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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

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!  

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Daily Dose

Giving Your Child Medicine

1:15 to read

Since I recently wrote an article about teaching young children to swallow pills, here is another reason to teach this to children sooner than later. The American Academy of Pediatrics has a new policy statement encouraging parents, physicians and pharmacists to use only metric measurements on prescriptions,medication labels and dosing cups to ensure that kids receive the correct dose of medication.

In other words, no measuring medications with teaspoons or tablespoons and especially not the ones in the cereal drawer.  Because spoons come in many sizes, they are not precise enough to measure a child’s medication.  For infants, toddlers and young children, a small error in dosing, especially if repeated for many doses, may be toxic.  

These recommendations also mean that doctors, like myself, need to prescribe medications in metric units like milliliters rather than teaspoons. We also need to instruct parents to use metric dosing devices, and not any measuring devices that have confusing markings with both teaspoons, tablespoons and milliliters. The medication should also come with an appropriate sized dosing device to avoid the possibility of two and three fold dosing errors.

The recommendations also call for manufacturers of over the counter medications to eliminate labeling, instructions and dosing devices that contain units other than metric units...no more 1 teaspoon, but rather 5 milliliters.

I am going to make a conscious effort to make sure that I am now writing my prescriptions with the correct units and help make dosing errors less of a problem and all medications safer for my “little” patients.

No more kitchen spoons!!!

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

Airborne & Your Kids

1.45 to read

It’s cold & flu season and I have already been receiving emails from parents asking what works/doesn’t work.  I reviewed a recent note from a well-meaning dad asking if he could give his 3 year old son Airborne to help “offset colds”. 

I myself have just recovered from my first cold of the “season” and have looked high and low for ANYTHING that might prevent or treat the common cold. As I tell my own patients on a daily basis, if I had the “magic pill” I would certainly not only manufacture it to distribute to everyone, but I would also be getting ready to accept Nobel Prize in medicine for solving the mystery of preventing the common cold!!  Airborne is NOT the magic potion and I see no reason to use it period.

I recently did an extensive review of complementary and alternative medicine for the common cold (selfishly trying to cure myself) and once again came up empty handed for any proven remedies. There are still a lot of ongoing studies (someone will win the Nobel Prize one day), but nothing so far has really proven to be the panacea.

Many people “swear” by Airborne.  I am just not sure what they are thinking it does. If you read their website it states, “there are scientific studies that the ingredients in Airborne have been shown to support the immune system”. I can’t find those studies anywhere. 

In 2008 a class action suit against Airborne resulted in a $23 million dollar fine for “misleading consumers and making false claims”, when Airborne claimed to “ward off colds”. They have now changed their advertising to the wording, “boosting the immune system” which also seems like deceptive advertising to me. Regardless, they continue to make millions (despite that huge fine).  My mother even called to say she thought she might take some before flying to visit at Thanksgiving asking, “did I think that would help her from getting sick?” OMG!

The ingredients in Airborne include Zinc, ginger, Echinacea, vitamins, minerals, and herbs.  This is what I commonly call “hocus pocus”.  Many of the ingredients in Airborne have been studied for use during a cold, without a lot of success.  Zinc is still being studied with varying outcomes, but there are still no definitive guidelines on using Zinc for a cold. Stay tuned for more as more studies are completed.

In the meantime, the answer to the email is NO; I would not give a 3 year old Airborne. What I would do is make sure that your child is getting nutritious meals, adequate sleep and that they learn to wash their hands and cover their mouths when they cough (hand hygiene). I would put the money you would spend on Airborne in their piggy bank for future college expenses.   I would also make sure to get your child their Flu vaccine. We do have data that vaccines work!

That’s’ your daily dose for today.  We’ll chat again tomorrow.

Daily Dose

Treating the Common Cold

Having a cold myself is a sobering reminder that the average cold lasts seven - 10 days and the cough may last up to two to three weeks.I have had this nasty fall cold for the last week, and I gotta say, " I am sick of it!" I am not really surprised that I finally succumbed to my first cold of the season. While I am seeing 20 -30 kids a day with colds, it's not hard to figure out why my own body just waved the white flag and joined the ranks of cold sufferers. But having a cold myself is a sobering reminder that the average cold lasts seven - 10 days and the cough may last up to two to three weeks. That being said, I still have a week to go and I just want to hibernate until it is gone. Unfortunately, that is not reality for most of us.

My sweet patients are always concerned about my health, and then wonder, "What do you do for your cold, Dr. Sue?" That just makes me giggle, as I know they have heard me say a million times, "there is really not much to do for a cold except rest, fluids, throat lozenges, and tincture of time." I wish I had been hiding the secret potion that only doctors can take to make their colds go away in a day. So for the last week I have sucked on any lozenge that people hand me (I personally think lemon helps the most), have had enough hot tea to float a boat, and really tried to get to bed at a reasonable hour, right after that warm bath with eucalyptus oil. Guess what? My cold is still here. If anyone else has the recipe for that "secret cold potion" I am open to suggestions, but figure at least I am half way through it and hope it will stay away until the spring? In the meantime, I am still washing my hands. That's your daily dose, we'll chat again tomorrow.

Parenting

Most Parents Give Their Child the Wrong Medicine Dose

1:30

According to a new study, most parents accidently give their child the wrong dose of liquid medication – sometimes, as much as twice the amount they should have.

The study, conducted at pediatric clinics in New York, Atlanta and Stanford, Calif., also found that most dosing errors occurred when parents used a measuring cup. There were fewer errors when parents measured the dose with an oral syringe.

Pediatric medicines generally rely on liquid formulations, and parents have to decipher a sometimes, bewildering assortment of instructions in different units with varying abbreviations — milliliters, mL, teaspoon, tsp., tablespoon. Some medicines come with a measuring tool, but often the units on the label are different from those on the tool. It can be very confusing, especially for a parent trying to treat a sick child.

The Food and Drug Administration (FDA) recommended in 2013 that over-the-counter products use a standard dosing tool with consistent labeling. The changes however, were not required.

The American Academy of Pediatrics (AAP) also recommended standard dosing tools for OTC products last year.

For this study, Dr. H. Shonna Yin and her colleagues ran an experiment to see what combination of tools and instructions would produce the fewest errors in dispensing liquid medication. They randomly assigned 2,110 parents to one of five pairings of the many possible combinations of tools and label instructions.

In nine trials, 84.4 percent of the parents made at least one dosing error, and more than 68 percent of the errors were overdoses. About 21 percent of parents at least once measured out more than twice the proper dose. Smaller doses produced more errors. When the dose was 2.5 milliliters, there were more than four times as many errors as when it was 5 milliliters.

The difference in errors was the tool used to give the medication. When a cup was used, there were four times as many errors as when an oral syringe was used.

“If the parents don’t have an oral syringe, the provider should give one to the parents to take home,” said Dr. Yin, who is an associate professor of pediatrics at New York University. “Especially for smaller doses, using the syringe made a big difference in accuracy.”

If you don’t have an oral syringe at your home, you can check with your pediatrician or pharmacist and they should be able to help you choose the right one for your child.

The study was published online in the journal, Pediatrics.

Story source: Nicholas Bakalar, http://www.nytimes.com/2016/09/13/well/family/most-parents-give-the-wrong-dose-of-liquid-medication.html?WT.mc_id=SmartBriefs-Newsletter&WT.mc_ev=click&ad-keywords=smartbriefsnl&_r=0

Daily Dose

Vapor Rubs: Do They Really Work?

1:15 to read

There was a great article recently published in the online journal of Pediatrics.  I had to read it as it was titled, “Vapor Rub, Petrolatum, or No Treatment for Nocturnal Cough”.  Having been a fan of both Vick’s Vapor Rub and Mentholatum since I was a child, I knew it was a MUST read article.

You can ask all of my family members, once we hit cough and cold season, the “vapor rub” jar goes next to my bed to help me during my frequent colds (see previous posts!).  I have such fond memories of being with my grandmother, Gaga, who at the first sign of a cold,  would rub Vicks all over my chest, which was then occluded by a warm damp CLEAN dishtowel, then followed by my flannel nightgown.  She would lovingly tuck me into bed, and shut the door and the whole room smelled like camphor, and menthol.   To me it was wonderful, my brother hated it!! As I grew older, my mother would hear me sniffle or blow my nose and down the hall she would come with the trusty Vick’s jar for self-application. Once I became a mother, in the family tradition, I too would rub a little Vick’s on my children’s chest, with no basis on medical fact, only what Gaga did. Funny thing, we all seemed to get better.

Two of my own children grew to despise the tradition, while one still asks for Vick’s or Mentholatum when he gets a cold.  There are old jars all over the house. I even bought several of the “plug ins” to use during cold season, which are the new fangled way to get that wonderful VR aroma into the room. They make a great stocking stuffer! So, with that history, what could be better than a study out of Penn State University that looked at the use of vapor rub (VR) to improve cold symptoms and nighttime cough.  With the recent FDA guidelines which limit the use of OTC cough and cold products in young children, many parents are at a loss as to what to do to help their child’s cold symptoms. The investigators looked at 138 children between the ages of 2 – 11 years. They were randomized to receive vapor rub (VR), petrolatum alone or no therapy.  Parents were then asked to grade their child’s symptoms and sleep on Day 1 when none of the children received therapy, and then again on Day 2 when they were randomized to therapy. 

The VR group scored best in improving cough, congestion and overall sleep for the children (and therefore their parents). This is the first evidence based therapeutic trial that I am aware of, for a remedy that is over a century old. As noted in the article, there were some irritant effects seen in the VR group with complaints of a stinging sensation to eyes, nose and or skin (I can hear my own children saying “it’s stingy”). Most of these complaints were transient in nature.  Despite older concerns about camphor when it was used as an oil that could cause possible toxicity if swallowed, skin exposure alone really has little systemic effect.   The FDA has approved camphor as an effective anti-cough preparation (anti-tusssive), but has limited concentrations to 11%. The concentration in VR is 4.8%. So, if parent’s are trying to improve nighttime cough and sleep disturbance in their children over the age of 2, there is a study to show it is time to go back to vapor rub preparations.  The mechanism for improved sleep is not really known, but whether it improves cold symptoms directly or through the aromatic effects, a better night’s sleep is good for everyone!!!  Could there be coupons to follow?

That's your daily dose for today.  We'll chat again tomorrow. Send your question or comment to Dr. Sue!

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