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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. 

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

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

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.

 

Daily Dose

A Little Review About Fever

My phone rang several times yesterday with concerned parents whose children had fever.We had a guest on our show yesterday who is a pediatrician, who also started a pediatric after hours clinic. He discussed when to call the doctor, and it must have been foreshadowing for the day. My phone rang several times yesterday with concerned parents whose children had fever. Now that the swine flu issues seem to be behind us for now, they were not concerned about flu, but they were concerned about fever. The funny thing was the calls were all from fathers who were home with the children while their wives (and mothers) were out enjoying Mother's Day. Made me giggle as I wondered if their wives would have handled the fevers, who knows?

At any rate a little review about fever seemed to be in order for the spring viral season. In spring, we still see kids with fever, although typically not as many children get sick, and they often do not have other symptoms with their virus. These spring and summer viruses are usually "quieter" than the winter variety, which was accompanied by hacking coughs lots of congestion. Fever may be the only symptom, and children may still run high fever. Fever in an infant under two to three months old is a separate issue (we'll cover that tomorrow), but for a young child it is not the height of the temperature that is important (that is what prompted the concerned Dad phone calls), but rather it is how your child is acting and responding to you. A five-year-old with 104 degree temperature will be pathetic, whiny and uncomfortable, but they should be responsive, and taking fluids and not so lethargic you can't awaken them and you should be able to console them and "your-baby" them with a little TLC until you get the temperature down. Best always to start treating the fever with an acetaminophen (Tylenol) product and have a dosage chart based on weight available to ensure that you are giving your child the correct dosage. Make sure give appropriate dosage for the product you are using (drops, syrup or caplets). If the fever persists and does not come down with that, you can alternate giving an ibuprophen (Motrin, Advil) product. Again, consult the dosage chart. The Tylenol can be given no more often than every 4 hours, and the Motrin/Advil is given every 6 hours. It helps to write down what you are giving when, as it is often the middle of the night and a tired parent may forget which medicine they gave. If there are no other symptoms other than fever, I would recommend watching your child for 24 - 48 hours to see if the fever resolves. A spring virus typically does not last as the nasty winter ones. Fever is only a symptom, and not to be feared. Thanks to all of the Dads for a great Mother's Day! That's your daily dose, we'll chat again tomorrow.

Your Child

Flavored Spray May Help Pills Go Down A Little Easier!

1:45

When your child is sick, chances are you have a difficult time getting him or her to swallow their prescription pills. It’s a problem parents and caregivers have in common- getting a child’s medication into their body. Liquids typically come in several flavors, which can be helpful, but pills are another matter.

Some pills are tiny and smooth – making the job easier. But others can be large powdery and oddly shaped. To make things worse, they may need to be taken throughout the day. So, what’s a parent to do?

The results of a small study may be just what the doctor ordered. Researchers have found that a flavored spray, called Pill Glide, may make pill taking a lot more flavorful -- and maybe even enjoyable.

"There was a significant decrease in the difficulty of taking medicine with these sprays," said Dr. Catherine Tuleu, a pharmaceuticals researcher at University College London, who conducted the research with colleagues at Great Ormond Street Hospital in the UK. "The kids liked to be in charge and to change the flavor."

What is Pill Glide? It’s a spray that is squirted into the mouth to lubricate and add flavor to tablets and capsules to make them easier to swallow. It's available in five flavors: strawberry, peach, grape, bubble gum and orange, with strawberry coming through as the favorite in the trial. Its ingredients include artificial flavors and sweeteners. This spray was used in the trial study with results published in the journal Pediatrics.

Tuleu and her team tried it among 25 children ages 6 to 17 that were receiving long-term therapies for HIV or organ transplants and who were transitioning from liquid medication to solids or were known to struggle with swallowing pills.

Keeping diaries, the study participants used a six-point scale to note the levels of difficulty they experienced when taking their regular tablets for two weeks and then using the Pill Glide sprays for one week. The final analysis was conducted on 10 children who had kept complete diary entries.

The flavored sprays were found to decrease the level of difficulty by a score of 0.93, almost one full level on the scale used by the team.

"The swallowing of medicine in the form of pills often poses a real challenge for a good many children, making this study of definite interest," said Dr. Laura Jana, a pediatrician and director of innovation at the University of Nebraska Medical Center College of Public Health, who was not involved in the research. "Something as seemingly simple as improving the taste and ease of swallowing a pill can have a significant impact on the proper and effective use of medicines."

The trial was very small and limited especially when you look at the number of participants, their health issues and the age group. But it may still be a process worth considering.

Tuleu acknowledges these limitations, and in addition to trying Pill Glide among larger groups, she wants to test its benefits in children who are less familiar with taking pills and who start out on solid pills, rather than transitioning from liquids.

"It would be interesting to try it with more naïve patients," she said. "If swallowing is not the challenge anymore, giving medication could be a lot easier."

Will this product make it easier for all kids to take a pill? Probably not. But this new approach may help some kids get past their difficulty with swallowing larger, more uncomfortable pills. It’s worth a try!

Story source: Meera Senthilingam, http://www.cnn.com/2016/11/01/health/kids-swallowing-pills-spray/

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!

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!

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