Twitter Facebook RSS Feed Print
Daily Dose

Medicine Dosing Errors

1:30 to read

How do you give your baby/toddler/child their medications? In a recent article in Pediatrics it was found that up to 80 percent of parents have made a dosing error when administering liquid medicine to their children.  The study looked at children eight years old or younger. 

 

In the study both English and Spanish speaking parents were asked to measure different amounts of liquid medicines using different “tools”, including a dosing cup, and different sized syringes. They also were given different instructions with either text only or text with pictures. The different dosing tools were labeled with either milliliters/teaspoon or milliliters only.  Lots of variables! 

 

Not surprising to me, the parents who used the texts/picture combination instructions and who also used the milliliter only labeled dosing tools had the lowest incidence of dosing errors.  When parents had to use any math skills to calculate the correct dosage there were more dosing errors.  Most dosing errors were also overdosing rather than under-dosing the liquid medications.

 

This was an important article not only for parents to realize that it is not uncommon to make an error when giving their child medication, but also for doctors who write the prescriptions.  Before electronic medical records and “e-prescribing” I would typically write medication instructions in milliliters and teaspoons…in other words “take 5ml/1 tsp by mouth once daily”.  With electronic record you can only make one dosing choice which I now do in milliliters. But, with that being said, I still get phone calls from parents asking “how many teaspoons is 7.5 ml?”.

 

Previous studies have also shown numerous dosing errors when parents use kitchen teaspoons and tablespoons to try and measure their child’s medication. 

 

Some over the counter drug makers have tried to cut down on dosing errors with their liquid medications by making all of their products, whether for infants or children, the same strength. The only difference is the dosing tool that accompanies the medicine (syringe vs cup).  Interestingly, these medications may have a price difference when they are actually the same thing.  

 

This study may help to find strategies for comprehensive labeling/dosing for pediatric liquid medications, which will ultimately reduce errors.  Stay tuned for more!

 

 

 

 

 

Daily Dose

Codeine & Children

1:30 to read

I order to keep us all safe, the FDA is constantly monitoring drugs and their side effects.  For many years codeine was prescribed for children for pain relief as well as to suppress coughs.  Over the last few years there has been more and more discussion about limiting the use of narcotics in children, but I continue to see some children who come from seeing other physicians and have received a prescription that contains codeine.

 

The FDA just issued new warnings against using prescription codeine in children and adolescents. The FDA reviewed adverse event reports from the past 50 years and found reports of severe breathing problems and 24 deaths linked to codeine in children and adolescents. Genetic variation in codeine metabolism may lead to excessive morphine levels in some children.

 

The FDA also performed a literature review which noted excessive sleepiness and breathing problems, including one death, in breast-fed infants whose mothers used codeine.

 

Due to these findings the FDA is now recommending that “codeine should not be used for pain or cough in children under 12 years of age”. They have also issued a warning that codeine should not be used in adolescents aged 12-18 “who are obese or have conditions associated with breathing problems, such as obstructive sleep apnea or severe lung disease”. In retrospect, codeine was prescribed to more than 800,000 children younger than11 years in 2011. Amazingly, codeine is currently available in over-the-counter cough medicines in 28 states.  

 

Lastly, the FDA “strengthened the warning” regarding codeine and breast feeding. They now recommend that breast- feeding women do not use codeine…which may change the post delivery pain protocol. Nonsteroidal anti-inflammatories (Ibuprofen) and acetaminophen (Tylenol) are preferred and are effective for mild to moderate postpartum pain. As a pediatrician it is important that I discuss this with new breast-feeding mothers as well. 

Daily Dose

Gassy Baby? No Problem!

1:30 to read

So you are home from the hospital with your newborn baby and suddenly you realize that the babies you see on TV never cry -  but your newborn is not reading the same script.  All babies have some fussy times, and this is especially true of a newborn in the first few months of life.  While a “typical” baby cries for a total of  3-4 hours a day, there are other babies that seem to be more difficult.  

 

Besides praying for an easy baby it seems to be luck of the draw and you don’t get to pick your baby’s temperament. In many of the cases of an “irritable” infant parents point to the fact that their baby acts uncomfortable and will frequently pass gas or draw up their legs or arch their backs as if something “hurts”.   

 

Your newborn’s tummy and intestines are just as “new” as they are and early on it may be more difficult for some babies to digest breast milk or formula.  In this case pediatricians often try to make changes in a breast feeding mother’s diet (taking out dairy), or changing a formula to a lactose free formula to see if that helps a baby to be more comfortable and less fussy. There are also “elemental formulas” that may be tried for extremely fussy babies. Discuss this with your own pediatrician.

 

Little tummies do make a lot of gas (you hear those toots all of the time) and I often recommend a trial of Little Remedies Gas Relief Drops® which contain simethicone (to help break up gas bubbles). These drops are especially made for infants and do not contain any alcohol, preservatives or dyes.  You can try using the gas drops after your baby has been fed as well as at bed time. 

 

Colic is defined as crying that occurs in an infant for at least 3 hours a day, for 3 days a week, for at least 3 weeks.  Colic typically “rears its angry head” after a baby is 3 -4 weeks of age.  For those irritable, colicky babies (I had one and you will know) I also like to try Little Remedies Gripe Water which is made with ginger and fennel, herbs that have been shown to help relax the  smooth muscle of the intestine.  Again, these drops do not contain any alcohol….which is very important. 

 

I also recommend swaddling and a pacifier for “non- nutritive” sucking to help calm a crying baby.  Many babies also like being on their tummies (tummy time is important developmentally as well) when they are fussy, and you can even massage their backs as well. Remember, even if tempted,  NEVER let your baby sleep on their tummy, even if you are in the room!! Backs to sleep only.

 

Babies also seem to like motion to calm them so holding your baby and rocking or swaying may help decrease crying. A walk in the stroller is sometimes another great way to get a fussy baby to settle down. Fresh air is good for both parent and child!

 

Daily Dose

Asthma

1:30 to read

May is Asthma Awareness Month and I am certainly seeing many patients whose asthma and wheezing is getting the best of them right now. With all of the major weather changes across the country, pollen counts through the roof, and upper respiratory viruses still circulating, there are quite a few triggers to set off wheezing.

 

Asthma is a chronic lung disease and affects more than 6 million children in the United States. Asthma causes wheezing and chest tightness in some, while it may only cause nighttime cough and cough with exercise in others. There is not one single presentation to asthma and the diagnosis is best made with a good history and physical exam.  Although asthma is a chronic disease you may only have attacks when something is bothering your lungs (triggers).

 

The biggest challenge I see as a pediatrician is teaching both parents and children to recognize their triggers and to know what their medications are. Every patient should have an asthma action plan, but in some cases, a child may have only wheezed once..and their parents received an inhaler or a nebulizer but really does not know what to do if their child wheezes again.

 

If your child has wheezed before, and you have a family history of wheezing, your child has a greater chance of wheezing again.  You should have a discussion with your pediatrician about how to recognize wheezing in your child. At the same time, if you have ever received a medication for wheezing, make sure you know the name or names of the medication. I see many parents who come in to the office and they may have been seen at an ER or urgent care when they were noted to be wheezing. They received an “inhaler”, but the parent has no clue as to the name of the inhaler (they may say, “it is blue”), and they don’t understand how the medications work.

 

The two points I try to make with every patient I see with wheezing:  

#1  Know the names of the medications that you have

#2  Know what the medications do

 

There are two issues with asthma, lung inflammation and broncho spasm (narrowing of the airways). So…there are two medications commonly used to treat these issues.  Inhaled steroids (there are tons of brands) are used as a preventative and decrease inflammation, while albuterol (again tons of brands) is a broncho-dilator and opens up the narrowed airways.  I see too many patients that bring in a bag full of medications, from numerous doctors and still don’t understand what their medications are used for, when to use them and that several of their inhalers, while having different names, are actually the same medicine.

 

Lastly, children with divorced parents need to have inhalers available at both homes. I think it is too complicated to try and have parents hand the inhaler or medication back and forth and think they will not forget or lose the medication.  Ask your doctor to have meds for both houses.

Seeing that is is Asthma Awareness month, get your medications out and make sure that they are not expired and if you don’t understand how or when to use them, make an appointment with your pediatrician and get an asthma action plan in place. Be prepared!  

Daily Dose

Cough and Cold Medicine

1:30 to read

My husband has a cold (I have been fortunate not to have one) and he decided he needed some over the counter (OTC) “cold medicine”, despite the fact that I told him they don’t work!  At any rate, I stayed in the car while he went in to buy “some things.”  It wasn’t too long before he was back empty handed…..and asking for some help in deciding what to buy!  It seems that he was overwhelmed and confused by all of the different choices….so I thought this was a good time to review all of the “ingredients” in OTC cough/cold medications. But remember, OTC cough and cold products are not recommended AT ALL for children under the age of 4. 

Most of the products that are advertised and sold for treating coughs and colds contain either a decongestant, antihistamine, expectorant, or anti-jussive (for cough).  But many of the OTC medicines contain some combination of these ingredients and there are many similar products with different brand names. Just gazing at the row of choices is enough to confuse anyone….even a doctor.

The most common decongestant used in OTC products is phenylephrine but its effectiveness in reducing nasal congestion from the common cold has been inconclusive. Another decongestant, pseudo ephedrine (Sudafed) is available, but has become restricted (it is a precursor in the manufacturing of methapmphetamine) and is now found behind the counter. Both of these drugs are often found in combination with other ingredients.

Antihistamines are also in many products. First generation antihistamines include diphenhydramine (Benadryl) and chlorpheniramine and are known for their tendency to be sedating. Second generation non sedating antihistamines such as loratadine (Claritin), fexofenadine (Allegra) and cetirizine (Zyrtec) are also found in some preparations ( typically with wording “daytime”) and are not sedating. In either case antihistamines do not seem to help the common cold.  Antihistamines do help allergies which are histamine mediated while a cold is not.

Anti-tussives or cough suppressants are commonly found in OTC cold medications, as cough is one of the most irritating aspects of a cold.  Dextromethorphan acts on the cough center in the brain to suppress coughing. It is the main ingredient in many OTC cough syrups but may also be found in many cough and cold combos in either liquid or pill form.

Guaifenesin is an expectorant and is found in many products, but again has not been found to have a measurable effect on mucous production from a cold.

Lastly, there are many products that are advertised to help with the “aches and pains” of a cold including acetaminophen and ibuprofen which may be found in combination with some of the above ingredients.

So…you have to read labels and make sure you “know” what you are getting. Too many people do not realize that they may be taking the same medicine but with different brand names, and this could cause an overdose.  

But the take home message is that “we” spend billions of dollars on these OTC products with continued studies showing minimal if any effect on the common cold when compared to placebo!  

I would spend my money on some Vicks, honey, and chicken soup and forgo the confusion on the cough and cold aisle.

Daily Dose

Over The Counter Products

1:30 to read

So, if you have read my daily doses you are aware that my “news watching” comes from morning TV while I am getting ready for work!!  I often find myself talking to the TV, especially when it is a medical segment which includes pediatrics.  While I am excited that morning TV is covering health topics, some of the information may be a bit “misguided” when a pediatrician is not the one discussing a pediatric topic.

I “heard” another example of this the other morning when the morning shows were discussing the “top pharmacist picks for over the counter products”.  It seems they surveyed pharmacists  and then compiled a list of “favorite” name brand OTC products in numerous categories - I don’t  think there was much science behind this. At any rate, we all have our “favorite” go to “OTC” products which for one reason or another we prefer. Does that actually mean they are better?

So, here are a few that I had issue with:

Allergy medications: They picked Claritin, but why not Zyrtec or Allegra?  They are all second generation anti-histamines and there is not a great deal of data that one is better than another. If push came to shove and I could only pick one antihistamine it would be Benadryl (diphenhydramine) - despite its sedating properties it is still a great drug.

Topical antibacterial medication: They picked neosporin and I would pick polysporin. Neosporin contains neomycin which may cause an allergic contact reaction. Other than neomycin they are quite similar and both contain topical lidocaine for pain relief.  Guess what -  they are made by the same company!!  

Pain relief:  They picked Advil, but why not Motrin or generic ibuprofen.  I am frugal and buy whatever is on sale, same drug.  I always remind parents of this as sometimes they get confused and say, “Advil didn’t work so I gave them Motrin” double dosing them with same drug. Be careful.

GI complaints:  Pharmacists picked Pepto-Bismol. I do not recommend Pepto-Bismol to  children as it contains  bismuth subsalicylate which is related to aspirin and has been associated with Reye’s Syndrome.  The bottle is labelled “do not use under the age of 12 years” due to this concern, but parents may not read the fine print. There is a Children’s Pepto that contains only calcium carbonate and may be given to children as young as 2 years….really important to read the labels as there are many choices with similar names.

Lip balm: Their choice was Carmex. I do not recommend lip balm/gloss that contains menthol or camphor as it may actually damage the lips and cause more drying…so you apply more then it is a vicious cycle.  You want to use lip balm with bees wax or petrolatum and no fragrance. I like Aquaphor, Burt’s Bees and Vaseline.  

Formula: Their choice was Enfamil.  I recommend any of the formula brands including Simliac and Gerber as well as some Organic Formulas if my patients desire.  I don’t know why they would pick only one brand…no data on that either.

Sunscreen:  Their choice Neutrogena, which I also love. They make good products that are hypoallergenic and PABA free, and they have many different vehicles (spray, lotion, stick) to choose from. I am also a fan of Cerave products and they now have sunscreen for babies.  But the most important fact is to use a sunscreen of any brand with an SPF of at least 30 and one that contains zinc or titanium dioxide and no PABA or oxybenzone. 

Those are just a few of my comments and favorites.

 

Your Teen

Acetaminophen, No Threat To Child's Liver

2.00 to read

With more than eight million American kids taking the drug every week, acetaminophen is the nation's most popular drug in children. It's toxic to the liver in high doses, and can be fatal if taken in excess. Very rarely, adults may also get liver damage at normal doses, so doctors had worried if the same was true for kids. Concerns about liver injuries in children who take the common painkiller acetaminophen, sold as Tylenol in the U.S. are unfounded, researchers said on Monday. "None of the 32,000 children in this study were reported to have symptoms of obvious liver disease," said Dr. Eric Lavonas of the Rocky Mountain Poison and Drug Center in Denver. "The only hint of harm we found was some lab abnormalities." With more than eight million American kids taking the drug every week, acetaminophen is the nation's most popular drug in children. It's toxic to the liver in high doses, and can be fatal if taken in excess. Very rarely, adults may also get liver damage at normal doses, so doctors had worried if the same was true for kids. "This drug is used so commonly that even a very rare safety concern is a big concern," said Lavonas, whose findings appear in the journal Pediatrics. Some researchers suspect there is a link between long-term use of acetaminophen and the global rise in asthma and allergies, but the evidence is far from clear at this point. For the new report, researchers pooled earlier studies that followed kids who had been given acetaminophen for at least 24 hours. There were no reports of liver injuries leading to symptoms such as stomachache, nausea or vomiting, in the 62 reports they found. Ten kids, or about three in 10,000, had high levels of liver enzymes in their blood, which usually means their livers have been damaged. In most cases, however, those elevations were unrelated to acetaminophen. And even if they were caused by the drug, they don't indicate lasting damage, according to Lavonas. "Acetaminophen is extremely safe for children when given correctly," he said. "Parents should not be afraid to give acetaminophen to their children when they need it, but they should be very careful about giving the right dose." "If you suspect that you have given a child an overdose, call your state's poison center," he added. The Rocky Mountain Poison and Drug Center receives funding from McNeil Consumer Healthcare, the Johnson & Johnson subsidiary that sells Tylenol, but the researchers said the company did not support this study.

Daily Dose

Treating Scabies

There has been an outbreak of scabies recently. Here's how to treat it.I received an email via our iPhone App from a mother whose 6 year old son had scabies and had been treated two times with permethrin cream, but had just had another re-occurrence.  She wondered if there were any other options for treatment.

Scabies is a mite that causes an eczematous skin rash with associated horrible itching. Infestation with the scabies mite is the result of skin to skin contact.  The mite burrows beneath the skin and the feces of the mite causes an allergic hypersensitivity reaction with resulting skin inflammation and itching. It can be fairly miserable when it goes on for awhile. (Once again my own son had it 20 years ago and that was actually one of the first times I had seen the rash of scabies and it took 3 different doctors including an allergist to finally diagnose it! ). It is sometimes easily diagnosed as a child will have a classic rash on their, trunk, arms and legs, and may even has the classic burrow tract of the mite between their toes and fingers. At other times scabies can be a great masquerader and the diagnosis may be made by scraping the skin and looking at it under the microscope where the actual mite or mite parts may be seen. If in doubt it is always a good idea to do a scraping. The time from infestation with the mite to actually symptoms may be as long as 6 weeks. During this time the “index” case in a family harbors the mites and are infectious, but they may not yet be symptomatic with the typical rash of scabies. When you diagnose a child with scabies the most important thing to do is to not only treat the child but treat the entire family unit.  Because the mite has such a long infectious incubation period it is important to treat all family members at the same time.  The standard treatment is with 5% permethrin cream, which is typically applied at night to all body surfaces from neck to toes. (do not bath before putting on the cream as this will help reduce the systemic absorption of the medicine). Make sure to get the cream between the web spaces of the fingers and toes.  The cream is left on over night (remember entire family) and then washed off in the am.  The next day I would wash all of the clothes and sheets in hot water.  If there are clothing that will not tolerate this put them in a platic bag for 72 hours (which is the life span of the mite off of the body). Even after a patient is successfully treated the itching may continue for several more days and may be treated with topical steroid cream (Cortaid over the counter or a prescription steroid cream).  What you will notice is that while the intense itching is diminishing, there are no NEW areas of rash. Most treatment failures seem to be due to not applying the cream with attention to complete coverage,  or to not treating the entire family at the same time. Another medication Lindane (Kwell) has been used to treat scabie,  but has been associated with the potential for neurotoxicity and is rarely prescribed, especially for younger children. There is also an antiparasitic medication, Ivermectin that is currently being studied for the treatment of scabies. That's your daily dose for today.  We'll chat again tomorrow. Send your question to Dr. Sue!

Daily Dose

Cold Season is Here

School starts and colds start almost simultaneously no matter how old your child is.School starts and colds start almost simultaneously. It even amazes me to see kids with their first cold of the season within 15 minutes of starting school, whether it is Mother's Day Out or high school, it affects every age.

The worst part of a having a cold is knowing that it is going to last seven to 10 days, no matter what you do. The old adage of rest, fluids and nasal irrigation is still the mainstay of treatment. Remember that over the counter cough and cold medicines are not recommended for use in children under the age of 2 and really are not very effective in the overall scheme of things. There has been some renewed interest in zinc and reduction of symptoms and decreased duration of colds so stay tuned for more info on that. In the meantime, keep up hand washing and good cough hygiene to try and prevent getting one of the first colds of the season. That's your daily dose, we'll chat tomorrow!

Pages

Please fill in your e-mail address to be included in our newsletter.
You may opt out at any time.

 

DR SUE'S DAILY DOSE

Are vaccines safe for pregnant moms?

Please fill in your e-mail address to be included in our newsletter.
You may opt out at any time.

 

Please fill in your e-mail address to be included in our newsletter.
You may opt out at any time.