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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

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

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

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

Fever In Infants

An infant who runs a fever is much more perplexing to a pediatrician.Well, the office was full of kids of all ages with fevers today, so the topic was indeed timely. They all just had fever and a presumed viral infection and no one was very sick, but they sure had hot little bodies. Pushing lots of Gatorade, popsicles, and ice cream today as a remedy for fever (along with their Tylenol and Advil or Motrin). Made lots of points with my little patients today with that prescription.

But, fever in an infant is another story. One of the reasons that we try to limit an infant's exposure to large groups of people for the first two months is related to risk of infection. An infant who runs a fever is much more perplexing to a pediatrician. A very sick infant may only have a temperature of 100.6 degrees and not show other signs of an infection like an older child would. Any infant under two months of age with a fever should be seen by their pediatrician for evaluation and possible hospitalization for their fever. Obviously a completely different story than an older child who is treated with fever medication and watched for several days before being seen. Once a child reaches the age of eight to 12 weeks it is easier to "read" them a little better, as they have begun to smile and are more responsive, which enables us to judge their behavior a little better. The older a child gets, the easier it is to gauge their responsiveness while sick, which is one of the most important aspects of evaluating a sick child. Every time a pediatrician walks into a room with a sick patient the doctor is watching that child, whether they are sitting on their Mom or Dad's lap, or playing on the exam table, or even if they are playing with a sibling, etc. A lot of the exam is done before even touching the child. Sick children do not even turn to look as you enter the room, and there are not tears of apprehension. A child who "fights' during the exam is usually reassuring to the pediatrician. Every new parent should have a thermometer on hand as this is the one item that you will use throughout parenting. They don't need to be fancy or expensive, they are all useful. I still use digital thermometers at my house, and little ones love learning how to read the numbers! That's your daily dose, we'll chat again tomorrow.

Daily Dose

Colds & Suctioning Your Child's Nose

1:30 to read

I am beginning to sound like a broken record, but we are in the throes of cold and flu season and unfortunately there are a few more months of this.  As every parent knows, colds (aka upper respiratory infections) are “age neutral”. 

In other words, there is not an age group that is immune to getting a cold and for every age child (and adult for that matter), the symptoms are the same. Congested nostrils, scratchy sore throat, cough, and just plain old feeling “yucky”. When an infant gets a stuffy nose, whether it is from “normal” newborn congestion, or from a cold, they often have a difficult time eating as an infant is a nose breather.  When they are nursing and their nose is “stopped  up”, they cannot breath or even eat, so it is sometimes necessary to clear their nasal passage to allow them to “suck” on the bottle or breast. 

Of course it is self evident that an infant cannot blow their nose, or rub or pick their nose so they must either be fortunate enough to sneeze those” boogers” out or have another means to clear the nose.  This is typically accomplished by using that wonderful “bulb syringe”. In our area they are called “blue bulb syringes” and every baby leaves the hospital with one tucked into their discharge pack.  As a new parent the blue bulb syringe looked daunting as the tip of the syringe appeared to be bigger than the baby’s nose.  But, if you have ever watched a seasoned nurse suck out a newborn’s nose, they can somehow manage to get the entire tip inside a baby’s nose. For the rest of us the tip just seemed to get inside the nostril and despite my best efforts at suctioning nothing came out. Once a nurse showed me the right “technique” I got to be a pretty good “suctioner”.  With the addition of a little nasal saline, which you can buy in pre made spray bottles, or which may be made at home with table salt and warm water, the suctioning gets a little easier as the nose drops helped to suction the mucous.

Now, I have become a firm believer that there is a place for suctioning a baby’s nose, but once a child is over about 6 months of age they KNOW  what you are getting ready to do. I am convinced that a 6 month baby with a cold sees the “blue bulb syringe” approaching their face and their eyes become dilated in fear of being suctioned!!  Then they begin to wail, and I know that when I cry I just make more mucous and the more I cry the more I make. So a baby with an already stuffy nose gets even more congested and “snotty” and the bulb syringe is only on an approach to their nose. It also takes at least two people to suction out a 6 – 12 month old baby’s nose as they can now purposely move away , and hit out to you to keep you away from their face and nose. It is like they are saying, “ I am not going to give in to the bulb syringe” without a fight! I swore I would not have a child with a “green runny nose” that was not suctioned.

As most parents know, don’t swear about anything, or you will be forever breaking unreasonable promises to yourself!  I think bulb suctioning is best for young infant’s and once they start to cry and put up a fight I would use other methods to help clear those congested noses.  Go back to the age old sitting in a bathroom which has been steamed up with hot water from a the shower. Or try a cool mist humidifier with some vapor rub in the mist (aroma therapy).  Those noses will ultimately run and the Kleenex will come out for perpetual wiping. Unfortunately, it takes most children many years before they learn to blow their nose, but what an accomplishment that is!!!  An important milestone for sure.

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

Daily Dose

Homeopathic Medicine

1:30 to read

I am sitting here writing this while “sucking” on a honey-lemon throat lozenge and drinking hot tea…as it is certainly cough and cold season and unfortunately I woke up with a scratchy throat. I am trying to “pray” it away and drink enough tea to drown it out. While I am not sure it will work, drinking hot tea all day will not hurt you!

 

At the same time (multi-tasking) I am also reading an email from a mother with a 4 month old baby, and they are out of town. Her baby now has a fever and runny nose and she sent me a picture of a homeopathic product for “mucus and cold relief” and wonders if it is safe to give to her infant.  The short answer is NO…even though the product says BABY on the label and has a picture of an infant.

 

Although homeopathic medicines were first used in the 18th century and are “probably safe” it is still unclear if they really work. Unfortunately,  there have been adverse events and deaths associated with some products ( see articles on teething tablets). The principle of homeopathy is that “ailments can be cured by taking small amounts of products that, in large amounts, would cause the very symptom you are treating. In other words, “like cures like” as these products contain “natural ingredients” that cause the symptoms that you are trying to treat, but that have been so diluted as to hopefully stimulate your body’s immune system to fight that very symptom. In this case, congestion and runny nose due to a cold.

 

So…I looked at all of the ingredients which included Byronia, Euphrasia, Hepar and Natrum…to name a few. Byronia is used as a laxative for constipation, Euphrasia is supposed to help with inflammation, Hepar is for people who tend to get “cold and therefore cranky and irritable” and Natrum is used for inflammation due to “too much lactic acid”.  This is the short version. The bottle also says contains less than 0.1% alcohol, but it has alcohol! 

 

While the FDA does monitor how homeopathic medications are made, they do not require these companies to show proof that these medications do what they say they do, as they are “natural”.   With that being said, natural does not always mean effective or safe.  Just as over the counter cold and cough medications are not recommended for children under the age of 2, I too would not recommend homeopathic products be given to an infant.

 

Best treatment for a cold and cough in young children?  Use a saline nasal spray followed by nasal suctioning to relieve the nasal congestion and mucus. I would also use a cool mist humidifier in the baby’s room to keep moisture in the air and help thin the mucus ( especially once the heat is on in the house). Make sure the baby is still taking fluids (breast or bottle) but you may also add some electrolyte solution to give your baby extra fluids if you feel as if they are not eating as well.  Lastly, always watch for any respiratory distress or prolonged fever and check in with your pediatrician!

Daily Dose

How to Swallow a Pill

1:15 to read

I have always been a proponent of teaching children to swallow a pill.  In fact, I think I taught my boys to swallow a pill before they were 5 years old, mainly because I was tired of trying to find the measuring cup or syringe for the liquid medicine, which often didn’t go down “like spoon full of sugar”, even though we would sing the song during dosing. 

By the time one child had learned to swallow a pill the other two boys, as competitive as they were, decided that they too could do it, even the 2 year old.  So, based on that experience I have been encouraging young patients to swallow pills, and even teaching them in the office with my stash of mini M&M’s and Tic Tacs!  I also know that if you wait too long it becomes a huge ISSUE.

Well, who knew that someone would actually study “pediatric pill swallowing”?  In an article just published in the May issue of Pediatrics the authors looked at different pill swallowing interventions.  They found that up to 50 % of children were unable to swallow a pill.   Problems swallowing pills included a variety of reasons including fear, anxiety and intolerance to unpleasant flavors. 

The authors reviewed 5 articles published since 1987 which found that behavioral therapy, flavored throat sprays, specialized pill cups and verbal instruction with correct head and tongue positioning all helped children to swallow pills. They also found that pill swallowing training as “young as 2 years helped increase the likelihood of ease of pill swallowing”.

So, like many things....jump in with your young child and master the art of pill swallowing sooner than later. It will make everyone’s life easier.

Last caveat, I always tell my patients who are older “non-pill” swallowers, “you cannot possibly operate a motor vehicle if you can’t swallow a pill”! This is usually a huge motivator for the “late swallower” and they conquer the challenge. 

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