, and then quickly take your finger off, you will see the redness disappear for a very short time, then come back. That is a good sign of a rash, if it doesn’t blanch, we need to see you ASAP.
What causes hives?
You are trying hard to figure out what caused the hives. My best advice, unless the hives are recurrent, is to stop trying to figure it out! We almost never do. 80% of hives are an immune system reaction to a common virus that your immune system is allergic too, which causes releasing of histamine and activating your immune system’s mast cells.
How long will they last?
50% of people will have their hives less than 1 week, and 75% of people will have their hives less than 2 weeks. Unfortunately, a minority of people may have them up to six weeks long. Regardless of how long they last, hives are very safe and are not scary.
How can we treat them?
Topical treatments will do nothing for hives because they come from inside the body, and they move too quickly for a steroid cream to make a difference. The main treatment for hives is antihistamines. Benadryl was traditionally used, but can be dangerous and too sedating. Experts recommend using Zyrtec once daily. Sometimes if that is not effective we will prescribe hydroxyzine. Oral steroids are only used for the worst of cases, and typically are not needed.
The goal of treatment is to reduce itch, not to make the rash go away. Only time will make the rash go away! If we prescribe hydroxyzine, only use it if you are itching.
Anything I shouldn’t do with the rash?
Hives are not contagious, so you should do your normal activities. Some activities can bring the rash out worse temporarily. Hot showers, exercise, strong emotions, anything that gets your body “worked up” can increase them, but that doesn’t mean you have to avoid those things.
Asthma/Breathing Problems
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