Neutropenia: One Reason Your Kid May Be Sick All The Time

Posted on March 20, 2018July 7, 2020

Posted by Dr. Monica Wonnacott | March 20, 2018

If your child is frequently ill, it may be due to a condition called neutropenia. Neutropenia is when your body doesn’t have enough of a certain type of blood cell that helps fight infection.

The 30 second science lesson…

In the blood, there are different kinds of cells, including white blood cells. The white blood cells are the ones that help fight infection, essentially the body’s defense. When you get sick, the number of white cells goes up, trying to defend the body. Within the broad term of white blood cells, there are different subtypes of cells. One of those is called the neutrophil. Generally speaking, the neutrophil helps fight bacteria. Neutropenia is simply low levels of this particular type of white cell, the neutrophil. So if your neutrophil count is low, you won’t be able to fight off infection.

Why does it happen?

Neutropenia can happen when:

The body uses up or destroys all the neutrophils it makes.
1. Example: Your child gets one really bad infection and has to use all of the neutrophils to fight it, thereby making him/her more susceptible to other infections.
2. Example: Your child’s cells are destroyed during chemotherapy or radiation, or;
The body simply doesn’t make enough to start with.
1. Example: Your child has an underlying autoimmune disorder.
2. Example: Your child has an underlying bone marrow diseases like aplastic anemia, cancer, or leukemia.

Signs and symptoms of neutropenia

Fever
Frequent infections essentially anywhere:
1. Ear infections
2. Sore throats
3. Sinus infections
4. Pneumonia
5. Urinary tract infections
6. Skin infections, etc.

How is neutropenia diagnosed?

The only way to diagnose neutropenia is by doing a blood test, specifically a CBC (or complete blood count) with a differential. The “differential” component means that the doctor is looking specifically at the various types of cells. You cannot look at a person and surmise that he/she has neutropenia.

What is an ANC?

The ANC is the “absolute neutrophil count.” If your child has neutropenia, this number is one you will become very familiar with. This tells you how many of the actual little neutrophils your child has circulating in the blood stream. In medicine, we measure how severe the neutropenia by the sheer number in the body. The fewer neutrophils there are (i.e., the lower the ANC), the more severe the neutropenia.

What do I do once diagnosed?

There isn’t a specific treatment for just neutropenia (it’s not like you can take a pill or get a transfusion of just neutrophils to boost the numbers). There are a few basics though.

Assess the clinical situation. If the condition was picked up incidentally, you may just wait and watch (allowing the body time to recover on its own). If there are serious other factors (e.g., life threatening infections or cancers), you may be much more aggressive.
Treat any symptoms or complications that result from neutropenia. For example, give an antibiotic for pneumonia or a urinary tract infection.
Evaluate for underlying causes. For example, there may be a problem with the immune system in general or the bone marrow (which is responsible for making blood).
Prevent complications and/or further infections. A child who has a weakened defense system needs to be kept out of the line of fire. Don’t allow the child with neutropenia to be around sick people. Depending on the severity of the neutropenia (and what underlying conditions exist), it may be appropriate to keep your child home from preschool/school, daycare, and public places (like grocery stores, etc.)

Should I be worried?

Yes and No. While freaking out never helped anyone, having a healthy respect for the serious nature of an illness is appropriate. Neutropenia can leave your child very vulnerable. While most children recover without any serious complications/problems, there are kids who get very serious life threatening illnesses.

If you are worried that your child may have neutropenia , talk to your doctor. He/she can easily test for it and let you know if there is something worth worrying about.

Fever: How High Is Too High?

Posted on January 7, 2017August 18, 2020

Posted by Dr. Monica Wonnacott | January 7, 2017

I just finished 7 straight days of being “on call.” By far, the number one question I got from parents was, “My child has a fever of ….(fill in any number)….should I be worried and take them to the ER?” Their follow up question was always, “How high is too high for a fever?” This is a completely understandable worry. Parents just want to make sure that they are always doing best by their children, especially when they are sick.

What temperature constitutes a fever?

The official cut off for fever is 100.4 F or 38 C.

So… How high is too high?

The short answer is 105. However, there is always more to the explanation. Be worried about a lower number (101-103) if your child looks terrible, I mean REALLY terrible. A sick kid with a fever will be hot to the touch and feel generally miserable, but a child that is listless (limp), having trouble breathing, or is dehydrated is another story. Those kids need to seek urgent medical care.

Infants: The exception to the rule.

All infants under 2 months of age who have any fever greater than 100.4 F (or 38 C) (rectal temperature) need to be seen by a medical professional.

Should I go to the ER with fever?

The short answer is maybe. Different factors play into the answer.

Age. An older child with a fever and cold-like symptoms can likely be treated at home.

Duration. A fever that has been going on for more than 5 days, needs to be seen by a doctor.

Infants. Again, anyone less than 2 months should be seen by a doctor.

Time of day. Generally, fever concerns can be handled by your doctor in the office (skip the expense and waiting of the ER) during the day.

Recurrent. If the fever happens initially with an illness, goes away for a few days, then comes back, you should seek medical care. A fever that returns can be a sign of a complication (e.g., a cold that has developed an ear infection or pneumonia).

Other symptoms. Fever plus certain other symptoms change the level of concern. Fever and one other very focal painful symptom usually warrants being seen without delay (examples: fever + sore throat may be strep throat; fever + painful urination may be a urinary tract infection; fever + right lower abdominal pain may equal appendicitis; fever + ear pain may be an ear infection). Fever and many other mild symptoms (e.g., cough, runny nose, body aches) generally indicate viruses and can often be handled at home.

I gave Tylenol/Motrin and the fever won’t break.

The goal in treating a fever with Tylenol or Motrin is to make a child feel better. It isn’t necessarily a more “worrisome” sign that the fever didn’t “break” (that is, drop below 100.4) with the medication. The medication isn’t a cure, it’s a symptom reliever. Don’t worry too much if the fever doesn’t go away completely. More concerning is always the question: “How does your child look?”

Good luck!

I hope this helps you navigate what to do when your child has a fever. You might also want to look at my article, “Should I Worry About Fever?”

Adenovirus: This Virus Is Super Tricky

Posted on July 25, 2016July 8, 2020

Posted by Dr. Monica Wonnacott | July 25, 2016

Adenovirus is going around. It’s a sneaky little virus (it can infect just about anywhere and happen anytime of the year). However, the sore throat, fever, pink-eye combo that happens most commonly in the summer is in full swing in our community now. The key to this little bug is prevention. Don’t get it in the first place. Wash your hands like crazy and make your kids do the same.

Adenovirus causes all sorts of problems

It can infect multiple organ systems, which makes it unique. There aren’t many viruses out there that can cause respiratory illness, GI illness (the vomit/diarrhea bug), conjunctivitis (pink eye), urinary tract infections, you name it. Stupid, but interesting random fact: the virus causes cancer in rodents, but not in humans. Go figure. Here’s the low down.

Kids hit the hardest

While anyone can get this nasty little bug, kids get the short end of the stick. Young children are affected the most. Interestingly, there is also a peak seen in military recruits (accounted for by their close quarters).

What are adenovirus symptoms?

This is the trick. Because adenovirus can infect all different parts of the body (and sometimes at the same time), it can present in all different ways.

Respiratory symptoms: Cough, runny nose, sore throat, fever. The symptoms can be pretty severe and will even look like RSV. The key is what symptoms go together. If you have a case of bronchitis and conjunctivitis (pink eye), that is almost always adenovirus. Other viruses don’t usually give you pink eye with lower respiratory tract infections.
GI symptoms (Gastroenteritis): Vomiting and diarrhea. It is quite common in the daycare setting.
Urine/kidney symptoms: Painful urination, frequent urination, and blood in the urine.

How do you catch adenovirus?

The site of entry usually determines the site of infection. If the virus goes in the respiratory tract via inhaling infected droplets, you get a respiratory bug. If you ingest fecal material, you’ll get a GI (gastrointestinal) bug. I know the concept is gross, but this is how it works. Infected person A doesn’t wash his/her hands after going to the bathroom (or changing their infected child’s diaper) and touches the door handle. You come along and touch the infected door handle. Your hands now have infected material. When you later wipe your mouth, voila, you’re infected. It’s a hardy little virus and can survive a long time outside of a host (which means surfaces stay infectious for a long time). FYI, water can get infected also. Once again, here’s another reason to make sure pools are chlorinated properly.

How is adenovirus diagnosed?

There are fancy lab tests to diagnose adenovirus. Most of the time we don’t do them as there isn’t a cure and the tests are expensive. However, sometimes there are circumstances where testing is done (e.g., severe symptoms, young infants, prolonged fever, immunocompromised patients). The patients that we have specifically tested in our office over the last few weeks have all been positive for adenovirus. The location tested reflects the presenting symptoms. If the symptoms are respiratory, we usually use a swab that goes up the nose. If the problem is diarrhea or bloody urine, a stool sample or urine sample is tested. Blood tests are hit-and-miss whether they are helpful (as most people will have positive titers anyhow by the time they are school-aged). Most of the time, the diagnosis is made clinically. I feel like such a detective when I piece together some of the adenovirus unique infectious qualities, and make the diagnosis.

Is there a treatment?

Unfortunately, there is no cure to adenovirus. Since it is a virus, antibiotics don’t help. In fact, antibiotics will just make matters worse. Antibiotics screw with your child’s normal flora and contribute to antibiotic resistance. So don’t buy into the “just in case” mentality with antibiotics.

The treatment is completely supportive. In essence, you treat the symptoms to make the infected person feel better. If there is fever, treat the fever (with Tylenol or Motrin). If there is vomiting and diarrhea, push fluids to keep the person hydrated.

Should you take your child to the doctor?

I end up seeing a ton of cases of adenovirus in the office because what to do often isn’t clear cut. The problem is that the symptoms of adenovirus often cross over with more concerning illnesses that should be seen. For example, if your child has a sore throat, it is reasonable to ensure the infection isn’t strep (which has to see a doctor for antibiotic treatment). If your child has pink eye, you probable should get that checked out to make sure it isn’t bacterial and needs a drop. So you can see how it’s a difficult call for a parent to make. If the symptoms are severe, prolonged, or questionable you probably should take your child in (or if your child is under 2 months old). If you’re certain it’s adenovirus (e.g., another child of yours has already seen the doctor and been diagnosed), then you don’t need to see the doctor.

When are you out of the clear?

Now that you have a child infected with adenovirus at your house, when are you done with it? When can you stop worrying about the other kids in your house getting it? Here’s more bad news. Once exposed, it can take 2 days to 2 weeks to develop symptoms. To make matters worse, as already mentioned, the virus is really hardy and lives on surfaces a long time (toys, towels, light switches, etc). Unfortunately, that means more cleaning (add it to the never ending list, right?). It’s not uncommon for me to see families who have been dealing with this virus in one way or another for weeks and weeks in their houses. I’m sorry to be the bearer of the bad news.

One special subtype: the “super cold”

It’s worth mentioning, since it’s gotten a fair amount of press coverage over the years, there is one serotype (which is essentially a certain strain) of adenovirus called serotype 14 that is sometimes referred to as the “super cold.” When people get this strain, the symptoms tend to be very severe (with roughly 40% requiring hospitalization and half of those in the intensive care unit). This is diagnosed when specific testing is done (once again, getting to the severe cases).

Do You Know The 5-day Fever Rule?

Posted on July 16, 2016August 18, 2020

Posted by Dr. Monica Wonnacott | July 16, 2016

I tell parents the 5-Day Fever Rule on a daily basis, and everyone should know it. Here it is in a nut shell: If your child has a fever that lasts for 5 days, you should worry. Fever that lasts 5 days usually represents badness. Generally speaking, the fever that happens with viruses (with very few exceptions) lasts less than 5 days. So if your child has a fever that lasts longer than that, you are generally talking about more serious conditions. So…

Go to the doctor on the 5^th day of fever (if other symptoms haven’t taken you there sooner).

When you go to the doctor, be prepared for a “work up” (looking for the source of the fever), which may include blood work, urine, or respiratory/nasal swabs.

I just finished another call week today and most of the parent calls I got revolved around fever questions. As parents, we worry when our children look sick and are running a high temperature. While I have posted on fevers before (see Should I Worry About Fever), here are a few quick reminders.

What is a fever?

Fever is an internal body temperature of 100.4 Fahrenheit or 38 Celsius or greater. Normal body temperatures are in the 97-99 range (hence the 98.6 average).

What’s the best way to take a temperature?

In infants younger than 1 year: Rectally (yep, up the actual rear end)—just use a cheap, digit thermometer. The silver tip goes in the rectum and then you squeeze the butt cheeks together until the thermometer beeps with the reading. While some studies support other methods as being reliable in infants, the rectal temp is still considered the “gold standard.”
Toddlers, kids, and teens: various methods.
1. Tympanic: Measured in the ear (this is the kind I own). It measures the infrared heat waves released by the ear drum. FYI, it doesn’t work great if you have a kid with super waxy ears.
2. Temporal artery: Measured on the side of the forehead. It measures the infrared heat waves released by the temporal artery (which is just under the skin on the side of the forehead).
3. Oral: Measured under the tongue (using a digital thermometer). Not very accurate (easily altered it you eat something hot or cold).
4. Axillary: Measured under the arm (using a digital thermometer). Not a reliable measure (one I steer parents clear of).

When to worry?

Remember the 5-Day Rule—if the fever goes beyond 5 days, seek medical care.
Worry if there is a fever initially that goes away (for a few days) and then returns.
Your child is lethargic, has a really bad associated symptom (say a wretched sore throat to go with that fever), or looks terrible.

How high is too high? Don’t be surprised….

I didn’t write a magic fever number to worry over. The great exception is newborns. Any fever over 100.4 in infants under 2 months must be seen by a medical doctor. Otherwise, a 103 fever doesn’t make me more stressed medically than a 101 fever. Fever is just the body’s way of mounting an immune response to something. Some people mount bigger responses than others. I know what you’re thinking (because I get calls every night about it), 104 degrees is toasty—I know. The number however, does not correlate to seriousness. Yes, kids are miserable that warm, but generally they can handle it (See article Febrile Seizures: Is Your Child at Risk? for the few exceptions to this rule). The reason to treat a fever is to make a kid more comfortable.

In short (I have digressed), keep the “worry on the 5^th day of fever” rule in your mind. Stay cool!

Rhinovirus – The Bug That’s Going Around

Posted on May 4, 2016August 17, 2020

Posted by Dr. Monica Wonnacott | May 4, 2016

Rhinovirus seems to be the virus de jour in the last few weeks. In medicine, we often don’t go to the effort to do specific viral testing on kids who appear to have “just a cold.” The test is painful (a swab up the nose), is expensive (hundreds of dollars), and takes time and effort. If there was a cure, it would probably be worth doing more often. However, there are still plenty of reasons to test (e.g., a child who isn’t getting better, a child with an underlying immune problem, a newborn with fever). In the last few weeks, most of the kids we have tested for one reason or another have been positive for rhinovirus. So it is definitely going around.

What is rhinovirus and do I need to stress about it?

Rhinovirus is the most common viral infection in humans. It is the predominant cause of the “common cold,” although there are other viruses that cause colds. It typically infects the upper respiratory system. Random trivia: “rhino” comes from the Greek word meaning nose, so I always think of it as the bug that causes all your crummy runny/stuffy nose symptoms. Rhinovirus is the most common in the fall and spring.

Rhinovirus Signs and Symptoms

Runny or stuffy nose
Cough
Sore throat
Fever
Headache
Decreased appetite
Muscle and body aches (can happen, but are atypical).

Rhinovirus Incubation

Everyone always wants to know where they got a bug (secretly we want to shake our fist and curse the person who possibly gave us the bug). Knowing the incubation period (the time it takes from exposure to showing signs of illness) will help in your detective work. The typical incubation period is 2 days. There have been reports of as short as 20 hours and as long as 4 days, but usually 2 days. The bug is passed via respiratory droplets (people coughing/sneezing around you) and from direct contact or touching (e.g., an infected child wipes his/her nose with his hand, touches a toy, then your child plays with the infected toy and later touches his/her own face).

Rhinovirus Treatment

In case you haven’t heard, there is no cure for the common cold. I’m working on it, but failing miserably. For now, treatment is all symptomatic. (See my article DECODING COUGH AND COLD MEDICATIONS for specifics.) As a quick reminder, rhinovirus is a virus and an antibiotic won’t help (since antibiotics only treat bacteria). So unless there is a complication (e.g., pneumonia, an ear infection), your doctor shouldn’t prescribe an antibiotic. In general:

Treat fever, sore throat, and/or body aches with Tylenol (if over 2 months) or Motrin (if over 6 months)
Run a humidifier
Keep the nose as clear as possible
Try OTC meds (depending on age of child and symptoms)
Encourage fluids
Rest
Let time pass

Colds tend to go away on their own, so be patient. Rhinovirus typically lasts 7-10 days. Complications can happen (e.g., pneumonia, ear infections), but are uncommon. Complications tend to happen in children who are compromised in some way (e.g., have weakened immune systems, asthma). FYI, there is not a vaccine to prevent rhinovirus.

Rhinovirus Prevention:

Wash your hands often
Don’t touch your face (the virus enters through the mouth, nose, and eyes)
Steer clear of sick people (if one of your children is sick, try to keep them away from the others as much as possible)
Disinfect infected surfaces
Improve your immune function (eat healthy, exercise, and sleep well)

Call your doctor if (because I’m worried about developing complications)

Your sick child is under 2 months old (just about any bug under 2 months should be seen by a doc)
The fever goes beyond 5 days or reoccurs (e.g., has been gone for 3 days and starts again)
Any one of the symptoms is getting significantly worse when it should be getting better (e.g., after a week of coughing it should be gradually improving not getting worse)
Your child is disproportionately symptomatic or miserable (e.g., a child shouldn’t cry inconsolably for hours with the common cold)
Your child is having trouble breathing

Rhinovirus isn’t fun, but also isn’t the worst virus out there. If you or your child falls victim, take heart. It too shall pass.

Respiratory Bug (Coronavirus) Is Going Around

Posted on April 7, 2016July 8, 2020

Posted by Dr. Monica Wonnacott | April 7, 2016

If you’re feeling like you’ve simply had enough of the miserable cough and cold bugs this season, you are in good company. I feel like it’s been a particularly bad season this year, and just when I think it is starting to let up, we’ve got a new bug on the forefront: Coronavirus.

Coronavirus is a common virus that causes mild-to-moderate upper respiratory illness. To date, there are 5 different Coronavirus strains that make people sick (that I’m aware of). The infamous SARS outbreak of 2003 and the Middle East Respiratory Syndrome (MERS) of 2012 are both Coronavirus strains. Fear not, the strain that we are seeing in our community right now though is not SARS or MERS. Random trivia, the virus is called Coronavirus because the little virions look like spikes on a crown under the microscope (take that piece of trivia to your next dinner party).

Coronavirus top 10 quick facts:

Most people will get infected at some point in their life with Coronavirus.
Young children are far more likely to get it.
You can get infected over and over with it (there isn’t life-long immunity with it).
Symptoms include: runny nose, cough, sore throat, and fever. (Kind of sounds like every other bug right?)
It’s usually a fall and winter bug, which makes the outbreak in our community this time of year even more interesting.
It’s easily spread from person-to-person through the air by coughing and sneezing, or via direct contact, like touching or shaking hands.
There are no vaccines against it.
Reduce transmission by frequently washing hands, staying away from sick people, and not touching your face.
There is no cure. Treatment is all symptomatic (i.e., decongestants, humidifiers, fever medications, rest, fluids) until your body conquers the bug on its own.
The diagnosis is made by a clinical test (swabs up the nose are easiest, but blood tests also exist). Most doctors don’t bother to test, since there isn’t a specific treatment anyhow and the test is costly, takes time, and isn’t comfortable.

Hopefully, you’ll manage to avoid this one, but in case you don’t, at least you’ll know what you’re up against. Stay healthy!

Febrile Seizures: Is Your Child At Risk?

Posted on March 25, 2016August 18, 2020

Posted by Dr. Monica Wonnacott | March 25, 2016

A febrile seizure is a seizure that happens when a child has a fever. Febrile seizures happen in 3-5% of children, and usually occur between the ages of 6 months to 6 years. Children who have had 1 febrile seizure have a 20-30% risk of having another. Most febrile seizures happen as a result of viruses (like what causes a common cold).

How do I know if my child is having a febrile seizure?

Febrile seizures cause involuntary twitching, shaking, or stiffening of the body. It usually involves the whole body (not a partial seizure that causes just a part of the body, like an arm to shake). During the seizure, the child’s eyes will often roll back, or to the side, and the child is unresponsive to you calling. Your child’s breathing may be unusual, and the skin can change color (darker or paler). While the seizure will seem like it goes on forever when it is happening, febrile seizures are typically very short, less than a minute. Rarely, they can last more than 15 mins. Usually the child recovers fairly quickly (a few mins) after the seizure.

What to do when it happens.

Get your child into a safe position. Lay him down on the floor so he doesn’t fall or hit his head on anything hard or sharp.
Position your child’s head to the side, so he doesn’t choke on any saliva or potential vomit.
Look at the time. Two minutes can feel like an hour when your child is seizing. It is important you know how long it lasts.
Record it. Everyone has a phone on them nowadays. Record the seizure. It helps tremendously for your pediatrician to be able to see what happened.
Call your child’s name and put your hand on your child to see if you can stop it. In a true febrile seizure, your child will not respond to your calling and the shaking will not stop with your touch. These two simple moves help distinguish seizures from other causes of shaking.
Seek medical care if it is the first time. This will help confirm the diagnosis and may help determine the cause of the fever.

The long-term consequences.

This is the good news. While it will scare you to death to watch your small child have a febrile seizure, there are almost no long-term consequences in an otherwise healthy child. Febrile seizures are not life threatening and do not cause brain damage or nervous system problems. Most kids “outgrow” them as they get to be school-aged.

Can I prevent them?

Did you know that everyone has a seizure threshold? For most people, the value is so high (maybe 105-108 degrees) that you can’t naturally get there, even if you’re sick. For whatever reason, some small children have what seems to be a lower threshold. In those children, it seems logical to prevent the seizure, by preventing the fever from getting too high. As a general rule, most docs will tell you to treat fevers in kids with febrile seizures more aggressively (Tylenol, Motrin, cool baths, etc.). With that said, there was a study in 2009 in the Archives of Pediatrics and Adolescent Medicine that revealed no difference in recurrence rates of febrile seizures in those treated with fevers from those not treated. As for me, even though I know it may not make a difference, if it were my kid, I’d probably still treat the fevers. As a parent, if there is anything I can do to help prevent it, I’m all over it. If nothing else, it will help my kid feel better (from whatever is causing the fever in the first place).

Should I Worry About Fever?

Posted on January 23, 2016July 8, 2020

Posted by Dr. Monica Wonnacott | January 23, 2016

There isn’t a day in clinic or a night on call that I don’t field questions from concerned parents about fever. What’s a fever? When I do I worry? Should I come in? What should I do? And the list goes on and on. Here are a few guidelines.

In pediatrics, fever is defined as a temperature of 100.4°F or 38.0°C. This is best measured rectally, meaning in a child’s bottom (for further instruction, see article Taking A Temperature). Fever on its own is not inherently dangerous. In fact, it is the body’s natural defense against infection. The reason we treat a fever is to make a child more comfortable.

The degree of the fever does not correlate to the seriousness of the infection. As a pediatrician, I do not get more worried over a 104°F fever than I do over a 101°F fever. For example, Roseola, a very benign viral infection, is well known to have high spiking fevers prior to breaking out in an impressive red rash. On the other hand, a case of life threatening meningitis may only present with a low grade fever of 100.8°F. The important questions to ask are how does your child look and act? Is he running around the room or lying lethargic on the couch? Is he still drinking enough to prevent dehydration?

Your child must be seen urgently (and in an emergency room if it is after hours) if signs and symptoms include severe headache, stiff neck, severe abdominal pain, difficulty breathing, rapid breathing, frequent vomiting, or extreme sleepiness/lethargy/irritability (by the way, this list is not exhaustive). The other caveat is if your child is 2 months or younger, then he or she must be seen urgently because fever can be the only sign of a serious infection in an infant this young. Your child should be seen during regular clinic hours if the fever has lasted longer than 3 days, there is associated ear pain, sore throat, persistent rash, or cough.

As for what to do once your child has a fever, these are all comfort measures. There are medications to try, such as acetaminophen and ibuprofen (see medication section for dosing). Please note that you should not use acetaminophen in infants less than 2 months of age (as previously mentioned, infants this young must be seen) and ibuprofen in infants less than 6 months of age (not FDA approved). Decrease the amount of clothing your child is wearing (a onesie or tee is about right). You can also try a tepid bath. Avoid a cold bath as this will cause chilling. Increase the amounts of fluids your child is drinking. He or she will be utilizing extra fluid through sweating. A cool wash cloth on your child’s head and armpits can also help.

As always, if you have questions, concerns, or your parent instinct is telling you there is something seriously wrong, call your pediatrician’s office.