Friday, December 8, 2017

What to do when children and teenagers vomit with exercise.

     Some athletes vomit during exercise. This can happen at younger ages, but typically occur when teenage athletes push themselves hard during workouts. There are some things to do to help prevent this issue.
     One of my teenage sons has struggled with vomiting when pushing himself during workouts. He does vomit more easily with bad coughs or stomach upset versus some other folks, but he did not have vomiting with exercise until high school.
     If someone struggles with this issue, we would ask some other questions to make sure it was not from something more complicated. We ask questions about acid reflux and and whether the vomiting happens after coughing. We ask about timing of eating and drinking when it comes to exercise.
     If nothing else is complicated about the history, there are some helpful recommendations to help reduce the chances of vomiting during exercise.
-- Eat a small snack 30 minutes before exercise.
-- Avoid exercising in extreme heat.
-- Watch your exercise intensity. The athlete may need to dial-back their intensity.
-- Stay hydrated. Drink 8 ounces of water every 20 minutes of exercise. If the exercise is going to be high-intensity for more than 45-60 minutes, drink sports drinks instead of water.
-- Cool down gradually.

     If your child struggles with this issue and is not improving while following these recommendations, call during routine office hours to discuss.
    

Why do children tell lies?

     At some point during your child's early life, they will lie to you. It is aggravating and frustrating for parents, but inevitably it happens. Our hope as parents is that it does not happen very often. Here is some more information about how to approach this issue.
     Why does anyone lie? To get what they want or to avoid punishment. "No, Dad did not give me a cookie today!" (when they have already had their once-a-day treat). "I was not running in the living room!" (when the lamp got knocked over again). "My brother was on the iPad longer than me!" (when they want more iPad time).
     Sadly, we are in a current situation where it is hard to point to well known adults that your child may look up to - athletes, politicians, etc. - as good examples of "always tell the truth". This makes it difficult when we all get mixed messages from daily life, including for children. When others see someone not tell the truth then get what they want or avoid punishment, even otherwise well-behaved children (and adults) are more tempted to not to tell the truth.
     Certainly, when you know (or are quite certain) that your child is not telling the truth, your best bet as parent is - as always - consistency. By that I mean that you should routinely give your child some negative consequences for lying whenever it happens. We all are more likely to keep repeating an action or behavior if we are not negatively reinforced for it. And we are more likely to stop an action or behavior if we are regularly and consistently negatively reinforced for it.
     Those negative consequences may be a time-out, a removal of privileges (no iPad for the day or no cookie for tomorrow), etc. Stick to your guns: if you say it ("no TV today"), follow through with it (they get no TV today). Otherwise, you are accidentally giving your child the idea that they can sometimes "get away with it".
     One more note: I think it is important to model good behavior to your children. I truly believe if you model to your child that it is important to tell the truth, they are more likely to tell the truth themselves. I recall a time my one son and I were in a fast-food restaurant. When I handed the cashier money, they gave me back too much money. I said "Here, take the $5 back. Then we are even. You gave me too much cash back." The cashier was happy and I was happy for a small moment to emphasize to my son that telling the truth is important.
     So to conclude, do not be too frustrated if your children lie, be consistent with your negative reinforcement, and - as always - call us during routine office hours if you have other concerns.

Friday, December 1, 2017

Keratosis Pilaris

     Keratosis pilaris is a chronic skin condition that is quite common. It is one of the skin issues we are asked about frequently in the office. It often appears in the first few years of life, it is worse when the weather is colder, and cannot be entirely cured. The rash rarely itches, but it does for some folks. It tends to be genetic with some families having multiple folks who have keratosis pilaris.
     Keratosis pilaris appears as small rough bumps on the back sides of the upper arms, sides of the thighs, and cheeks of the face. It tends to look flesh colored in paler skinned individuals, but can look darker pigmented in persons with naturally darker pigments. It can spread from these areas or be just in one of these areas (arms) but not others. It may worsen when the air is more dry (during the winter months when heating the house drops the humidity in the house).
     Keratosis pilaris is more common in families with allergic illnesses - eczema, allergic rhinitis/hay fever, asthma, and food allergies. Many times, a person only has some of these issues, not all. So if dad has allergies and mom has had eczema, their children could have keratosis pilaris even if they have no other of these issues.
     Keratosis pilaris is not curable. You can keep it under control, but it cannot be made to go away permanently. It keep it under control, it needs to be regularly treated. Often that treatment will be on a daily or multiple days per week.
     For many years, our go-to treatment for keratosis pilaris was a lotion called Lac Hydrin Lotion. Sadly, it appears the manufacture has discontinued the product. Some of the available products are ones you may need to check in stores and online to find. All of these products are available at Amazon.com. Here are the products I would recommend now, with the CeraVe product being the best:

CeraVe Renewing SA Lotion
AmLactin Alpha-Hydroxy Therapy Daily Moisturizing Body Lotion
Geritrex Geri-Hydrolac Lotion

If you have tried one of these for a few weeks without relief, try a different listed product. Note that many other great creams and lotions used for dry skin (Eucerin, Aveeno, Cetaphil, or other CeraVe products) often do not work on keratosis pilaris.
     If all else fails and the rashy bumps are bothersome, we often refer a patient to a dermatologist for further help.

Tuesday, November 28, 2017

Prenatal Meetings With the Pediatrician

     Many pediatricians hold meetings with expectant families. This allows parents who are expecting their first child to meet with the pediatrician before the birth of their child. This allows you to meet the doctor, see the office, and ask questions.
     We call these meetings "prenatals". We schedule those with one of our doctors and a handful of couples. They are scheduled in the early evening and we meet in our lobby. The doctor will tell you more about themselves, our office, and what you can expect at the hospital and with bringing your child to our office. We will show you our exam rooms. You will have an opportunity to ask questions of the doctor. The meetings usual last 20 minutes or so. If there are a number of questions, they can go longer. If you see a particular doctor at a prenatal, we anticipate that you will have that doctor as your primary care doctor here in the office.
     You do not need to do a prenatal to bring your newborn to our office. You also will not need to let us know prior to the birth of your infant that you are bringing your infant to our office. In other words, you do not need to tell us at the prenatal that you will bringing your child to our office.
     If you are interested in scheduling a prenatal meeting with a doctor here in the office, call our routine office number 614-777-1800 during routine office hours and speak with the front office staff.

Friday, November 10, 2017

What happened with your flu shot supply?

     You may be asking yourself this question: what happened with Hilliard Pediatrics flu shot supply?
     I will answer that. But some background. We order the vaccine from a supplier. Most offices place their order in February to receive the vaccine in August to September. How do we determine how much we order? We look at previous years supply and use and make an educated guess. The year that FluMist went off the market, we dramatically increased our flu shot order to have enough vaccine for those who had received the flu shot and those who received the FluMist in the past.
     We have about 10,000 patients. If we gave each of the infants two doses and all the older children 1 dose a year, we would go through more than 10,000 doses a year. We do not use that many. We realize some families do not vaccinate their children with the flu vaccine routinely. Other patients receive the vaccine in other places.
     Last year, it was the second year without the FluMist. We felt like the demand in the office was steady but not high. By the end of January, we ran out of our supply and most of the families seeking the vaccine from our office received it here. Typically we run out of the vaccine between late November and early January.
     This past Winter, we placed our current order for the same number of flu shots as last year. Although we added a new doctor, our total number of patients has not changed much. We received the vaccine in August (earlier than some years) and then began vaccinating our patients. As usual, we were giving the vaccine in the office and check-ups and (were appropriate) sick visits. We also had our usual flu shot walk-in clinics. How busy each flu shot clinic is seems to vary over the years. This year, we were less busy than usual until the last few clinics where the numbers went up.
     The week before we ran out, we realized we would need more vaccine. When we called, we were initially told we could order as much as we needed. After discussing in the office, we called the next day to be told the previous days information was in fact not true -- they could not supply us with any further vaccine.
      We have been asked why we do not hold back vaccine for the youngest of patients who need a second dose. We do not do that. In fact, we could not as we believed up until the last minute that we could order more vaccine. And we fully intended to order more. There other logistical issues with holding back vaccine to give to someone else.
     So what about next year? Surely we will order more vaccine. But we have found that each year has its challenges. We appreciate that many of our patients are able to and do receive the vaccine in the office each year.
   
   
   

Monday, October 23, 2017

Children with Easy Bruising Who Take Fish Oil Supplements

     We are asked regularly about children who bruise easily. If children have impressive bruises that occur after minor injuries, we will likely ask about your child's history with other issues that make us worry about a bleeding disorder. These questions include:
     Does your child have easy bleeding with minor mouth injuries or teeth cleaning?
     Does your child have frequent or hard to stop nose bleeds?
     Has your child had excessive bleeding after minor procedures?
     Does your child pass blood with a bowel movement?
     Has your child had painful, swollen joints after minor injuries?
     What medications or supplements does your child take?

     A combination of history and physical exam can prompt us to do screening labs or a referral to the hematologist at Nationwide Children's Hospital. Other histories and physical exams are reassuring.

     On a personal note: I spoke with my eye doctor in the last year about my eyes being dry. I had already tried some other remedies, so my eye doctor recommended that I try taking fish oil supplements. I began taking Occuvite and noted only so much improvement. I then switched to a higher dosed supplement, this time Member's Mark Triple Strength Wild Alaskan Fresh Fish Oil Softgels with 900mg of Omega 3. At my annual check up last week, I mentioned my easy bruising this year and the first thing my doctor said was "It is those Omega 3 supplements you take!". So now I am weighing the "eyes less dry" with the "easy bruising" tendencies.

     So a good thing to know is that fish oil/omega 3 supplements can increase the tendency to easy bruising. If your child is regularly taking these supplements, let your doctor know this if they are going to have surgery or if they have been prone to easy bruising.

Friday, August 25, 2017

Safe Sleep for Newborns and Beyond

     My oldest son is now 22 years of age. Back in 1990's, the cribs had wide enough slates that it was possible to get an arm or leg stuck between the slats. This prompted it to become nearly universal to use bumper pads to keep the arms or legs getting stuck and to pad the area so an infant would not "get hurt".
     This was not the safest sleep environment. We know now that there were more cases of SIDS and injured arms and legs with that setup. Now the slats are close enough to prevent these issues and it is recommended to not use any bumper pads. The chairman of the Consumer Product Safety Commission, Elliot Kaye states "I reiterate my belief that the public should stop using padded crib bumpers. The overwhelming evidence show that they do nothing more than contribute to the deadly clutter in many of our nation's cribs. Based on the real risk they present, it is a mystery to me why they continue to be sold." I agree.
     The Ohio legislature recently passed a law, Sub Senate Bill 332. It includes a bumper ban. I believe it goes into effect at the end of 2017. The law prohibits the manufacture or sale of non-mesh crib bumpers. The law allows for the sale of mesh crib bumpers for the next 3 years. The law will then ban the mesh crib bumpers if the Consumer Product Safety Commission (CPSC) has not created safe standards for mesh crib bumpers.
     "Bumpers are unnecessary and pose a real risk to the safety of infants." - Dr. Sarah Denny, Nationwide Children's Hospital.
     For more information about safe sleep for infants: here on the Ohio AAP website.

2017 Flu Shot Walk-In Clinic Dates and Times

     It is the flu shot season! We have a good supply this year of the flu shot. We are announcing the dates for walk-in flu shots for Sept.-Nov. 2017. Depending on the supply, we will schedule further dates in the Fall. We have shifted the weekday clinic date to Wednesday from Thursday (to accommodate our exam room needs in the office).
   
     Wednesday clinics are from 2-5 p.m. Saturday clinics are from 9 a.m.-12 noon.
     Wednesday dates: September 13, September 27, October 11, October 25, and November 8.
     Saturday dates: September 23, October 7, October 21, November 4, and November 18.

     We occasionally have to cancel/reschedule dates due to our supply of the vaccine. We will announce on the Hilliard Pediatrics Facebook page (maintained by Dr. Tim) if that occurs.

Monday, August 21, 2017

Solar Eclipse Safety

     Here it comes! The solar eclipse! Exciting as it is a fairly rare event. Now let us experience it safely!
     I love the Healthy Children website. Here is their article about safely enjoying the solar eclipse. Here is an article about eye safety during a solar eclipse from the American Academy of Ophthalmology.
     Be safe out there!

Friday, August 18, 2017

Car seat and car safety website

     I became aware of a very nice, accurate website recently. It is maintained by the National Highway Traffic Safety Administration. It has lots of resources regarding proper car seat use, safety tips for teen driving, and other safety information regarding cars. The website can be found at the Safer Car website.

Tuesday, August 15, 2017

Nationwide Children's Dublin Urgent Care has reopened.

     Due to staffing issues, Nationwide Children's Hospital's Dublin urgent care was temporarily closed for some months. As of August 2nd, 2017, it has reopened.
     We recommend using Nationwide Children's Hospital facilities when your child needs an urgent care or emergency room.
      The hours for the Main Campus (downtown) and Lewis Center Emergency Departments are 24 hours a day, 7 days a week. The Hilliard and Dublin (the two closest to our office) Urgent Cares are open Mon.-Fri. 3-10 p.m. and Sat.-Sun. 12-8 p.m.
     Laboratory and x-ray services are available as walk-ins with a doctors orders at both the Hilliard and Dublin locations. Laboratory hours are Mon.-Fri. 8:30 a.m. - 10 p.m., Sat. 9 a.m. - 8 p.m., and Sun. 12-8 p.m. X-ray services are available at both locations Mon.-Fri. 8:30 a.m. - 10 p.m. and Sat.-Sun. 12-8 p.m. Of note: patients needing TB screenings (often for volunteering, work, or college) can be seen from 3-7 p.m. everyday with no appointment needed at either the Dublin or Hilliard Close to Home Centers.
     As always, further information is available at www.nationwidechildrens.org

Monday, August 14, 2017

The flu vaccine has arrived!

     The influenza vaccine ("flu shot") has arrived for the 2017-2018 season. We received hundreds of doses. We will receive further doses in the future months.
     There are 4 strains of influenza in the vaccine and one is a new strain this year. Each year, scientists predict what strains are most likely to be in the communities for the coming season. For the '16-'17 season, the protection was only fair. On average, for every year like last year, we will have two years where the protection is much better.
     We agree with the recommendation that all children 6 months and above routinely receive the vaccine each year. This provides the best protection against influenza and it's complications, including dehydration and pneumonia.
     The only influenza vaccine we will stock this year is the flu shot. Although the "flu mist" is back on the market after concerns about its effectiveness, we want to make sure that it provides equal or better protection versus the flu shot before potentially recommending it in the future.
     Although the flu shot contains a small amount of chicken egg protein, the majority of egg-allergic patients can safely receive the flu shot. If a child has a history of anaphylaxis (a severe allergic reaction) to eggs, we should further discuss the issue. Some of these patients will see the allergist to receive the vaccine at their office.
     For those patients receiving the vaccine for the first time AND before their 9th birthday, two doses of the vaccine are needed one month apart. This supplies them with the best protection for that season. All other children need one dose each year.
     The flu shot cannot "give you the flu". In other words, if you or your child felt ill soon after receiving the vaccine, it was just a coincidence. Mild local reactions including soreness, redness, or swelling at the site are common. Less common are fever, achiness, headache, or nauseousness.
     We will soon schedule walk-in flu shot clinics. These have typically been scheduled on select Thursday afternoons and Saturday mornings in the Fall. We will announce on our Facebook page and on our website (www.hilliardpeds.com) when we know the schedule.
     One thing we are often asked about: Is my child too sick to receive the flu vaccine? The answer is "It depends". Mild cold and coughs, mild diarrhea, and low grade temperatures 100.4 degrees and below are not reason to postpone the vaccine. In fact, it has been shown that it is still safe and effective to receive the vaccine if someone has active asthma or croup and will need a steroid -or- has recently been on a steroid.

Tuesday, August 1, 2017

Menveo vaccine back in stock.

     As of last week, our office received the previously back-ordered Menveo vaccine. We are contacting by phone the families whose children had been in the office and had not received the vaccine due to the shortage. We have a good supply of the vaccine now and anticipate being able to vaccinate on-time the patients who need the vaccine.

Tuesday, July 18, 2017

Meningitis Vaccine for 7th and 12th graders on back order.

     The Menveo meningitis vaccine is recommended by the CDC and AAP for prevention of bacterial meningitis. It is required for Ohio schools to be received before starting 7th and 12th grades. We have consistently given to 11 year olds and 16-17 year olds in our office.
     We were recently informed that the vaccine was on back order by the manufacturer. Soon afterwards, we ran out of our supply of the vaccine. As of this morning, we do not have any further doses of the vaccine. Many pre-teens and teens have appointments with us in the weeks before school who will be due for the vaccine. What to do?
     When this happens, we typically are not informed when we will receive further doses of the vaccine. This is true now. We anticipate receiving more vaccine before school starts. Since we ran out of the vaccine, we are keeping track of those who needed the vaccine at a visit but did not receive it. We plan to contact those families when the vaccine arrives. In addition, we will post on Dr. Tim's Hilliard Pediatric page on Facebook when the vaccine is available. When it arrives, those patients will be able to be promptly scheduled for a nurse-only vaccine visit.
     In the unlikely event that the vaccine is still unavailable to us when the school year begins, we can provide a note to the school detailing the situation.
     We will keep you informed!

Tuesday, April 18, 2017

Testing for Food Allergies -- a great article by Dr. Stukus

     Food allergies and the testing for them can be befuddling for many families (and their doctors). We very often use the expertise of an allergist in these cases. Testing for food allergies can be a challenge (yes, that is a pun). Dr. David Stukus, M.D., pediatric allergist at Nationwide Children's Hospital here in Columbus, Ohio has an excellent discussion of testing for food allergies. Here is the article.

Wednesday, April 5, 2017

Testing for Strep Throat in Our Office

     I have been practicing pediatrics since 1994. When I started in practice, a rapid strep test was done in the office and an culture test was done on the negative (no strep found) rapid tests to confirm whether strep was there or not. This culture took 1-2 days to get the results. A few years ago, we and most practices in Central Ohio switched to doing the over-night tests at Nationwide Children's Hospital that was completed by the next morning, so we would know for sure if the child has strep by the start of the next office day. One of the on-going issues with the Nationwide Children's test has been the expense.
     As of April 4th, 2017 we are now doing an in-office DNA probe test for strep. It takes a few extra minutes, we swab the throat in the same way (although the swabs may be a little different), and it eliminates the need to do an overnight test. We believe the insurance coverage will be good, and in fact it will be cheaper if the previous overnight test would be needed. We like that the results are available right away, where for years we have called families the next day to tell them the overnight test was positive for strep. This delayed getting back to school (and parents back to work). Now we will know a definitive "Is it strep or not?" in about 8 minutes.

Tuesday, April 4, 2017

New Once-Daily Amoxicillin Dosing for Strep Throat

     For many years, the standard way to treat strep throat has been to use twice-daily dosing for amoxicillin. A recent study confirmed that once-daily dosing for amoxicillin was effective in treating strep throat. For children who are not allergic to amoxicillin or penicillin, this will be more and more common to treat strep in this way.
     The once daily dosing may seem as if the dose is a little higher than before. We commonly use the 400 milligram/5 milliliter suspension and have the children 45 pounds and above take 2 1/2 teaspoons (10.5 milliliters) once a day for 10 days. Smaller children with strep throat will take a small dose.
     One nice change: if the first dose is given before 5 p.m., your child is not contagious the next morning. The higher dosing works so quickly that the usual recommendation to wait 24 hours before your child is not contagious does not apply. We recommend that the first dose of the amoxicillin be given right away once it has been prescribed. Note that the twice daily dosing would still mean that the child was not contagious until they have been on the antibiotics for 24 hours.
     So do not be surprised if your child is given once-daily amoxicillin if they are diagnosed with strep throat. We think treating this way has some real benefits.

Tuesday, February 14, 2017

The American Academy of Pediatrics has a newly released Allergy and Anaphylaxis Emergency Plan form.

     I like most pediatricians am a member of a national organization of pediatricians called the American Academy of Pediatrics. They are the experts on many topics about infants and children. I was interested this week when they released an Allergy and Anaphylaxis Emergency Plan to assist families, caregivers, and school personnel in the event of an allergic reaction. Other action plans exist for this purpose. The FARE (Food Allergy Research & Education) Food Allergy & Anaphylaxis Emergency Care Plan has been commonly used in Central Ohio by pediatricians.
     I like things about both forms. The AAP form is easy to read and follow the instructions. The FARE form has simple diagrams that make it easy to quickly read through the instructions that match the symptoms. Both talk about when to use antihistamines and epinephrine. Both talk about a plan for what to do after these are given. One difference is that the FARE form specifies something that is very important: it says that after giving epinephrine, "Transport patient to ER, even if symptoms resolve. Patient should remain in ER for at least 4 hours because symptoms may return." This is very important advice!
     The FARE form is here. The AAP form is available here. The American Academy of Allergy Asthma and Immunology has a similar (though simpler) form and it is here.
     Although I think both the AAP and FARE forms are very good, I suspect some schools may show a preference to one or the other. The important thing is to have a plan in place should an emergency occur with a food allergy reaction.

Wednesday, February 1, 2017

Is there a safe short-cut to getting bigger, faster, stronger for sports?

     As a pediatrician who sees many pre-teens and teenagers, I am frequently asked "My child wants to take ______ (sports supplement). Is it safe?" I explain that the current supplements available have not proven to be safe and effective. It is possible to have sports performance worsen because of supplements. In addition, the short and long term safety of these are in doubt, with side effects including kidney damage, growth issues, stomach issues, heart issues and high blood pressure all under investigation.
     Here is a link about safely improving sports performance. Here is a link to a different article about the sale of these products to under-age teens. It is good to remember the store is trying to make a sale, not look after your safety. Be very skeptical about claims these sports supplements.
     The safest way to gain strength and muscle is to add lean protein in your diet. If you Google search this, millions of articles come up. Some of these, sadly, will lead you to purchase their supplements (which I hope our patients will avoid)! Here is an article with good information about good sources of protein.

Monday, January 16, 2017

CVS Is Offering a Cheaper Alternative Epinephrine Injector

     As previously discussed in this blog, epinephrine injectors are often very expensive. They also can be life-saving in the case of a dangerous life threatening allergic reaction.
     As is being publicized, CVS is offering a less expensive alternative. It is a generic equivalent of a prescription epinephrine injector called Adrenaclick. They are going to be offered at $109 for a twin pack. Here is a webpage from CVS about these. Note that the doctor's office will need to write something specific ("epinephrine auto-injector") to qualify for this. When your child who needs an epinephrine injector needs a refill or is getting a new prescription, ask your doctor about this less expensive alternative.

Thursday, January 12, 2017

Another great blog about the new peanut guidelines.

     Dr. Carina Venter is a nutritionist with extensive knowledge of food allergies. She also has an excellent blog post about the new guidelines encouraging early introduction of peanut products. It includes some excellent answers to questions that might come up. Here is a link to the post.

Tuesday, January 10, 2017

New Guidelines About Introducing Peanuts At a Young Age

     Dr. Dave Stukus is a terrific pediatric allergist at Nationwide Children's Hospital. I can highly recommend him. Dr. Stukus is very active on social media in addition to his busy practice. He is a trustworthy source of information.
     Dr. Stukus' has a terrific blog post that summarizes the recent new recommendations about introducing peanut products at a young age. The blog post can be found here. It is well worth reading.