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Daily Dose

Penicillin Allergy

1:30 to read

Has your child ever been labelled “penicillin allergic”?  Interestingly, up to 10% of people (of all ages) report having a penicillin allergy, but only about 1% are truly allergic. I see this often in my own practice, especially when seeing a new patient and inquiring about drug allergies, and the parent replies, “ she is penicillin allergic, and developed a rash when she was younger”.  In many if not most of those cases the child is not allergic to penicillin.

 

Penicillins are a class of antibiotics known as beta-lactams and include not only penicillin but  amoxicillin, augmentin, oxacillin and nafcillin, just to name a few.  If you are incorrectly identified as penicillin allergic, when your doctor needs to prescribe an antibiotic they may resort to another class of antibiotic, which are not only more expensive but often may cause more side effects.  

 

Penicillins are the antibiotic of choice and the first line treatment for many pediatric bacterial illnesses including otitis ( ear infections ), strep throat, and sinus infections. They are not only effective, but they are typically inexpensive and have few side effects….which includes allergic reactions.

 

Penicillin allergy is an immune - mediated reaction which usually causes hives ( raised rash ), face or throat swelling, difficulty breathing and in some cases life threatening anaphylaxis.  Intolerance to penicillin is different than being allergic, and in this case symptoms are more likely nausea, diarrhea, headache or dizziness, which may make you uncomfortable but are not immune mediated. 

 

In pediatrics, many children present with a viral illness that includes several days of fever and upper respiratory symptoms, and are then also found to have an ear infection. They are given a prescription for amoxicillin and several days later develop a rash. Many viral infections in children also cause a rash, which is typically red, flat and covers the trunk, face and extremities and does not cause any other symptoms which are seen with a true penicillin allergy.  This rash is benign, but unfortunately many young children will be seen at an urgent care or even an ER due to the rash. The parents are told that their child is penicillin allergic and the antibiotic is changed…and the label “pen allergic” sticks….for many years or even life.  I even saw this rash occur in one of my own sons while on an antibiotic. He is NOT allergic!

 

The good news is that most children are truly not penicillin allergic, and if possible I try to see all of my patients who report a rash while they are on an antibiotic. At times this is not possible, and now with the advent of “smart phones” I have parents send me a picture of the child and the rash. This often helps in determining if the rash truly appears allergic and to identify if there are other symptoms.  Back to the “get a good history”. 

 

If I see an older patient who has had a rash on amoxil when they were little and had no other adverse effects (get a good history), I will sometimes try using a penicillin again, as most people also “outrgrow” their sensitivity after about 10 years. If it is my patient and I have seen the rash I tell the parents that this is not a “pen allergy” and I will use penicillins again.  Some  patients will report a “pen-allergy” but say I can take “augmentin” which is penicillin derivative, so that makes it easy to know they are not allergic.  If I am unsure if a child has had a true penicillin allergy I will refer them to a pediatric allergist for skin testing.  Skin testing is not painful and is an important method for documenting a true allergy. 

 

 

   

Daily Dose

Kids Who Snore

1.30 to read

Does your child snore?  If so, have you discussed their snoring with your pediatrician.  A recent study published in Pediatrics supported the routine screening and tracking of snoring among preschoolers.  Pediatricians should routinely be inquiring about your child’s sleep habits, as well as any snoring that occurs on a regular basis, during your child’s routine visits.  

Snoring may be a sign of obstructive sleep apnea and/or sleep disordered breathing (SDB), and habitual snoring has been associated with both learning and behavioral problems in older children. But this study was the first to look at preschool children between the ages of 2-3 years.

The study looked at 249 children from birth until 3 years of age, and parents were asked report how often their child snored on a weekly basis at both 2 and 3 years of age.  Persistent snorers were defined as those children who snored more than 2x/week at both ages 2 and 3.  Persistent loud snoring occurred in 9% of the children who were studied.

The study then looked at behavior and as had been expected persistent snorers had significantly worse overall behavioral scores.  This was noted as hyperactivity, depression and attentional difficulties.  Motor development did not seem to be impacted by snoring.

So, intermittent snoring is  common in the 2 to 3 year old set and does not seem to be associated with any long term behavioral issues. It is quite common for a young child to snore during an upper respiratory illness as well .  But persistent snoring needs to be evaluated and may need to be treated with the removal of a child’s adenoids and tonsils.

If you are worried about snoring, talk to your doctor. More studies are being done on this subject as well, so stay tuned.

Daily Dose

Fever

1:30 to read

It’s starting….fever, fever, fever season and lots of concerned parents, so figured it was a good time to talk about fevers….AGAIN.  

 

Remember that fever is simply a symptom that your body’s immune system is working, and in most cases, in children, it is fighting a viral infection.  We docs call a fever a temperature above 100.4 degrees…but I do realize that day care and schools will send your child home when they have a temp above 99.5 degrees ( in some cases even lower). Some parents “explain” to me that their child’s body temperature is always lower than 98.6 degrees so a 99.9 degree temperature is abnormal for them….I’m just saying. 

 

The first thing to try and remember is that the thermometer is simply showing you a number and that the number should not scare you…it is only a number and a higher number does NOT necessarily mean that your child is any sicker.  Some children do tend to have a higher temperature with an illness than another, and even in the same family.  Again, the number should not make you concerned that one of your children is sicker than another…it is still just a fever.

 

Parents always ask…”what degree of fever is dangerous, and when do I go to the hospital?”  The number that registers on the thermometer should not be the deciding factor as to how sick your child is. They will look and feel worse with a higher temperature ( as do you when you are sick), but the important thing is to always look at their color (never dusky or blue), how they are breathing (you do breath faster and more shallow with a higher body temperature, but do not appear to be in any distress), and if they are hydrated (you do need more fluids when you are running a fever).  If all of this seems to be okay, the best thing to do is treat the fever with either acetaminophen or ibuprofen.  Once their temperature comes down a bit, and that may not be 98.6, look at your child again…children with lower temperatures typically “perk up” for a bit and may play or eat and drink for awhile, until their fever returns and they look pathetic again.  I would always check with my doctor before heading to the ER just because of a fever.

 

Parents also worry about their child having a seizure due to a fever…and this is true some children may have a febrile seizure. But, they can have a seizure with a temperature of 100.8 or 104.2…it does not seem to be the higher the temperature causes a febrile seizure. Febrile seizures do seem to “run in families” and they are also most common during the toddler years. (see another post on this).

 

So… as we are getting into sick season make sure you have an acetaminophen and ibuprofen dosing chart handy and always dose your child’s medications based on their weight and not age. I would also make sure to have a “working” thermometer, and I prefer a rectal thermometer for children under 12 months of age. Rectal temps are really easy to take and in my experience far more accurate (when I am really concerned if a child has a fever) than a tympanic or temporal thermometer. 

 

Be ready and relax….it is just a fever and having an anxious parent is not going to make your child feel better any faster.

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Daily Dose

Monitor Your Busy Teen for Depression

1:30 to read

THis is hard fo rme to admit, but I am beginning to see a fair amount of adolescent kids (way too many!) who are feeling overwhelmed with school and all of the other things thing have going on in their lives.

For many of my patients the day begins before dawn as they head out the door (frequently without breakfast) to begin their very long day. Many have before school practice for drill team, band or even an off-season sport that involves an early workout. These teens then get finished with their early morning commitments just in time to shower and head to class. Still, no time to eat or even down a smoothie or granola bar, or so they say. Next comes a full day of classes, often with honors and AP classes (up to five in one semester) with a 30 minute break for lunch, if they choose to eat. For those that do eat, it is not a well-balanced lunch, but rather pizza, hamburgers, or a bagel and Gatorade. Remember this is the first food they have had since the previous night (when I am sure they went to bed far too late).

As the end of the school day approaches many of these teens will head to after-school jobs, or extracurricular activities such as yearbook staff, newspaper staff, debate team or a different athletic team than their morning workout. If they remember, they might eat a Power Bar, or grab a Red Bull or Starbucks to keep them going until they eventually head home. For many they will not get home from their school day until long after dark with a lot more still to do. Hopefully, these kids will manage to sit down for dinner (can we say well-balanced) with some family member (many may have already eaten earlier), but they jump right up after gobbling down their food, to head off to do homework.

For many high school students, especially those carrying a heavy pre-college load, there may be several hours of homework, which won’t be finished until 11 p.m. or later if they are lucky. Somewhere they will also fit in on-line computer time to catch up on FaceBook, or emails and texts, while doing a multitude of other things like watching their favorite TV show that has been recorded to fit their schedule. Many report that they have difficulty falling asleep. DUH – their brains are on overload and can’t stop, and then they only get about five to six hours of sleep a night. With all of that being said I can totally understand how stressed out our adolescents are. They want to succeed, they want to be involved, and they constantly worry about what lies ahead. There are actually seventh and eighth graders already talking about SAT prep, and college resumes as if they were already high school juniors. How is this happening? How can we stop this out of control pressure? I certainly don’t know how to solve all of the issues surrounding adolescent stress, but I do know that parents can play an active role in helping their teens manage their time.

While we don’t want to be overly involved or helicopter parents, parents do need to discuss the issues of stress and over commitment when they see their child struggling. Sometimes it is appropriate to step in and say, “I see you need some help with this” and work together on time management. The days will come all too soon when you are not there to help lead the way or ensure that your son or daughter eats breakfast and dinner, or gets enough sleep. For many teens just helping them see the “big picture” and re-adjusting their schedule a bit, will be all they need to feel a little less pressure. Sometimes, they just need to talk about it and will move on. But if your adolescent seems to be overwhelmed, and is getting more anxious or depressed, make sure to talk to their doctor about getting some professional help. There are many people ready to help our teens, we parents just have to recognize when it is needed.

That’s your daily dose, we’ll chat again tomorrow. What do you think?  I welcome your comments and thoughts below!

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

Food Allergies

1:30 to read

With the holidays approaching and lots of family gatherings revolving around food and eating together, it seems a good time to discuss the differences between food allergies and food intolerance, as they are not the same thing.

 

When one member of your family tells you that their child is “allergic to nuts” and another tells you that their child cannot “drink milk”, they may not be talking about the same phenomena at all. There is a big difference and it important to understand why.

 

Food allergies are immune mediated adverse reactions to foods.  While any food protein can trigger an allergic response, only a few foods account for most allergic reactions.  Eggs, milk, peanuts, soy, fish, shellfish, tree nuts and wheat are the most common causes of true immune mediated food allergies.

 

The most common symptoms of an acute allergic (anaphylactic) reaction to a food include such things as:  itching around the mouth and lips, swelling of the throat, difficulty breathing, cough, shortness of breath, wheezing, nausea, abdominal pain, vomiting, diarrhea, flushing, and or hives.  A person may present with only a few of these symptoms after being exposed to a food, or may have multiple symptoms that occur.  The most common symptom of an allergic reaction is with the acute onset of hives (urticaria) and itching, which may then be followed by other symptoms of respiratory or gastrointestinal tract.

 

An allergic reaction to food is a medical emergency and may cause serious of even life threatening reactions and requires immediate treatment. If this is a new onset food allergy and a person is thought to be symptomatic call 911 as a serious reaction can happen quite quickly.  If there is a known food allergy and someone is inadvertently exposed to the food, they should carry injectable epinephrine and use it immediately along with an antihistamine….then call their doctor or go to the emergency room for follow up. Remember,  anaphylaxis is life threatening! 

 

Food intolerance is a different story. It is NOT an immune mediated event and while you may feel miserable after ingesting certain food, such as milk, it is not life threatening. In most cases of food intolerance a person learns that they may ingest small amounts of the offending food without any problems (maybe a small scoop of ice cream), but cannot tolerate drinking an entire glass of milk without experiencing GI complaints, often with abdominal cramping and diarrhea. Lactose seems to be one of the most common offending agents, while others seem to be sensitive to gluten or even food additives like sulfites and dyes.  The best treatment for this is to stay away from foods that cause you to have symptoms, or to only ingest small amounts.

 

So, if you have a relative with true food allergies make sure to check with them before planning a meal and avoid cross contamination of foods during preparation. For those with intolerances….they may just choose to skip the offending food and double up on others!

 

Happy Holidays!!

Daily Dose

Red Cheeks In Winter

1:15 to read

Why do children get red cheeks in winter?

It is the time of year for cold temperatures, low humidity and dry skin. It is funny, every year as the temperatures drop, I we start seeing these cute little babies and toddlers who have those bright red cheeks. I always say that they “look like British babies”.

Dry skin is just one of the many issues we see with colder temperatures, and babies red cheeks are one of the most evident. During the winter months we all experience dry skin and using moisturizer becomes very important.

I have written previous blogs about eczema, and while chapped skin is not synonymous with eczema, there are some similarities. The most important thing to prevent dry skin while the weather is cold is to use a moisturizer, and applying moisturizer is best on damp skin. After bathing your baby or child, pat them dry until they are just “a tad bit moist” and then take a moisturizer and apply it to the almost dry skin. The thicker the moisturizer the better, so a cream is preferable to a lotion. It will take a little more time to rub the cream in when the skin is a bit moist, but it will help the moisturizer penetrate the skin. The same thing goes for the face.

I always found that the best time for me to moisturize those rosy cheeks was really after the child had gone to sleep. When my children were younger I found that if I put the cream on when they were awake, that they either rubbed their faces more, or if they were verbal, complained about lotion on their faces. So…I decided that it worked best to have their bedtime routine, with baths, books, and prayers, and then once they were asleep I would slip in and lather up their faces and also even used Chap Stick on their dry little lips. Now, there is no science in this routine, but it seemed to work, and they were much more tolerant of lubricants when asleep than awake.

We are definitely in the low humidity season and the heat is on in the house (I am typing this as I sit by the fire with a blanket over my feet), so you can expect several months of dry skin and chapped cheeks. If moisturizers like Vanicream, Cerave, Aquaphor and Eucerin go on sale, stock up!!  April is a long way away.

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Daily Dose

Antibiotics

1:30 to read

Fall is here and winter is just around the corner, which will usher in another “sick season”. I am already thinking about illness as I just finished reading a JAMA article about the overuse of antibiotics.  Did you know that the CDC estimates that “30% of antibiotic prescriptions in the U.S. are unnecessary”? 

The CDC reported that the majority of these misused antibiotics were prescribed for viral upper respiratory infections including the common cold, bronchitis and sinus and ear infections.  Which gets me back to “sick season” and the busy pediatric office.

Parents frequently bring their child in for one of the many viral upper respiratory infections that a child has, especially in the first 5 years of life, and “assume” that they will receive an antibiotic. In fact, I am still amazed that with all of the news about “superbugs” and emerging antibiotic resistance, some parents continue to “push” for a antibiotic because their child has had a fever, cough and runny nose for several days.  

The head of the CDC recently stated, “antibiotics are lifesaving drugs and if we continue down the road of inappropriate use, we will lose the most powerful tool we have to fight life threatening infections”.  In other words, we doctors need to be very judicious when deciding to prescribe an antibiotic and patients need to ask questions as to the necessity for taking an antibiotic.  It seems much too often I hear a parent say to me, “I am sick as well, so I went to the doctor who gave me an antibiotic for my cough and congestion, why aren’t you going to give an antibiotic to my child?”.  They often follow this statement with, “I felt so much better after being on an antibiotic for several days….”, but I actually think many of them felt better as they were getting better on their own and not due to the antibiotic.

In this JAMA article it was noted that “prescribing rates were highest in children age 2 years and younger. (who also get the most viral URI’s in a year) . There were also distinctions in prescribing practices by region of the country with the West having a lower rate of antibiotic prescribing than the South. 

So…looking forward to “sick season” I may be quoting this JAMA article when I once again explain to a parent, or a child….that their fever, cough and cold is due to a virus and that there is not the need for an antibiotic. In fact, a parent might want to boast, “my child has never been on an antibiotic”...which is a good thing. Save the prescription for a time when it is really warranted, and at the same time “pay it forward” by helping to prevent even more antibiotic resistance in this country.

Daily Dose

Epi Pen Controversy

1;30 to read

I have more than several patients who have had serious allergic reactions (anaphylaxis) to a variety of things…including insects (fire ants, bees) as well as foods (peanuts, tree nuts, fruits, shellfish). All of these children need to have epinephrine auto injectable pens (EpiPen) on hand in case of “accidental” exposure to the allergen and a subsequent life threatening allergic reaction.  These medical devices are seldom used ( thank goodness), but need to be replaced every 12-24 months and should always be readily available in case of an emergency.

For the longest time it was not a “big” issue (cost wise) to write prescriptions for these allergic children and to make sure that they had several EpiPens on hand. This included having them available at home, school, in the mothers purse or in the car or in the gym bag…many people also wanted “extras” to have at the grand- parents house or at the lake house…etc.  So….I would write a script for the EpiPen 2 pack and the family might get 4-5 sets to disperse to the appropriate people. Prior to 2009 the cost was less than $100/two pack. 

It was several years ago that a few families started talking to me about the expense of these devices and also how quickly they seemed to expire…in fact we started asking the pharmacist to look at the expiration dates and to try and dispense the ones that had the longest expiration, in hopes of saving some expense.  At that time there were also two companies that were making the epinephrine devices.  

Then in the last year parents started calling me complaining that the EpiPens were becoming cost prohibitive and “did they really need to keep filling them?”….especially seeing that they had never needed to use one?  Of course I replied that “by the grace of God” and their vigilance they had not needed one, but YES, they indeed needed to continue to have them on hand.  In many cases families reduced the number that they bought and tried to make sure that they handed them off if their child left home….terribly hard I would think to keep up with.

This issue came into view most recently as parents across the country started complaining to not only their physicians, but to the pharmacy, their insurers and the drug maker Mylan Pharmaceuticals….why in the world had the price jumped to over $600? In retrospect, the price had been raised 15% twice a year over the past 2 years!  ( It was also pointed out that this was a 6 fold price increase in the past decade).

I do know that epinephrine has been around for a long time and the drug itself is not that expensive, and is used everyday in hospitals around the country….but the EpiPen auto injector which allows “anyone” to inject the medicine into a muscle without any measuring etc. has become cost prohibitive for many families, even some of those with insurance. It seems that Mylan Pharma  is setting prices “based on whatever the market may bear” and not on the fact that the drug is new or expensive to produce…

This is one of the times that all parents with children who need to carry an EpiPen need to contact their representatives in Congress, as well as their insurers to see if the public can be influential in trying to remedy this situation.  The public will have to let their concerns and voices be heard…

Just as I am writing this, Mylan has announced an “instant savings card” for those people who are paying out of pocket and help for those who do not have the means to buy the EpiPen….but this does not correct the problem as a whole. While the discount may be helpful for some, but not all, it is not the answer to the ever growing problem of exorbitant drug costs in this country. I have several families who are going to try and buy the EpiPen while on trips to Mexico and Canada. I have no idea of the costs there…but worth a try.  

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DR SUE'S DAILY DOSE

If your child snores, is this a sign of something more serious?

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