Tuesday, November 19, 2013

Generic medications for children

      Health care is really expensive. Despite the fact that I am a full time physician, I am constantly amazed at how expensive things are -- medications, hospital stays, tests, treatments, and many more. One way to reduce medical expenses is to use generic medications.
      Generic medications are the same active ingredients without the added cost of the name brand medication. In general, they work just as well. If you want to read more details, Wikipedia has a good article about generics here. Occasionally, we run into issues with patients not responding as well, but this is quite rare.
      A few things come to mind:
1. If the price is the same and it works the same, the only reason to buy the name brand liquid medication may be the taste. Although many generics taste just fine, often the name brand liquid medications for fever, cough and cold, and allergies, the name brands sometimes taste significantly better. The Teller twins still fondly talk about the blue raspberry Advil. So if your child is struggling with the taste of a liquid generic, I would try the name brand.
2. We have generally found no issue with generic creams, lotions, or gels not working as well as the name brand. For steroid creams (for eczema, poison ivy, and other rashes), acne medications, and anti-fungal creams for yeast infections (ringworm, athlete's foot, and jock itch), we have found that we have had generics work as well as the name brand. I would recommend saving some money and buying the generics if they are available.
     My dream would be for me to be able to look up the costs of different medication options and tell the family: "This medication would be free at your pharmacy, this one $4, and the other $40. All of them will work well -- which one would you prefer." Sadly, the pharmaceutical companies and the pharmacies will never let us have that information (unless there is a major uproar from consumers) as they would lose money if we consistently went with the cheapest medicine that was going to work. Just in my practice, families would save thousands and thousands of dollars every year having this information. Maybe one day...
      So to summarize: we certainly encourage you to use generic medications when they work for your child and you save some money in the process.

Should everyone with a positive Strep test be treated with antibiotics?

      I realize it can be frustrating to figure out when to bring your child with a sore throat into the office for a Strep test. Sadly, there is not a single "oh, THAT means you have Strep!" symptom or sign of illness. Although the classic quick-onset of a sore throat (felt fine then all of a sudden then "wow, my throat hurts!"), fever, headache, and a stomachache 2-5 days after a Strep exposure certainly can be Strep, many of these turn out to still be a viral illness that does not need an antibiotic. Having impressive cold and cough symptoms makes it less likely the child has Strep (but not impossible). In a large study looking at the size of the tonsils, red throat, mucous in the throat or on the tonsils, and palatal petechiae (small pin-point red dots on the back of the roof of the mouth) found that the only finding in your throat that made it more than a 50% chance that someone with it indeed had Strep was the palatal petechiae. It turned out that 80% (but not 100%!) of those kids with sore throats and palatal petechiae has Strep.
      I explain all of the above because I have many parents asking why we do not have an over the counter Strep test. The question then becomes would everyone who was found to have Strep on such a test need to be treated. Would not that make it easier on everyone? It turns out that many of the positive Strep tests would not need to be treated. Read on to find out why.
      At any one time, many people carry a few Strep bacteria in the back of their throat. Depending on the person and the time of year, it can be as high as 10-20%. So if you stood out in front of the library and swabbed every child that entered the library (that would not be popular at all!!) on one day, tested all those swabs for Strep, and then called the families who were positive for Strep in 4-6 weeks to see if anyone they knew had been diagnosed with Strep, the number would be really small. So, our worry would be that if there was an over the counter Strep test, it would turn out many of these folks would have positive Strep tests who in fact are carriers. And carriers are not routinely treated.
      Those kids (and adults) carrying Strep in the back of their throats can become ill with a viral illness, have a sore throat from the virus, but they would show Strep on a throat swab because of being a carrier. So a positive Strep test for them would not necessarily need to be treated with antibiotics -- and we seeing someone in the office for an ill visit will often clarify all these issues. Are there still times when we in the office treat someone that may actually be a carrier that really "just" has a viral sore throat? Yes, but an over the counter Strep test would certainly confuse us on this point.
      So ultimately, a test for Strep not done by the doctor or nurse practitioner who has examined them would prove to be not enough information to make a decision about treatment. Therefore, it will always be good practice to see those patients with a possible Strep throat.

Tuesday, November 12, 2013

Hilliard Pediatrics New Overnight Strep Testing

     For 23 years, Hilliard Pediatrics did our over-night Strep cultures in our office. We did this when the quick Rapid Strep test that we do in the office and just takes 5-6 minutes did not show Strep throat. Our cultures were read each day by the doctors and we then treated anyone who we found had Strep throat on the culture.
     For the last few years, anyone seen by Nationwide Children's Hospital and most other pediatrician offices in Central Ohio who had a negative quick test was tested through Nationwide Children's Hospital with a Gen Probe test. The results are quicker than a culture and more accurate. 
     About a month ago, we decided to switch to doing the over-night tests to confirm that someone does not have Strep from our own culture plates to Nationwide Children's ChildLab's Gen Probe. So far, we like it very much. The results come the next day into our inbox on our computerized records. We can often call the families and call in the antibiotics earlier than before (by 9:00 or 9:30 a.m.). We have felt the number of positive Gen Probe tests fits for what "seems right" (about 7-15% of the Gen Probes are positive for Strep). 
     We do not want this more accurate and quicker test to be a financial burden to our families, however. We understand you may get a separate charge/bill from ChildLab through Nationwide Children's Hospital. As we are no longer doing the culture tests in our office, we as an office are saving some expense. Understand that the vast majority of pediatrics offices in Central Ohio are now doing exactly as we are doing. We are monitoring this cost issue and will, as always, keep you posted if we change how we handle this issue.

Why don't pediatricians just treat everyone with a sore throat for Strep throat?

      We are asked on occasion why we pediatricians do not "just treat with antibiotics" everyone with a sore throat. I want to answer that question. I feel pretty strongly about it.
      1. Antibiotics only treat bacterial infections -- not viral infections.
Most sore throats are not caused by bacterial infections. Less than 1 in 7 of our rapid strep tests done in the office show strep. And 1 in 14 of our over-night strep tests (through Nationwide Children's Hospital ChildLab) are positive for strep. So for the vast majority of sore throats, antibiotics will not help. They will not help because the sore throats are caused by viral illnesses.
      2. The overuse of antibiotics is causing bacteria to evolve to become more resistant.
Many antibiotics are losing their strength against the usual bacteria we treat. As important it is to take an antibiotic when you need it, taking one if you do not need it is bad. This will kill healthy bacteria. Any bacteria that do survive through your course of antibiotics will now be resistant to the antibiotics. Many common infections (ear infections, sinus infections, pneumonia, skin infections, urinary tract infections) are caused by more resistant bacteria requiring stronger and stronger antibiotics. This is very worrisome.
      3. Although scientists are studying new antibiotics all the time, no new antibiotics for common infections are coming anytime soon.
New medications are being studied and tested all the time. New medications are available for many conditions. However, there are no new antibiotics "coming down the pipeline" that will help treat common bacterial infections. In fact, the antibiotics that are taken by mouth available for use in children have not changed since 1997. The commonly used antibiotics (amoxicillin, cefdinir/Omnicef, amoxicillin-clavulanate/Augmentin, azithromycin/Zithromax, and sulfamethoxazole-trimethoprim/Bactrim) are the same ones used for 16 years. Thank goodness they work for the common bacterial illnesses so far!
      4. The chances of "missing a Strep infection" and something bad happening is tiny.
Although there are brief sore throats that are not tested (for strep throat) that do turn out to be strep, it is very rare to have someone tested, miss a strep infection, and have an untreated strep throat complication -- such as rheumatic fever.

       We are all frustrated with sore throats. Especially when they are accompanied by headache, fever, and upset stomach, we hope someone with a sore throat has strep so that we can treat them with an antibiotic and they will quickly feel better, they will be not contagious quickly, and complications (such as rheumatic fever) will not occur. But if you do not have strep throat, taking an antibiotic will not help -- and can be dangerous.

Fiber in children's diets

     Fiber is not a very glamorous topic. But is important for your health. It helps keep our bowels moving in a healthy way. And it helps make us feel "full", an important part of maintaining a healthy weight. Healthy Children, sponsored by the American Academy of Pediatrics, has a very good article on fiber in children's diets here. As it says, a good guideline on how many grams of fiber per day for children: your age + 5 (so a 10 year old needs 10 (their age) + 5 = 15), up to 25 grams per day. Eat healthy!

Wednesday, November 6, 2013

Your child going off to college.

     My oldest son Sam headed to Otterbein University this year to start college. Sam is a mature, responsible teenager. We are very proud of him.
     No matter how you feel about your child's maturity level and history of responsible behavior, it is good to have a discussion with them before college about all the things they will face in college. Taking care of themselves, in all the meanings of the phrase, is an important part of transitioning to higher education. Tread lightly as you do not want to sound too preachy or overbearing. I think the average high school graduate wants some advice and wants to know you are there to help, but they do not want you telling them "never do this".
      Nutrition: You have spent years trying to help your child become a healthy eater. Remind them about eating a well-rounded diet, eating breakfast (even a protein or cereal bar), and avoiding over-eating and excess snacking. Encourage calcium intake with milk, cheese, and yogurt.
      Sleep: Your child in college is likely not going to get enough sleep! I would love it if they did get plenty of sleep, but college students will stay up too late and be sleep deprived. Part of this is socializing and part of it is staying up to study. Good time management will help them from having to stay up until 2:30 a.m. completing that paper that is due tomorrow. Encourage your child to get enough sleep so they are not overly tired.
      Socializing: College is, of course, a huge opportunity to meet and become friends with a huge new group of young people. Many college students find this exciting. Some more reserved or shy students find this distressing. It is like life after school: your child will need to learn to interact with people from all walks of life, with different interests and backgrounds. For those college students dreading the "getting along with roommate"/"meeting new people" issues, giving them a pep talk about the fact that meeting one or two people with similar interests will help with the transition. Many times at college orientation, some upperclassmen students will mention that it was hard to balance the socializing with academics that first year of school. You hope that your children hear this message and they themselves find a good balance.
      Alcohol and drugs: Despite it not being a good idea or legal, many freshman have access to alcohol and drugs at college. Talking through with your child how to handle this will help. Review with them the dangers of drunk driving or riding with someone who is intoxicated. Remind them how they can get into legal trouble or trouble with the university for public use of alcohol or drugs or public intoxication. Please tell your daughters to NEVER leave any beverage unattended -- there are far too many cases of an acquaintance or stranger adding a date rape drug to young women's drink.
      Sexual activity: Although I tell patients to wait until they are in a committed, long-term relationship (ideally marriage) for sexual activity, many college students are sexually active. Besides the possible emotional and social consequences, the big issues we worry about for sexually active young adults are sexually transmitted diseases and pregnancy. You know your comfort level and your child, but it is a good time to discuss these issues with your son or daughter. Consider taking your daughter to the gynecologist to discuss birth control.
      Money: Not only will your college student learn to budget time, but they will learn to budget money. I had a time in college where I could not send my girlfriend a letter at her college because I could not afford the stamp. Although it helped me learn to appreciate when you can afford those things you do not absolutely need, I do not wish this situation on anyone. Many college students learn about budgeting their money because they have more control over their spending when they are away from home. Whether they have their own debit card, a check book, or some other arrangement, discuss before they go off to college how you as a family are going to keep track of spending, whether parents can have access to online account information, and what to do if there is an issue.
      Good luck!