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Daily Dose

Teething Pain

1.15 to read

I am getting a lot of questions from patients related to teething, pain, and the routine use of products to alleviate the pain.  

The FDA recently issued a warning to parents who use OTC products like Oragel and Anbesol on their infant’s gums for relief of teething pain. These products come as both liquids and gels, and benzocaine is the active pain reducing ingredient.

It has now been found that excessive amounts of benzocaine may lead to a very rare condition called methemoglobinemia. (Hemoglobin is the molecule in the red blood cell that carries oxygen) . With methemoglobinemia there is a reduced amount of oxygen that is carried in the bloodstream which may lead to a bluish gray discoloration to the skin, shortness of breath, a rapid heart rate and fatigue and lethargy. Again, key word is rare.

Although the FDA did not withdraw these products from the market, they did recommend that they not be used in children under two, and then should be used “sparingly”. Unfortunately, the benzocaine containing products do not yet contain warning labels and some of my patients are still asking about using them.

I have never recommended using these products in the first place. I always wondered if they really helped a baby who was teething, as I am not sure you can tell when a baby is actually teething.  If you watch any infant over the age of 4 months, their hands are always in their mouths, and they are constantly drooling!  Does that mean they are getting teeth? Unlikely, as most babies don’t even cut their first tooth until about 6 months, so they have been drooling and putting anything they can in their mouths for months prior. The drooling and “gnawing” on their hands (and sometimes feet too) is rather a developmental milestone and not always a sign of teething.

My theory is let the baby chew on a teething ring, a frozen piece of a bagel (cut into quarters, good for gnawing but you need to throw it out when getting soft to avoid choking) or rub their gums with a cold washcloth if you think your child has discomfort.

The same thing goes for using acetaminophen or ibuprofen excessively. Some parents are giving a nightly dose during the “teething months/years” and this is too much medicine.  Children go through a lot of sleep changes and awakenings which tend to occur during suspected early teething times and many parents attribute nighttime awakenings to teething pain. They are not synonymous. Remember that temporal events are NOT always causal.

Babies will get teeth for many years to come and once the first several have broken the skin we don’t seem to pay as much attention anyway, right? I mean, who is going to worry about a child cutting their 2 year old molars, there are way too many other issues to deal with (tantrums, climbing, throwing food) than if their molars are erupting.

So, save your money and don’t buy teething products. Now even the FDA agrees!

Daily Dose

Bug Spray & Bug Bites!

1:15 to read

 It’s that time of year again when the bugs start to return from their “off season vacations” and pediatricians start to see children who are suffering from uncomfortable bug bites.

The best way to prevent bites from the myriad of insects including mosquitoes, mites, chiggers, flies and fleas is by using an insect repellent. Insect repellents do not prevent bites from stinging insects such as bees, hornets and wasps. The AAP recommends using bug sprays in children who are older than 2 months of age when necessary for preventing insect bites during outdoor activities. The most common insect repellent is DEET, a chemical that has been studied for over 50 years. Most of the OTC bug sprays contain DEET in different strengths. The higher the concentration of DEET, which typically ranges from 5 – 30 %, the greater the protection and length of effectiveness. I usually recommend starting with the lowest concentration of DEET, which typically provides protection for 1-2 hours, and use a higher concentration as needed for longer protection.

The number of bites a child receives and their reaction to bites are different in all children, so each child may need a different concentration of DEET to be effective. With concentrations of DEET above 50% (not recommended for children), the effectiveness and duration of protection actually plateaus, so there is really no benefit from higher concentrations.

Another product approved for use in the U.S. about 5 years ago is picardin. Picardin provides similar protection in both duration and effect to DEET. Cutter, Skin So Soft and Off all have some products containing 7-10% picardin. The advantage to picardin containing products is that they are odorless (unlike DEET) and do not feel as greasy on the skin and are less likely to cause skin irritation and damage to fabrics . With all products you must read the labels to see what you are getting. There has been some recent data on the use of natural products such as oil of eucalyptus which the CDC has found to be comparable in its duration of effectiveness in preventing mosquito bites, to lower concentrations of DEET. It may also work well against ticks (Repel).

Eucalyptus oil may be poisonous if ingested in large quantities and should not be used in children younger than 3 years of age. Other studies have found that 2% soybean oil (Bite Blocker for Kids) has similar levels of protection to products containing 5-15% DEET, and may provide up to 90 minutes of protection from mosquitoes. This may be a useful product for short term exposures. Chemical repellents containing permethrin kill ticks on contact but should never be applied to the skin, but may be applied to clothing. Insect repellents should not be reapplied throughout the day, as is sunscreen. Parents should be instructed to spray the insect repellent on their hands first and then apply to their child and do not apply to the areas around the nose and mouth. 

It is a good idea to wash the repellents off with soap and water at the end of the day. That’s your daily dose for today. We’ll chat again tomorrow.

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

Why Fever Is Your Child's Friend

Every parent is concerned about fever and why their child is running a fever. During the "sick season" I see 20 - 30 patients a day with a fever. Every parent is concerned about the fever and why their child is running a fever. Fever is one of the most common symptoms of childhood. Younger children run fevers quite frequently when they are sick. As we have talked about before, that may be four to eight times during the fall and winter season.

"Fever is our friend" has been one of my mantras for years. It is comforting for parents to understand that fever is a symptom that the body is fighting an infection. That is usually a viral infection that only lasts a few days, and lo and behold the fever is gone. The biggest myth is that fever, in and of itself, causes brain damage. Remember again, fever is simply a symptom.

The height of a fever does not correlate with severity of illness. Once again, higher fever does not necessarily mean you are sicker. Your child may feel awful with a fever of 101 or 104 degrees. Typically, once given either acetaminophen or ibuprofen for their fever, the temperature comes down a little and they symptomatically feel better for a while. Once the anti-pyretic (fever reducing) medications wear off, the fever will often return.

Children typically have more fever in the night, seems like darkness brings out the fever monster (that is the mother in me, but it was always true at my house) and those nights of fitful sleep, and hot little bodies seem very long. The other thing I have noticed, why do children who have had little sleep due to fever, coughs etc get up in the morning and do not long for a nap like their parents?

The other thing you need to keep in mind is that the higher the fever, the faster your child's heart will beat and the higher respiratory rate they will have. It is easy to climb into bed with your "hot" two year old and feel their heart pounding away, and know they have a high fever, even before the thermometer is out. This is the body's natural way of expending heat. Once the fever comes down you will notice that they are breathing less rapidly and their heart rate has come down too. Remember to offer plenty of fluids to a child with a fever, as they need extra fluids. They can eat too, but if not interested, a Popsicle or jell may be a good alternative. Just keep chanting, "fever is our friend." 

That's your daily dose, we'll chat again tomorrow.

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

E. coli Outbreak Continues

E. coli bateria is spreading across Europe with more deaths reported. What you need to know about this deadly bacteria.I was on the treadmill this morning simultaneously watching a plethora of channels on the flat screens TV’s at the gym. One of the headlines at the bottom of the MSNBC screen caught my eye as it read, “deadly virus spreading across Europe”, while the next headline read, “e. coli continues to spread in Europe.”

Unfortunately, there does continue to be concern over the deadly BACTERIA that has been spreading across Germany and has caused illness in at least 10 other European countries as well as several cases in the United States. But the concern is not due to a virus, but a bacterial infection!  Viruses and bacteria essentially have nothing to do with one another except that they can both cause illness. The bacteria, a new strain of Escherichia coli (E.coli), have caused an outbreak of diarrheal disease with over 2,900 people being infected. Of these, over 500 have suffered life-threatening complications, and there have been 30 deaths reported. The sickest patients have developed hemolytic uremic syndrome, a kidney disease which may result in renal failure. It seems that this “new” bacteria has caused the most serious illness among previously healthy women, including those that are pregnant. This is unusual as it is typically thought that children and elderly have more serious complications from hemorrhagic E.coli strains. Several of the cases of this specific type of E.coli have been reported in the U.S., with all persons except one having had recent travel to Germany. E. coli is a bacteria that had long been known to cause food borne gastroenteritis (vomiting and diarrhea). The bacteria may be found in fecal material and then may be spread via food that has been contaminated.  It was just announced that the most likely source of this E.coli infection is not cucumbers as was previously suspected, but rather by contaminated bean sprouts. The initial source of infection looks to be from a farm worker who has tested positive for E.coli and is thought to have spread the bacteria while working. The mainstay for preventing any food-borne illness is HANDWASHING!!  It is also important to thoroughly wash fruits and vegetables, especially those that are eaten without being cooked.  Peeling the produce is also a way of helping to prevent disease. The WHO and also the CDC have put U.S. doctors on alert for this disease. If you or your children develop bloody diarrhea it is important that you seek medical care, and if possible have a stool specimen available for your doctor. In the meantime, have your children practice good hand washing, especially after using the bathroom!  Remember, this is a bacterial rather than a viral infection. There is a difference. That’s your daily dose for today. We’ll chat again tomorrow.

Daily Dose

Hand-Foot-Mouth Disease

1:30 to read

I am back on my soap box about what is a newsworthy announcement…..especially as it pertains to viral infections. While I know that day care centers and pre-schools are “keen” on posting notices or sending emails to parents about the latest virus to be found at school, I am still baffled as to the necessity to do this and alarm parents. Aren’t there HIPPA violations or something?  Knowing that a child in school has been diagnosed with  “hand-foot-mouth" disease (HFMD) does not seem to be anything out of the ordinary. Pediatricians are used to seeing HFMD, sometimes daily, and yes it does seem that these viral illnesses cluster at different times of the year. But, with that being said, does it really do any one any good, and does it maybe actually “worry” already anxious parents about possible exposure. Are we forgetting that children are exposed to these pesky viral infections all of the time…and that in most cases they are fairly minor, inconvenient and cause several days of fever and generally not feeling well.  End of story.

But now HFMD has made the national news….as there have been 22 cases of HFMD diagnosed at Florida State University…..which has an enrollment of over 41,000 students!!!  Statistically speaking, that is not a significant “attack” rate….and this news is being reported on all of the networks.  While I realize that adolescents and young adults are less likely to acquire HFMD and they may feel worse than a toddler who in most cases seems to “power through”  with fever reducing medication, popsicles and ice cream, is this really a national news story?  

HFMD is caused by an enterovirus (Coxsackie A16) and typically causes several days of fever and not feeing well followed by small ulcers and blisters that may occur in the throat (painful) as well as on the hands and feet. (younger children seem to often get a rash on their buttocks too).  HFMD may be spread in a variety of ways including direct contact with saliva or fluid from the blisters that may occur on the hands and feet, from fecal contamination, and also when a person coughs or sneezes in close proximity. The virus may also live on surfaces that we touch and then touch our eyes, nose or mouth and cause infection.  As I always say, “good hand washing” and keeping yourself home when sick is the best way to prevent the spread of a virus. While I believe in good sanitation and clean public spaces is it really necessary to “wipe down” classrooms, dorms, cafeterias and even toys in school due to several cases of HFMD. Do you have to do this all day long?  HFMD is not a bacterial disease like meningitis and does not have life threatening consequences.  There will be another viral infection  (or 2 or 3 or 4)  soon to follow and one of these will be influenza.

So, rather than talking about HFMD and mass “cleaning efforts” I think we should focus on another way to prevent illness. VACCINATIONS!  We do know that vaccines work to prevent disease and despite the science behind that, there are still those that “opt out” of vaccines, and this includes getting a flu vaccine.  I wonder if there are students at FSU who have opted out of vaccines and if so how many….maybe more than 22/41,000?  At the same time, how many of those students will opt “in” and get a flu vaccine? That is the bigger story ….get vaccinated for flu now…so we don’t have another even bigger “outbreak”.   I know there will be more than 22 students who get the flu at FSU and will that make the news?  It is the same thing for schools everywhere…lets put up signs about flu vaccines and keep those numbers down.I hope the news reports this.

 

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Daily Dose

Common Thumb Injury

1.00 to read

Have you ever slammed your finger in the door or has your child hit their thumb with the head of a hammer?  If this has happened to anyone in your family you may recognize the bruised and bloodied nail bed, which is called a subungual hematoma.  Essentially this is a collection of blood, like a bruise, beneath the nail. 

This kind of trauma, albeit not life threatening, can cause a lot of pain and discomfort. Because the blood has no where to go due to the overlying protective coating of the nail, the injured finger or thumb just pounds and throbs as the blood pools under the nail.  

If the hematoma is fairly small and the injury minor, the nail just looks dark and the pain goes away fairly quickly and the nail may not even fall off. But with a bigger crush injury and more damage, the hematoma involves the entire nail bed and it is pretty painful and won’t stop pounding.  

The treatment is really fairly simple and I can remember keeping a large paper clip at home for just this reason. With my own children and friends and neighbors, I often was the “hero” Mom for a second or two as I would clean the injured finger and then heat the tip of the paper clip and just “magically” poke a hole through the fingernail to let the oozing blood out!!! Voila, no more pressure or pounding and really no pain with the procedure. Kids loved to watch his trick! 

Modern medicine has advanced and we have now moved to an electric cautery in the office. It does the exact same thing, puts a hole in the nail and relieves the pressure of the blood beneath the nail. It is just a little “slicker” than that handy dandy paper clip. 

So.....here you go, my last patient was happy to oblige with this picture of the procedure and I promise you there were no tears. Maybe a few tears of joy when the nail quit throbbing! 

 

 

 

Daily Dose

The Truth About Antibiotics

1:30 to read

Despite warmer than normal temperatures in much of the country it is certainly already cough and cold season. Our office background music is already a lot of coughing coming from children of all ages…and a few of their parents too. In fact, a few of our nurses and docs are fighting a fall cold as well.

 

This makes it timely to discuss (once again) the difference between a cold which is a viral infection and a bacterial infection (example strep throat).  Viruses are NOT treated with antibiotics!! In other words, antibiotics are not useful when you have the common cold. Asking your doctor to put you on an antibiotic “just in case “ it might help is not advised, and doctors should be taking the time to explain the difference between a viral infection and a bacterial infection, rather than writing an unnecessary antibiotic prescription.  

 

While some people (fewer and fewer young parents) still think an antibiotic is necessary, the overuse of antibiotics has been called “one of the world’s most pressing public health problems”s, by the CDC. Not only does the overuse of antibiotics promote drug resistance, it may also cause other health concerns as well. While antibiotics kill many different bacteria, they may also kill “good bacteria” which in fact help the body to stay healthy. Sometimes, taking antibiotics may cause diarrhea and may even allow “bad bacteria” like clostridium difficile to take over and cause a serious secondary infection.  

 

At the same time that there are too many antibiotic prescriptions being written for routine viral upper respiratory infections, a new study in JAMA also found that bacterial infections (sinusitis, strep throat, community acquired pneumonias), are not being treated with appropriate “first line” antibiotics such as penicillin or amoxicillin.  Of the 44 million patients who received an antibiotic prescription for the treatment of sinusitis, strep throat, or ear infections, only 52% were given a prescription for the appropriate first line antibiotic. When a doctor prescribes a broader spectrum, often newer antibiotic, instead of the recommended first line drug, they too are responsible for increasing antibiotic resistance.

 

So, you should actually be happy when your pediatrician reassures you that your child does not need an antibiotic, and that fever control with an over the counter product, extra fluids and rest will actually do the trick to get them well.  I “brag” about my patients who have never taken an antibiotic…..as they have never had a bacterial illness, and tell their parents how smart they are for not asking for an antibiotic “just because”.

 

At the same time, if your child does have a bacterial infection, ask the doctor if they are using a “first line” drug and if not why…? It could be because your child has drug allergies to penicillins, or that your child has had a recent first line drug and has not improved or has had ‘back to back” infections necessitating the use of a broader spectrum antibiotic.  Whatever the reason, always good to ask.

 

Keep washing those hands, teach your child about good cough hygiene and run don’t walk to get your flu vaccines….November is here and flu usually won’t be too far behind.

 

 

  

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DR SUE'S DAILY DOSE

Norovirus is going around and is very contagious.

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