Christmas Time Allergies

     A common scenario is for us to be asked about allergy symptoms at this time of the year. If someone has watery eyes, runny nose, sneezing, and congestion during the Christmas season, it is commonly due to the Christmas tree brought into the home. Live Christmas trees naturally have lots of mold on their branches and trunk. Once they are brought inside, the heat allows the mold to multiply and the mold count inside the home goes up quickly. For those many people who are allergic to mold, this means they are regularly blasted with mold during the time the Christmas tree is in the house. Luckily, the symptoms should get better quickly once the tree is removed from the house at the end of the Christmas season.
     If you suspect this is happening to someone in your home, there are a few options. We as a family have had to replace a live tree with an artificial tree. There are multiple members of my family with mold allergies (including me!), and we had too many allergy symptoms each year to make a live tree an option. Many people will be helped by taking an allergy medicine (Claritin(r), Zyrtec(r), and Allegra(r) are all commonly recommended antihistamines available over the counter), such that their symptoms will be so mild that they are not miserable.
   

Teen Prescription Drug Abuse

     Not a fun topic but an important one: teen prescription drug abuse. An excellent overview is here. And the Drugfree.org website has lots of excellent information about the issue. Educating yourself, educating your kids to avoid taking medications in abusive ways (not prescribed for them, taken in ways not recommended, taken to get high, etc.), and being watchful for concerning behaviors is important.
     Unusual changes in behavior, finding empty spray containers in their room (inhalant abuse concern), finding empty cough medicine containers in their room (dextromethophan abuse), and other "red flags" are listed here. The Drugfree website also has a clear guide to the different prescription and over the counter medications or drugs that teens commonly abuse -- here is the link to this list.
     If there are concerns about or evidence of drug abuse, we refer children on to the professionals in the Adolescent Medicine department at Nationwide Children's Hospital. A link to their website is here. Please call us if you have questions or concerns. Be vigilant. Be safe.

Article in the Dispatch on youth weight lifting.

     I recently posted on this blog about growing children doing weight lifting. The Columbus Dispatch had an article in the Sunday edition on October 28th, 2012 that is also online here. We, at this point, feel confident in saying that if weight training is done properly, that it is safe.

Earlier onset of puberty for boys

     A study by the American Academy of Pediatrics, the largest professional group of pediatricians in the United States, recently completed a study on the onset of puberty in boys. The article is available here on the AAP website. More research is needed to answer the "Why is this happening?" question. With girls, it is thought that some combination of health changes and nutrition have pushed the onset of puberty into earlier years compared to the past.
     One thing this research does help is to provide us with an expected baseline for when it is "normal" for boys to start puberty. In an otherwise-healthy boy with the start of puberty at 10-11 years of age, we can now consider this in the normal range. Meaning it is not likely some bigger health issue is happening.

Pertussis (whooping cough)

     The number of cases of pertussis (whooping cough) are on the rise in the United States. There have been over 4000 cases in the State of Washington (when the usual number would be about 50 cases by this time in the year). The vaccine to protect against whooping cough is good but not perfect. The sad thing is that many children are going unprotected because their parents are deferring or declining the vaccine. This has left many children vulnerable to the illness. There have been at least 16 deaths in the United States this year. This number is going to continue to rise if a larger number of children and adults are not vaccinated.
     There is a new recommendation that all pregnant women should receive the vaccine (DTaP) in the 2nd or 3rd trimester. This helps protect mom and infant. The infant then is better protected while they themselves receive the vaccine and develop better immunity. Here is the CDC information.

Constipation update

     We have a handout and protocol about constipation on our website here. I realize there are more products available on the market. One website that I think is helpful for parents and families is the Pedialax website. It has good information on their products and how to help kids with constipation.
     I have had confidence in the safety for long-term use of propylene glycol ("PEG"; Miralax(r) by Merck) over the years. In fact, one of my sons uses it regularly (almost daily) to keep the bowel movements regular. The head of the gastroenterology department at Nationwide Children's Hospital, Dr. Carlo Di Lorenzo, M.D., is quoted in an article from the New York Times. I feel comfortable with children being on the medication long-term at this point. Having said that, further research needs to be done to ensure the safety. Ask your pediatrician if you have further questions.

Arsenic in rice.

     The November 2012 issue of Consumer Reports has a fascinating and scary article about arsenic in rice. After reading the article, I think it is clear this issue needs more study and further action in the future. Because of the long-term increased risk for certain types of cancer after exposure to arsenic, it is wise to make some changes now. The most important is to limit infants to one serving of infant rice cereal per day. Infants can be offered other single grain cereals instead of the rice (oat cereal is the other big single grain cereal available for infants). We will certainly have more information on this topic as time goes by. If you have questions, ask your child's pediatrician.

Pollen counts for allergy sufferers.

     For those with known or suspected allergies, knowing the pollen counts for the various seasonal pollens can be very helpful. The website I have bookmarked on my computer is the American Academy of Allergy Asthma and Immunology ("quad A-I" as my wife and other allergists say!) website. They list updated pollen counts for different regions. Our closest reporting station is in Dayton, Ohio. You can trust that whatever they find in Dayton would apply to Columbus and Central Ohio. You may find this helpful to see what pollens are "misbehaving" if you are having allergy symptoms act up. Here is the link to the Dayton pollen count report.

Nursemaid's Elbow

     A common injury for toddlers and pre-schoolers is "nursemaid's elbow" (also called subluxed radial head -- aren't you glad we call it nursemaid's elbow?). It typically occurs when the arm is tugged or pulled (lifting a child up by the hands or wrist, swinging them around by the hands or wrist, etc.). The child will have sudden pain in the elbow region. Often they will hold the arm to their side with their elbow bent, not wanting to move the arm. There is a terrific review article about it for parents here at Healthy Children. If you suspect your child has this condition, we want to see your child in the office or have them seen at Nationwide Children's Hospital. There are some children that have this happen once only. Other children have it happen a few times -- yet the orthopedic specialists will so often tell us that they will grow out of this once their elbow strengthens up over a few years. Discuss this with us if your child has this happens more than once.
     One note: if I help a four year old up onto our exam tables here in the office, I always reach under their underarms to lift the child. When asked why, I always explain that I am not wanting to lift by the hands or wrist so that I do not cause a nursemaid's elbow. I encourage you to lift your young children by lifting under their underarms.

AAP Video on Strength Training in Young Athletes

     I am excited about a new DVD and flash cards set available through the American Academy of Pediatrics here that emphasises the proper way for young, still-growing athletes to safely build muscle. Our recommendation is that if the weight is low enough that the child can do 8-15 reps at least once (2-3 sets of reps is best), it is a safe weight. This set from the AAP is designed to help with specific instruction and exercises. This is the AAP's first go at this -- I think that is great.

HPV Vaccine Update

     The American Academy of Pediatrics published an article in the November 2012 Pediatrics issue that looks at the issue of whether sexual behavior changes in pre-teens and teens after they have received the HPV (cervical cancer) vaccine series. The results are available here. The good news was that the study did not find any increase in sexual behaviors for pre-teens and teens after the vaccine series. I hope these results reassure those families that have been concerned that we are sending the wrong message (that we expect them to be sexually active before marriage) by vaccinating pre-teens.
     And remember that the vaccine is now recommended for the boys, also.

Good article from Parade Magazine about vaccine refusal.

     Adulthood often confronts us with balancing risks and rewards in life. One of those is vaccinating ourselves and our children. I strongly believe that the recommended vaccines are life-saving, safe, and critical to protecting our children's health. I strongly believe deferring them or refusing them is life-threatening, unsafe, and dangerous. Four years of college, four years of medical school, three years of pediatric training, 18 years of medical practice, and lots of reading and studying have taught me this and reinforced the facts.
     There is an excellent article in the new Parade Magazine. It reviews how the come-backs of diseases (including approximately 4000 cases of whooping cough in the state of Washington) are related to large numbers of vaccine refusals.
     Protect your children! Vaccinate!

Should kids play different sports or specialize with one?

     An interesting topic to me is whether it is better for young athletes to play one sport only or to play different sports in different seasons. I had not thought about this for awhile but was reminded of the topic by Michael Arace's article here in the Columbus Dispatch. I also found this article on a site for coaches. I think one of the interesting points in Arace's article is that spending so much time doing the same activity likely increases the risk for injury as the same muscle groups are used again and again.
     I admire my nephew's attitude. He is a Wyatt Teller, 4 star high school defensive end recruit from Bealton, Virginia who has committed to Virginia Tech for 2013. He is the youngest of 5 children for my brother and sister-in-law. Although he may have dreams about playing in the NFL, I have not heard him speak of that possibility. He talks about going into law enforcement. Although many athletes dream of playing professionally, the realty is that the vast majority of athletes do not get a scholarship to play in college and so many fewer ever get paid to play professionally.
     The first time I coached youth soccer, my team of 6 year olds scored one goal the entire season but went 0-10. At the end of the season, they seemed to have learned a lot about soccer, had a number of hours of good exercise, and (probably most importantly) had a ton of fun. For the vast majority of youth athletes, those are the important things: the exercise, learning the sport, playing with team members, and having fun.
     I am all for pursuing one sport if that is what your child enjoys, they are not having excessive injuries with it, and it otherwise works for the family. But many children benefit from participating in multiple sports throughout the year.

Supplementing Breast Infants with Vitamin D

     Back in 2008, the American Academy of Pediatrics began recommending supplementing vitamin D in breast fed infants. The original report is here. For quite some time, the only form of vitamin D supplement was a drop with the vitamin D combined with vitamin A and C (TriViSol or ViDaylin ADC). However, newer forms of drops are available that allow us to just do vitamin D by itself. The recommendation is for 400 IU (international units) each day. Enfamil D-Vi-Sol, with 400 IU per ml, is available and is 1 ml by mouth once a day. The other option is Baby D Drops, which are 400 IU per drop. Therefore the dose for the Baby D Drops is 1 drop by mouth once a day.
     If a baby takes formula, it is 16 ounces per day that would supply 400 IU in a day. Therefore, if an infant is breast feeding but supplements with formula, it is 16 ounces a day that are needed to supplement to skip doing the vitamin D drops.
     We do recommend supplementing breast fed (or breast fed plus formula supplemented infants who take less than 16 ounces of formula per day) infants with vitamin D.

Trampolines

     My wife and I were once attending a play with friends. When the play was over, we were walking out. They have a son who is friends with my oldest son. We happened to be walking by Dr. Gary Smith, MD (a national specialist in children's safety) of Nationwide Children's Hospital. When they asked if we thought trampolines are safe, I introduced them to Dr. Smith and repeated the question. Dr. Smith said "No, do not buy one or let your child use one. They are dangerous". I said thanks and kept walking. That in a nutshell is how pediatricians feel about trampolines.
      There is a good review of this here at Shots the NPR Medical Blog. The American Academy of Pediatrics has again released an updated statement about trampolines and is available here. We know there is a "thrill" factor that attracts everybody to trampolines. And we have kids that jumping on a trampoline keeps them active when they may struggle to be physically active in other ways. But we urge you to have your children avoid trampolines, even those with safety features and when limiting the trampoline to one person at a time, to avoid the serious and not-too-serious injuries that can occur with their use.

Croup

     Croup is a viral upper respiratory illness. It is known to spike seasonally in how frequently we see it. Traditionally that is when we see a change from a steady (warmer or colder) temperature to a different temperature. So we can almost predict that we will hear more about this cough is the Fall and the Spring. It also goes on throughout the rest of the year. We have had dozens of cases in the office recently. Sometimes to rule-out Strep if there is a sore throat, sometimes to discuss treatment for stridor if that has occurred, and sometimes to check the ears and chest. Because croup is viral, it does not respond to antibiotics.
     We have an extensive description of croup, when to be seen, and when to just treat at home here on our website for Hilliard Pediatrics. Remember the vast majority of cases of croup do not need to be seen in the office and will pass soon in a few days at home. Also, some children and adults frequently get a croupy, barky cough or laryngitis (loosing your voice). One of my sons has had it at least two times a year since he was very little. He has not gotten terribly sick with the croup (although we have many a night where his barky cough has disrupted every one's sleep), but it is frustrating. If your child has had croup quite a few times, discuss it with us in the office.

When to see an allergist.

     Allergies are a big topic in my life. I have allergies. My wife and children have allergies. I have many family members and friends with allergies. As a pediatrician, I see many children with allergies of all sorts. My wife is a pediatric and adult allergist. A common question is when to see an allergist. The American Academy of Allergies Asthma and Immunology has a good website here with lots of excellent information, including when to see an allergist. Our website at www.hilliardpeds.com has a handout about Allergic Rhinitis. My wife's practice is Midwest Allergy. Their website is here and has a list of conditions in which it is recommended to see an allergist. Here is the list:

Anyone who has reacted to a food

Anyone who has reacted to a stinging insect

Anyone with moderate to severe eczema

Anyone with persistent asthma (on a controller medication)

Any asthmatic who requires more that one course of systemic steroids per year or who requires more than one canister of albuterol per year

Anyone with rhinitis who fails pharmacotherapy or desires to minimize medication use

Anyone with chronic or recurrent sinusitis/otitis

Anyone with recurrent infections of any type

My list of reasons to refer includes:
1. Allergic rhinitis symptoms that do not respond well to over-the-counter or prescription medications.
2. Allergic reactions to foods.
3. Allergic reactions to stinging insects (bees, wasps, hornets).
4. Difficult to treat eczema that may be triggered by allergies.
5. Persistent or difficult to control asthma.
6. Recurrent or unusual infections that may be a sign of an immune problem.
7. Recurrent sinusitis that does not respond to other treatments.
8. Finally, if someone is struggling with allergy symptoms that may be from a pet (cat, dog, gerbils, hamster, etc.) and would consider having the pet live somewhere else, I would confirm the allergy with testing first.

Certainly discuss with your primary care physician if you have concerns about the above issues.

2012-2013 Seasonal Flu Vaccines

     Many offices, including our own, have received the seasonal influenza (flu) vaccine for the coming season. The Centers for Disease Control has excellent information about the flu vaccine here. It is now routinely recommended that all children 6 months to 18 years of age receive the vaccine each year. We have both the nasal spray and the shot available. For children less than 24 months of age and those with a history of asthma, heart conditions, diabetes, and kidney disease, it is recommended to do the flu shot (not the spray). Children less than 9 years of age, if this is the first year they have received the vaccine, it is recommended to received two doses of the vaccine one month apart. We offer the flu vaccine at both well visits, sick visits (if not "too sick" -- we can discuss it), and walk-in flu vaccine clinics. The dates for our flu vaccine clinics are on our website here. It is not too soon to start receiving the vaccine now -- the CDC site has good information on that topic (when to receive the vaccine).

Swine flu and the fair

     As reported in the Dispatch, pigs from the Ohio State Fair have tested positive for the swine flu. There are at least 41 cases (almost all in children) of swine flu confirmed in fair-goers. The basic message is a common one: wash your hands or use hand sanitizer after touching animals. Especially before you eat (where you can pass germs from your hand to your mouth through the food)!
     Remember that despite all the different names for different types of "flu" (influenza), they essentially cause the same classic flu symptoms: fever, aches, cough, cold, stomach upset, and sore throat. Here is a good review of what to watch for with the swine flu and common symptoms.
     Bottom line: your mother was right -- wash your hands!

Sudden Cardiac Death among young athletes

     An ongoing discussion in this country amongst physicians, families, insurance companies, and others involves how to better prevent sudden cardiac death among young athletes. Many times these teenagers collapse suddenly and die unexpectedly on the playing or practice field. Since someone with a heart condition that would predispose them to this often has no symptoms and a normal exam, the question then is: Can we prevent these tragedies? It is possible to find these athletes before tragedy strikes with an electrocardiogram (EKG) and echocardiogram (ultrasound of the heart). One major issue is the expense and who will pay for it. These tests are not cheap and can cost more than $1000. If they are done for screening (not because there is already a problem -- dizziness with exercising, fainting with exercise, family history, etc.), insurance companies often do not cover the expense. One study estimated it would cost over a million dollars of money spent screening many athletes to prevent one episode of sudden cardiac death amongst young athletes. As much as it is easy to feel as a caring parent that this expense should be covered by insurance, remember insurance works as "shared risk" -- the more routine tests, the more expense for everyone. And with health care so expensive at this point, more of the cost of "not everyone needs that test" will fall on the people that use that care.
     One intriguing new option is mCore. There was an article in the Columbus Dispatch this week discussing the issue and mCore's ability to provide cost-effective screening. I think this is an exciting option. I hope these kind of screenings allow us to prevent more episodes of Sudden Cardiac Death.

Pediatricians and formula samples.

     Last week, the American Academy of Pediatrics Committee on Breastfeeding issued a "resolution" to encourage pediatricians to stop distributing formula samples at prenatal visits and upon discharge from the hospital. There are good studies that show that these samples decrease the number of infants fed breast milk exclusively and the number of infants fed any breast milk. The specific resolution is here.
     I and my partners at Hilliard Pediatrics have mixed feelings about this issue. As much as we want infants to successfully breast feed, we know many families find the samples helpful. We want to do what we can to encourage infants to have breast milk the first year of life. We also want to encourage infants who are going to receive formula to receive the best formula.
     We will continue to discuss the issue here at the office. I suspect there is going to be an ongoing discussion for many in the coming months and years. I will keep you posted!

Getting your child to take medication -- part 2

     Over the years, we have found getting children to take medication is not always easy. And sometimes it takes a major amount of effort! The following are a number of tips to try to help you get your children to take their medicine.
     First, there are some scenarios where it is not necessary for your child to take any medication to get better. Although we as adults may agree that your child would feel better if we got their 102 degree temperature down with a fever-reducer, that their stomach would feel better if they chewed up a chewable antacid for their stomachache after eating spicy food for dinner, or their nose would not run so bad if they would take an allergy medication. However, with these issues, they "will be okay" without taking the medication. Consider in these situations simply not stressing over the medications. One Christmas morning in the Teller household, we had our son vomiting with a fever of 102-103 degrees. He declined any fever-reducer (which stressed out his grandmother) because, in his words, "that will make me puke". So he just laid on a cool tile floor in the bathroom and rode out his fever. If he would have been more lethargic, we would have pushed the issue. It was a 24 hour viral illness and was better the next day.
     There are some instances when it is essential that the child take their medication. There are bacterial infections, such as pneumonia or staph skin infections, when it is very important for the medicine to be taken in full, each dose. In these cases, we worry that a child could end up quite ill and in the hospital if they do not do well taking in their medications.
     One issue with children taking their medication is "issues of control". Even nice children will test their parents. They may think they can refuse to do something their parent wants them to do and exert some control over the situation. Although it does not always work, sometimes these children can be convinced to take the medication with small bribes -- a small treat, a coin to put in their piggy bank, a special privilege. Do not hesitate to say "You will need to take your medicine now." Although giving them a choice (in a dosing cup or in a syringe?) may help, it is best to stay unemotional and matter of fact.
     A common issue is taste of the medication. Sometimes there is more to do about this than others. Thankfully, the pharmacist can often add flavoring (which may really help) to a medication if your child will not like the initial flavor. For better or worse, there is no flavor every child loves. One study showed that the 30% of all children would take even the worst tasting commonly-prescribed antibiotic (Vantin(r)) and only 80% of all children would take the best tasting (cefdinir/Omnicef(r)). With over-the-counter medications, you often have some choice over taste. I think you can assume that name-brands taste better than generics (although not always). Many times with a taste issue, "chasing" the medicine with something to eat or drink (a favorite juice, a lemon-lime soft drink, etc.) may help. Remind your child "As soon as you drink the medicine, you can have your juice".
     We are asked many times whether the medication can be added to something the child regularly drinks -- milk or juice. Keep in mind, you want to add enough beverage to cover the taste, but not so little the child can clearly still taste the medication. Also, if the medication is put into something to drink, they have to drink it to get the dose. If you drink half of the medicine, you probably got half of the dose if you mixed it up well. So proceed cautiously!
     It certainly helps to eliminate issues with the flavor of medication if the child learns to swallow a pill. The average child learns at about 12 years of age, but we see grade-schoolers who can swallow a pill and teenagers who cannot swallow a pill. I try to remind the "big kids" they swallow food pieces much bigger than the pill size. One good way to work up to swallowing pills is to try swallowing small pieces of candy and gradually increase the size of the piece. For instance, if your child can swallow Nerds(r) candies then move on to Tic-Tacs(r). The good news is that if your child fails to swallow it, they can always just chew it up. Reward your child's success with allowing them to have more of (and to eat it normally) the candy they just successfully swallowed.
     I hope this information helps!

Tick bites

     Tick bites are common during the warm weather months. The two most common ticks in Ohio are deer and dog ticks -- the deer ticks are smaller and the transmitter of Lyme disease. Dog ticks are larger and do not spread Lyme disease. There is an extensive review of deer ticks here and there is extensive information about management of ticks here. It has been shown to be helpful to take a shower within 2 hours of being outdoors, using DEET insect repellent while outdoors, wearing long sleeves and pants, and do tick checks when back indoors.
     When I practiced in Wisconsin for 2 years, I saw hundreds of ticks that I removed -- at check-ups and sick visits. So many of our families spent a lot of time outdoors and would get dozens and dozens of ticks every year. Although the chances of being exposed to a Lyme disease-carrying tick was thought to be about 1 in 100, I only saw a few cases of Lyme disease. The ticks were probably removed (by a shower or the family removing it at home -- or me doing it in the office!) before they had a chance to feed long enough for the germ to pass to the person. Most the kids who did have Lyme disease had the classic symptoms or Lyme disease arthritis. In that 2 years there, I did not, thankfully, run into any cases of difficult to treat, "bad" Lyme disease. So in a state, such as Ohio, where it is much less likely to get Lyme disease from a deer tick bite, we are very unlikely to see cases of Lyme disease.
     Tick removal is best done with fine-tipped tweezers. This is an excellent guide to tick removal from the CDC. To prevent a skin infection at the site after removing the tick, clean with soap and water or with hydrogen peroxide. Apply a small dab of Neosporin(r) to the site. Watch for redness, drainage, fever, or rash -- see us if this occurs in the next two weeks after you have removed the tick.

Mosquito Bites

     We are in the middle of the mosquito season here in Central Ohio. I had a request via Facebook to discuss this topic. What follows is information about prevention of bites, treatment of bites, and diseases that concern us that are transmitted via mosquito bite.
     The two major infections we worry about from mosquito bites are West Nile Virus and the group of encephalitis-causing viruses (arboviruses). Both are uncommon enough that we see very few cases of these. I do not know of a single case of confirmed West Nile Virus illness in a patient at Hilliard Pediatrics. I am aware of a few children in our practice who have had a mosquito-bite related encephalitis. Therefore, please realize that the chance of a life-threatening illness from a mosquito bite is very, very small. Having said that, the chance of being infected from a mosquito bite is greatly reduced if you use good bite-prevention.
     There are at least 175 species of mosquitoes in the US. The female mosquito bites us (the males do not) because they need blood to develop fertilize eggs. As experience tells you, some people are more prone to bites from mosquitoes than other people. Scientists are still studying what it is about some people that attracts the bites, but it is known that carbon dioxide released from the skin attracts the mosquitoes. Some people release more from their skin than others. Scientists believe 85% of this "mosquito magnet"issue is genetic.
     To reduce the possibility of being bitten, regularly use an insect repellent on exposed skin; wear long-sleeved shirts, long pants, and hats to cover exposed skin; avoid being out in the early morning and in the evening; and consider applying permethrin-containing to clothing, shoes, tents, and other gear.
     There are different insect-repellents. For children less than 2 months of age, drape their carrier or bouncy seat with mosquito netting. For children 2 months of age and above, DEET and picaridin are excellent repellents. Both have been extensively studied. This link to the CDC website is a good resource about the insect repellents. I recommend the DEET-containing or picaridin products for children 2 months and above. Although concerns have been raised over the years with the toxicity of DEET, the risk is very, very low AND the potential risk of being unprotected is real. The higher the concentration of DEET, the longer it lasts (for instance, 5-10% lasts about 2 hours while 20-30% lasts 5-6 hours). The CDC also has a Frequently Asked Question page about insect repellents. The American Academy of Pediatrics states that DEET is safe for children 2 months and older if used as recommended. If one product does not protect you and your child from insect bites, try a different product or stronger concentration.
     For the mosquito bites themselves, try your best not to scratch the bites, use an anti-itch cream or gel (over-the-counter hydrocortisone cream, Itch-X gel, and Calamine or Caladryl are all helpful), and use oral diphenhydramine (Benadryl) if the itching is not well controlled by one of the creams or gels, and expect that the bites should gradually fade away over a few days to a week. The bites can last longer if repeatedly scratched. It is rare for the bites to pick up a bacterial infection. If that happens, it will have a crusty discharge, be tender, and more red.
     Many people become mildly allergic to the bites of some species of mosquitoes. It is very, very rare to see someone have trouble breathing (a worse allergic reaction). The mild allergic reactions have large (even 6-7 inches across), red, warm, itchy areas that often need oral diphenhydramine (Benadryl). Cool compresses often help also.  

Vehicle Safety Laws in Ohio and Pediatric Recommendations

     It is a common question for us to be asked: what is the law in Ohio about car safety? And are the American Academy of Pediatrics (AAP) recommendations the same or different? As of June 2012, the following are the current Ohio laws (here is a link) and the current AAP recommendations (here is a link). Realize the AAP recommendations are more conservative, safety wise.
     Ohio law says:
-- if your child is under 1 year of age and under 20 pounds, they must be in a rear-facing child seat.
-- if your child is at least 1 and weighs more than 20 pounds, they can ride in a forward-facing seat until they grow out of that seat.
-- if your child weighs over 40 pounds, they must ride in a booster seat.
-- your child must use the booster until he is 8 years old or at least 4'9" (57").
-- children under 12 years of age should ride in the backseat to prevent airbag injuries and fatalities.
-- drivers and front-seat passengers must wear a seat belt, even if air bags are available.
     The AAP recommends:
-- all infants and toddlers should ride in rear-facing car seats until they are 2 years of age or until they reach the highest weight or height by their car safety seat's manufacturer.
-- all children 2 years or older (or those younger than 2 years of age who have outgrown the rear-facing weight or height limit for their car seat) should use a forward-facing car seat with a harness for as long as possible, up to the highest weight or height allowed by their car seat's manufacturer.
--all children whose weight or height is above the forward-facing limit for their car seat should use a belt-positioning booster seat until the vehicle seat belt fits properly, typically when they have reached 4'9" (57") in height and are between the ages of 8 and 12 years of age.
-- when children are old and large enough to use the vehicle seat belt alone, they should always use lap and shoulder seat belts for optimal protection. All children younger than 13 years should be restrained in the rear seats of vehicles for optimal protection.
     So what do we recommend? We recommend that you follow the AAP guidelines. You will be within the law of Ohio, but taking the extra step to be safe by following the American Academy of Pediatrics recommendations.
     By the way, the average child (boys and girls) does not reach 57 inches of height until they are 11 years of age. My 12 year old twins just stopped their booster seats in the last 6 months when they reached that height of 57 inches. Be safe!

Swimmer's Ear

     Swimmer's ear is a common summer time condition where a bacterial infection of the ear canal occurs. We want to see those kids for walk-ins or an appointment if you are suspicious of a swimmer's ear with pain in the ear and discomfort when the ear is touched or moved. Often these kids have been swimming recently. These infections are more common with untreated water (lakes, ponds, rivers, ocean), but often happen in treated water (pools, waterparks). See our website's protocol about ear aches for information about prevention and treatment of swimmer's ear here.

Hand, Foot, and Mouth Disease

     One of the common childhood illnesses that we see is Hand, Foot, and Mouth (HFM) disease. Many years, it is a later warm-weather illness (August, September), but this year we have seen cases throughout the Spring and still see cases nearly every day in the office. Nationwide, it has been reported that other doctors are seeing similar cases.
     HFM disease is a illness causes by a virus in the enterovirus family called Coxsackie virus. It runs it course without special treatment, but typically the fever and mouth discomfort will be helped by using fever-reducers and a combination of liquid diphenhydramine (Benadryl) and Maalox or Mylanta. See our website here for more information about the illness and its treatment.  
     On a personal note, my parents recall very well that I ruined a vacation to New York City with a bad case of Hand, Foot, and Mouth disease when I was little. And, fittingly, two of my children had the illness when we took a vacation they were toddlers. It is NOT a fun illness. But it will pass with a rough few days to a week.

Human Papillomavirus (HPV) -- warning: some mature content!

     We have now had the human papillomavirus vaccine available for the last 5 years. The ongoing research into the vaccine has shown excellent protection for those young women who were first vaccinated 11 years ago when it was first being studied. We have actively recommended the vaccine to pre-teen and teen females over the last few years. Now there is an added recommendation to vaccinate the boys. We recommend this for our pre-teen and teen boys in the office. We have recently found that the insurance coverage is now very good and the vast majority of insurance plans are covering it for girls and boys. There are two vaccines, Gardisil and Cervarix. Based on many factors, we now recommend (as many national experts do) that the girls receive the Cervarix and the boys the Gardisil. Vaccinating the boys protects them from genital warts and their partners and spouses from possible cervical cancer. For boys and girls, the vaccine is a three part vaccine: one initially, one 2 months later, and the final dose 6 months after the first.
     More background on human papillomavirus (HPV): HPV is a family of viruses with different types. The different types infect the skin or mucous membranes. They cause genital warts, cervical cancer, throat and mouth cancers, and other cancers of the private parts. HPV is the most common sexually transmitted infection in the US. It is estimated 75-90% of sexually active people will become infected some time in their lives. It has been shown that between 20-25% of all women who are virgins at marriage become infected with the virus through their spouse. HPV is passed from one person to another through genital contact, usually during sex.
     Most people with HPV do not develop symptoms or health problems (with no symptoms, it can be hard to avoid passing to someone else). The body's immune system clears the HPV infection 90% of the time within 2 years. If it does not clear the infection, it may be months or years later that a pre-cancerous or cancerous change occurs. During this time, the vast majority of these people have no symptoms or signs of a problem (no warts, no pain, no abnormal bleeding or sores). Most people with cervical pre-cancer or cancer find out with their Pap smear by their gynecologist at their annual visit. Cervical cancer causes 300,000 worldwide deaths every year. Some women with cervical cancer require a hysterectomy and then are unable to have children.
     Occasionally families ask me if I believe that vaccinating the teenager against HPV is sending a wrong message. I do not believe this is true. Although the virus is spread through sexual contact, I do not believe protecting someone against HPV is sending the wrong message. I often will tell teens "we hope you are not sexually active until you are in a long-term, committed relationship, ideally marriage". And I do not believe anyone has ever abstained from sexual activity due to a fear of cervical cancer.
     So we remain big advocates for the vaccine to prevent cervical cancer. If you have questions, please discuss it with your physician. The following websites contain lots of good information.
Gardisil
Cervarix
CDC's information

Fluoride

     Fluoride is important for helping to prevent dental caries. Fluoride is available in city water supplies, some bottled water, over the counter fluoride rinses, treatments at the dentist office, and prescription drops and dissolvable tabs. Too little fluoride in your system and the teeth are prone to tooth decay. Too much fluoride and your teeth (and bones!) will become speckled or permanently stained with a discoloration.
     The need to supplement with fluoride is based on wanting to protect the teeth from both tooth decay (caries) and too much fluoride. Over the 18 years I have been a pediatrician, the recommendation has changed in trying to make sure we find the right balance. These are the current recommendations as of now for daily adequate intake:
0-6 months: 0.0 1mg/day AND additional supplementation is not recommended at this time
7-12 month: 0.5 mg/day
1-3 years: 0.7 mg/day
4-8 years: 1 mg/day
9-13 years: 2 mg/day
14-18 years: 3mg/day

The recommended daily fluoride dose of supplement, if needed, is adjusted in proportion to the fluoride content of drinking water.
Fluoride content of water  ==> Daily dose of oral fluoride (mg)
<0.3 ppm
Birth-6 months ==> 0
6 mo-35 mo ==> 0.25 mg
3-6 yr ==> 0.5 mg
6-16 yr ==> 1 mg
0.3-0.6 ppm
Birth-3 yr ==> 0
3-6 yr ==> 0.25 mg
6-18 yr ==> 0.5 mg
>0.6 ppm
All ages ==> 0

Commonly prescribed forms of fluoride include the following:
Luride(r) Drops (0.5mg/ml -- comes in 50ml. bottle)
Luride Lozi-Tab (0.25, 0.5, and 1mg -- comes in a bottle with 120 tabs)

     If you have well water, it is important to check the fluoride content of the well water before supplementing. There are families with wells that happen to contain a high amount of fluoride and supplementing these kids will just stain their teeth. For families with no fluoride in their well [we have well water at our home and we found it has no fluoride], we can discuss when you are in the office if your child needs a fluoride supplement. For families who do not drink tap or well water and primarily get water from bottled water, we can discuss at their check-up whether your child needs a fluoride supplement.

A good concussion reference.

     The Healthy Children website has a very good information page about concussions. I am adding a concussion protocol and information sheet to our Hilliard Peds website in the near future. Here is a link to the Healthy Children website information page on concussions.

Summer Check Ups

     Many children, especially school aged kids, have summer time check ups. We can complete sports physicals for the new year, update vaccines, check on growth and development, and discuss other issues as needed. As these appointments tend to quickly fill up as we get closer to the summer season, now is the time to call your doctor's office and set up the appointment.
     Remember that we at Hilliard Pediatrics are welcoming our new physician, Dr. Beth Schloss, M.D., to the practice. She is starting the first week of July 2012. She is now completing a chief residency year after completing her pediatric training at Nationwide Children's Hospital. Dr. Beth and the other physicians are scheduling for the summer check up season. We, as always, will be available for sick visits throughout the summer also. Our terrific nurse practitioner, Lisa Canini, CNP, also can do check ups throughout the summer.
     Call now to schedule a time that is convenient for you and your family!

New OHSAA Pre-participation Sports Form

     The Ohio High School Athletic Association has a new Pre-Participation Physical Evaluation form that for the 2012-2013 school year, it will be the preferred form. We will soon have it up on our website here. It is also available at the OHSAA website here. We have copies in the office also if your child is here for a checkup and needs the form completed. By the way: it is six pages long now.

Butterbur for migraine prevention

     I am a long-term migraine sufferer and can empathize with my patients that have migraines. I have been on a number of treatment and preventative medications and know that it can be difficult to deal with migraines. It has taken me a long time to figure out my triggers (journaling about my headaches helped).
     I am open minded about recommending different preventative measures if they have been scientifically tested. One herbal supplement that has been scientifically tested is butterbur. A purified form without PAs (pyrrolizidine alkaloids) and 8mg total petasin called Petadolex(r) is the one I would recommend over alternatives. Side effects are considered minimal and include belching, itchy eyes, diarrhea, and headache(!). Butterbur should not be taken by those with ragweed allergy or a history of liver problems.
     For migraine prevention, the starting dose is 50mg capsule twice a day. The dose can be increased to 75mg twice a day if needed. One average, there were less headaches and less severe headaches, a decrease by about half. It has studied in children down to 6 years of age with success.
     If your child has migraine headaches, discuss with your pediatrician whether this may be something to try.

The choking game

     A recent study published in Pediatrics April 2012 issue showed that 6% (one in 16) 8th graders had played "the choking game". This involves applying pressure to the neck to limit oxygen and blood flow in the hopes of experiencing a "high" or "rush" feeling once the pressure is released and blood and oxygen rush back to the brain. Scary! In 18 years of practice, I have had only a few pre-teens or teens where this came up, but I am shocked how high the percentage is in this study of kids in Oregon.
     I suspect kids would deny it or say they had not done it very often, but 1 out of 4 of these Oregon kids said they had done it more than 5 times. Some of these kids may briefly lose consciousness and faint. It is possible someone would become injured with this -- hitting their head, getting a cut or laceration, and possible other injuries. The numbers of boys and girls involved with the "choking game" was the same in this study. These 6% of the 8th graders were also more likely to be involved with sexual activity, drug abuse, poor nutrition, and gambling.
     If you hear your children speak about this, see odd bumps or scrapes on the head or face, or see unusual marks or bruises on the neck, ask your child about it. If you are suspicious but your child will not further discuss it you, contact your pediatrician's office to further discuss it.
     A good website for more information and support is Games Adolescents Shouldn't Play (GASP).

Movie and video game ratings

     Every parent struggles with picking or approving of movies and video games for their children. This can be difficult. I personally have had struggles with this issue with my three children. Each family will have their own comfort level with different material. Many times, one scene in a movie or some occasional inappropriate language will tip the balance towards "not right for my child". I think one of things that make a good parent is being able to say "no" to your child when they want to watch or play something when you do not approve of it. Many adults can recall having nightmares from a frightening scene in a movie. Children are especially vulnerable to nightmares from frightening scenes. Exposure to violence, sexuality, and inappropriate language at a young age can make them more accepting of it -- not a good thing at a young age. Children do NOT need to grow up too quick.
     The Entertainment Software Rating Board at www.esrb.org provides the information on the package of video games but many parents will tell you it is inadequate in helping you decide if it is right for your child and family. There are two good websites that can give you more information so that you can make a more informed decision. One of them is Kids In Mind. This site thoroughly covers many parts of the movie and gives you more information to make an informed choice. The other site is Common Sense Media, which gives information about both games and movies.
     Stay involved in your children's choices about television programs, movies, and games. I hope these websites help you make informed decisions.

Poisonous plant rashes

     Our poison ivy season seems to be shaping up to be a bad one!  The combination of the warmer weather and damp late winter and early spring seem to have turned the outdoors green very quickly. This has apparently helped the poison ivy grow and we have seen quite a few cases in the office.
     The best treatment with any poisonous plant rash is PREVENTION. It can be helpful to Google search images of "poison ivy" if your child is prone to the rash to help try and avoid the plant. If you think you did get exposed, take a warm soapy shower or bath as soon as you can to wash the oil from the plant off your skin.
     A couple points: 1. You CANNOT tell which of the poisonous plants that caused the rash by looking at the rash -- they all cause the same rashy issues. 2. There is a lot of poison ivy (80% of the rashes we see) and poison oak (about 15% of the rashes we see) in Ohio, but almost no poison sumac -- that is a more Southern plant.
     Please see our website handout about treatment and prevention here.

Websites that are good resources for parents.

     There is so much information on the internet that it can be intimidating to try and figure out what information to trust. I will list some websites that consistently are good, reliable resources of information.
     The American Academy of Pediatrics, the major national organization of pediatricians, has a wonderful website called Healthy Children. It is a wonderful resource for many topics. I would rate it the top, reliable website for information on children's health.
     Another helpful website is Kids Health. It is run by a large nonprofit organization: Nemours. They cover many topics and has excellent information.
     If you are looking for information about a specific illness or about specific information about health risks in a specific country, the Centers for Disease Control and Prevention website is very helpful. Their information is top notch.
     One of top children's hospital in North America is Toronto's The Hospital for Sick Children. Their website at this link is comprehensive and helpful.
     Our local hospital, Nationwide Children's Hospital, has a very nice website that has some good information.
     I hope these are helpful!

Lingering stomach symptoms after a viral infection

     We are winding down in the "stomach flu" season. There have been at least two viral illnesses (probably quite a few more!) this year, norovirus and rotavirus. They have very similar symptoms (vomiting, diarrhea, possible fever) and it really is not possible to tell the difference between the two or other viruses that cause the gastrointestinal viruses. They generally run their course with help from rest, clear liquids, and a bland diet. The things that worry the pediatrician: dehydration, doubled-over abdominal pain not quickly relieved by vomiting or diarrhea, blood in the vomit or diarrhea, or a late fever. See our website for more information here.
     I want to review a common thing that happens after the viral illness starts to calm down. Your child is starting to feel better, act better, and wants to return to their normal diet. But many times, when you return to the normal diet, some cramping, vomiting, or diarrhea happen. The younger you are, the longer it takes to recover from these viral gastrointestinal illnesses. Many times when these symptoms come back, it is frustrating, but it is your body's way of saying it needs more time to recover. And the way to do that is to return to a bland diet and clear liquids. That means no dairy, no spicy foods, and no fried foods. That is not easy -- I know! But take the return of the symptoms as your body sending you a message.
     There are good studies that show rotavirus symptoms can linger with diarrhea in young infants for 4 weeks. And many other "stomach flu" viruses can cause lingering symptoms for 1-2 weeks after the viral infection has finished. Remember that we do not recommend any medication that says it is for vomiting, nausea, or diarrhea. We share your frustration with how these symptoms disrupt life, but the worry is that the medication is delaying how quickly your body is able to clear the viral infection out of its system.
     Certainly call our office during regular office hours if you have questions or concerns about these gastrointestinal symptoms. Children with dehydration or doubled-over pain need to be seen right away. We recommend the Nationwide Children's Hospital Emergency Department. More information about their services is available here. Warning: the link loads slowly.

Fifth Disease

     Fifth disease is a common viral infection of childhood. It is the "slapped cheek, lacey rash" viral illness. We have seen and heard of more cases of Fifth disease recently, so we believe there are more cases in the community. The Kids Health website has an excellent description of the illness here. Although if you have questions or concerns about the rash or are unsure if the rash is indeed Fifth's disease, we can see your child for walk-ins or a routine illness appointment. However, most children with Fifth disease do not need to see the doctor.

Hot Tub Folliculitiis

     A common rash pediatricians see is called "hot tub folliculitis". The rash appears most commonly on the areas where some one's swimsuit covered. It appears as small to larger pimplish bumps and sometimes other small red bumps. One can have a few or hundreds of these bumps. It usually breaks out in 2-5 days after the initial irritation.
     The hair follicles can become clogged with oil from our skin or sunscreen. Exposure to changing temperatures, as with getting in and out of a pool or hot tub, make the follicles open then close -- potentially clogging these follicles.
     The rash may cause no symptoms or can cause itching or mild pain. Many children do not seem to be bothered by the rash. The rash may fade on its own over a few days. If the itching or discomfort are more troublesome, a mild antibiotic ointment or hydrocortisone cream may be used. Occasionally, with worse inflamed-looking pimples, an antibiotic by mouth is needed.
     To avoid hot tub folliculitis, these things are all helpful: 1. Shower before you enter a pool or hot tub. This helps clean off the germs and oils on your skin, making hot tub folliculitis less likely. 2. Take a shower after being in the pool or hot tub. Get out of the swimsuit soon after being in the water and get into clean clothes. If you have plugged your pores while being in the water, getting out of your swimsuit, showering, and getting into clean clothes will make it less likely the you will end up with folliculitis.
     If your rash is larger pimples, very itchy, getting worse, or something you have other questions or concerns about, call your pediatrician's office during regular business hours.

Teething and fever

     Traditionally, pediatricians tell families that teething does not cause a fever (a body temperature of 100.5 degrees or greater). Pediatricians do not want families to dismiss a fever when there may be a more serious cause. Parents feel more comfortable placing blame for the fever on something they cannot control (teething) versus something they potentially can control (another illness after an exposure to someone else who was ill).
     Pediatricians base their recommendation on many things. One is that there was a large study of young children in the "teething age" (3 months to 2 1/2 years of age) who where carefully screened for bacteria or viruses when they had a fever but little other symptoms. Over 85% of this group were found to indeed have a virus (usually) or bacteria (less often). Many times, as your immune system fights off an infection, the only symptom is a fever. The authors of the study felt it was likely there were even more fever-causing  germs they did not find.
     We certainly do find some of these not-too-sick-appearing feverish children do have a viral or bacterial infection that needs some attention. Some of these would include urinary tract infections, ear infections, and viral or bacterial throat infections. Another common viral infection to cause a prominent fever with little other symptoms (until a rash occurs when the fever breaks) is roseola.
     On an interesting note, a study published last year on infants in Italy showed that they found temperatures peaking at 100.6 degrees with infants that they felt had no other sign of infection. The limiting factors in this study is that the temperature was only taken once a day by the researchers and they were not doing any lab studies to confirm or deny the idea that there may be viral or bacterial infections that were not evident on exam.
     So we want you to not assume that a fever is from teething. The usual worrisome things about fever (not perking up when the temperature comes down, a fever for five straight days, temperatures of 106 degrees or more) should be taken seriously. And remember these important facts about fever: fevers are caused when your immune system is trying to fight off an illness; we treat fevers for comfort reasons (not because they are dangerous) until the temperature is 108 degrees or more; and the chances of your child having a "dangerously high" fever (108 degrees or more) is very, very unlikely. Make sure you read our "Fever" protocol on our website here.
   

Clear fluids for vomiting

     In the Winter, we see and hear about many children with vomiting from the "stomach flu". One of the hallmarks of treatment is doing clear liquids while you have nausea and vomiting. I want to clarify some things about this instruction to help you avoid potentially making the situation worse. Remember to avoid milk, dairy (cheese and yogurt), and greasy foods (chicken nuggets, french fries, hamburgers, etc.) during the illness.
     For infants and young children, Pedialyte(r) is the best option. It has an ideal combination of sugars and salts for infants and young children. We want your child to take enough to stay well hydrated (urinating at least every 6 hours, tears if they cry, moisture in their mouth). If your child will take as many ounces in a day of what they normally would drink, that is great. If your child is 18-24 months of age and will not take the Pedialyte because of the taste, it is okay to try Gatorade(r) or Powerade(r) instead. Some children like the taste better with the sports drinks.
     For older children, water, Gatorade(r) or Powerade(r), lemon-lime sodas, or ginger ale are all likely to be well tolerated. Two big things to mention: the bubbles of carbonated sodas (7-Up(r), etc.) are NOT easy on an upset stomach. It is better to let the soda "go flat": pour it into a cup or glass then leave it out on the counter for a while before drinking it. Also, sometimes if it is cold, it is worse for the nausea. Letting the soda be flat and at room temperature is most likely have it not bother the stomach.
     Call your doctor's office if you have further questions about how to help your child through a vomiting illness.
   

Learning to swallow pills.

     There are many reasons to want to have your child be able to swallow pills: to avoid the taste of liquid medications your child may not like, to avoid spilling liquid medications, to make it easier to carry the medicine with you, and to avoid having to buy multiple forms of over the counter medications.
     We meet young grade schoolers who can swallow pills and teenagers who cannot swallow pills. There is no magic age where "you should be able to swallow pills" but the average child learns to swallow pills at about 11-13 years of age. Many children can start to take pills aimed at adults when they reach more of a petite adult size (85-100 pounds). Check with your doctor's office about specifics for fever reducers, cough and cold medicines, and antibiotics.
     Drink something: Every pill we would recommend for or prescribe to your child can be taken with something to drink. For many children trying to swallow a pill, having something to drink before and after helps tremendously. Take a drink and swallow first. This makes it less likely a tablet or capsule will feel more "stuck to your tongue" and more likely it can "slide down" well. Then pop the pill into your mouth and quickly follow that with a good-sized drink to "wash it down". If the pill did not go down, follow it with a few more swallows of something to drink.
     Mind where you put the pill in your mouth: Some folks find it helpful to "toss the pill back" as far as you can on the back of your tongue -- closer to where we want the pill to go. My partner Dr. Jeff Crecelius often advises tossing the pill onto your tongue, taking a drink of something and briefly hold it in your mouth, tuck your chin to your chest, then try to toss your head back and swallow at the same time. The idea is that this motion as well as the swallowing the liquid will propel the pill back so that it is easier to swallow.
     Practice with something small: Small bits of candy are a good way to practice. One of my sons liked starting with Nerds(r) candies. He would try those one at a time. If they went down easy with a drink or two of water, we moved onto something a little bigger: TicTacs(r) or M&Ms. If you can swallow one of those with water, you can swallow a reasonably sized pill. The good news is that if your child does not swallow the pill, they can always chew up the piece of candy and try again.
   

Preventing Birth Defects with a Healthy Diet

     Recent research published in the Archives of Pediatrics & Adolescent Medicine showed that a high-quality diet during pregnancy lowers the baby's risk of neural tube defects (such as spina bifida) and cleft lip and palate. Take a prenatal vitamin when you are trying to become pregnant and throughout the pregnancy. And eating a healthy diet is important.
     A healthy diet should include (1) a variety of fruits and vegetables, (2) dairy and calcium-rich foods, (3) lean protein (lean meat, fish, eggs, tofu, beans, and peanut butter), (4) breads and grains, and (5) iron-rich foods (lean red meat, poultry, fish, breakfast cereals, nuts, and dried fruit).
     Vitamins are important during pregnancy and these vitamin-rich foods help the babies growth and development: (1) Folic acid is a B vitamin that prevents the serious abnormalities of the brain and spinal cord called neural tube defects, including spina bifida. Cereals, leafy vegetables, and beans are all good sources of folic acid. (2) Vitamin C is in many foods, including oranges, grapefruit, strawberries, honeydew melon, papya, broccoli, cauliflower, green peppers, tomatoes, and brussel sprouts. (3) Vitamin D helps a baby have healthy bones and teeth. Good sources of vitamin D include fatty fish (salmon and tuna) and fortified milk or juice.
     The Mayo Clinic's website has helpful information about this topic here.

Kelch-Teller Syndrome

     Over the years, Dr. Lisa Kelch and I have noticed many cases of "pull-up dermatitis" in our office. Although we see it commonly, after a literature search a few years ago, we realize it is not something previously mentioned in the medical literature.
     We note that quite a few 3-5 year olds who are wearing big kid underwear during the day but still wearing a pull-up at night will have a rash on their bottom. It is often rough small to medium sized reddish bumps. They sometimes can itch but do not always. They seem to completely disappear when the pull-up is no longer worn at night as the child gets a little older.
     Although it seems as if changing to a different brand of pull-up would help, it rarely seems to help. We have found that doing a layer of Aquaphor(r) Healing Ointment at bedtime helps. It also may be needed again in the morning. If that does not help the itching, doing a thin layer of 1% over-the-counter hydrocortisone cream in the morning every few days can help.

Sunscreen

     As your children become older, their growing independence means we have to rely on them remembering to take care of some of their daily needs. One of those regular needs I want to remind you about is sunscreen. Although the current generation of children is doing so much better than previous generations with regular use of sunscreen. A recent study (Pediatrics, February 2012, Dr. Dusza and others) showed that many preteens have had a sunburn in the past year. Preventing this sun damage helps prevent skin cancer later.
     Remind your children to regularly use sunscreen before times outside, whether hanging out with friends, going to the pool, or playing sports. The Spring sports season starts soon and it is a good time to get back into the habit of using sunscreen -- for tennis, soccer, baseball, and softball, field hockey, lacrosse, and all the other awesome Spring sports. Follow the directions on the package. It is best to reapply if out in the sun for a long time. Use at least a SPF of 30. Higher SPFs have not been shown to be "much better" (and can be more expensive). If the cost is the similar, using a higher SPF makes sense.

Getting your children to take medication -- part 1

     One of my sons has not been the best medicine taker in our family. We have struggled over the years, especially with getting him to take liquid antibiotics. I will post here my sons method and follow up this with another post sometime soon about other methods.
     I will be honest. Before I had children and then before my one son has been a difficult medicine taker, I thought families that struggle with this were "just not trying". But the truth is many children make taking a routine medication difficult. No medication is liked by all children. Sometimes it is the taste. Sometimes the texture. But I have certainly come to appreciate that getting a child to take their medicine is not a given.
     Through trial and error (plenty of error), my son has found this to work pretty well. We pour the medicine into a medication dosing cup. He sprinkles the top with of the liquid medicine with Nerds(r) candies. He often will then chew up a few Nerds(r) to "get the taste in his mouth". Then he quickly drinks the antibiotic (or other liquid medicine) and chews the candies that were on top. He often follows this with a few more Nerds(r) to "get rid of the taste".
     From discussing this method with other parents, I know others have found this helpful. I hopes this helps someone!

ADHD and diet

     Much has been written over the years about the affect of diet on ADHD. It can be a challenge to help children with ADHD and no treatment (medication, diet, supplements, etc.) works for or is right for everyone. There was recently an excellent review article about this topic in the 'Pediatrics' journal February 2012 issue. It was written by Dr. Millichap and Nurse Practioner Yee of Children's Memorial Hospital in Chicago.
     To summarize the big picture of this topic: there are options to try with supplements or modified diets; they work for some but not all children; it is hard to predict who they work for and who will tolerate the diet; overall side effects are rare with supplements or modified diets; and most children needed prescription stimulant medications to control their ADHD symptoms.
     Omega-3 and -5 Fatty Acid Supplements: Probably the easiest to try and certainly could help. Dose: Nordic Gummie Bears (3 per day) or Nordic Fishes Chews (3 per day) or Nordic ProEFA (2 seoftgels per day) or Nutrigold Softgel (1 per day). They should be used for at least 2-3 month, longer if needed.
     Feingold Diet or Oligoantigenic Diets: A small group of children with ADHD symptoms respond well to these elimination diets. They are difficult to pull off (months of avoiding milk, cheese, wheat cereals, egg, chocolate, nuts and citrus (Oligoantigenic) or avoiding apples, grapes, lunch meats, sausage, hot dogs, and cold drinks with artificial flavors or colors (Feingold)). You and your child may benefit from meeting with a dietician to follow one of these diets. They certainly require patience and perseverance.
     Food sensitivities or allergies: Although a few children respond to avoiding certain foods, allergists will tell you this is not a likely help unless there is a very specific worry that "he is fine unless we eat this food and then things are a disaster". Also, avoiding sugar or artificial sweeteners in children with ADHD only needs to be done if you clearly notice that the child's behavior is worse when they have more intake of these. Otherwise, do not stress these.
     Iron or zinc deficiency: Although some studies have shown that children who are low on iron or zinc have ADHD-like symptoms, not enough has been done to help me feel strongly about investigating this (with blood work) or supplementing iron or zinc for the average child with ADHD. More studies are likely to follow in the coming years.
     I think this is a good summary of where we stand now with these issues. I hope this is helpful. If you have further questions about this, please discuss it with your physician.

New Prescription Lice Treatment

     Lice is a frustrating condition. I know it brings on a major "ick!" factor for parents and children. At the Hilliard Pediatrics website there is a protocol about lice treatment here.
     There is a new prescription only medication called Natroba (r) by ParaPRO. If the over the counter medications do not work, this is an option. Potentially we can call this in to the pharmacy during regular office hours or after seeing your child here in the office. It is approved for children 4 years of age and above. It is applied to the hair for 10 minutes then washed off with warm water. You reapply the Natroba (it is a "suspension") in a week if you still see live lice. Because Natroba kills live lice and the nits, nit combing is not required. One huge drawback: the cash price (with no insurance coverage for the prescription) is almost $300. This price will likely drop over time and the insurance coverage will improve. It remains an option, however.
     Our most used generic prescription strength lice treatment is malathion (the generic of Ovide), which often works when the over the counter medications do not work. It is less expensive than the Natroba at this time.

Keratosis pilaris -- a common rash

     One of the most common every day rashes we get questions about is keratosis pilaris. It often runs in families, starts at an early age, and lasts for years. Keratosis pilaris is fine, dry bumps on the side of the face, back of the arms, and side of the legs. It sometimes is easier to feel than to see the bumps. It can start at a very early age (in the first year of life) and cannot be cured. The rash is almost never itchy. The rash is more common in families who have a history of allergies, asthma, and eczema. It generally looks less noticeable and the bumps are softer if we regularly moisterize the skin with "keratolytics" (to break up the thick keratin layer of the skin at these areas). The two major brands of these moisterizers are Lac Hydrin and Carmol, both of which are available over the counter. Other moisterizers like Eucerin and Aveeno work also, but less so. Try using these once or twice a day on a regular basis. Feel free to ask us about this rash when you are in the office.

Lavender and Tea Tree Oil

     We get questions sometimes about the use of ingredients such as lavender and tea tree oil in topical products. Although these may be generally safe and helpful, many "natural" products can cause side effects. I just read a report today by Dr. Stan Block, MD in Pediatric Annals about an issue with lavender and tea tree oils used in various "calming creams" applied to the chest for young children. He reported a number of cases of breast swelling (premature gynecomastia) in these children after the cream had been repeatedly massaged into the chest. The vast majority of the cases of breast swelling stopped after the creams were stopped. It is not known for sure how these products caused the swelling.
     This information is not meant to stop you from using these products all together, but if something unusual such as breast swelling is occurring at a young age, it is good to examine the possible causes. And it is possible that a product that is generally safe and tolerated by others may be causing more harm than good.

Hives with illnesses

     This is a common time of the year for illnesses. Some of these illnesses (pneumonia, ear infections, sinus infections, Strep throat, etc.) require antibiotics. If hives (urticaria) occur during the illness, it can be quite tricky to figure out what has caused the rash: the illness? the antibiotic? the fever reducer? something else?
     A study was done by allergists that looked at school aged kids who had hives develop while ill and taking an antibiotic. They found if the children took the antibiotic during the study, they developed hives again only 15% of the time (about 1 in 7 times). That fits for what is commonly reported: that at least 80% of the time, illnesses cause the hives. It is thought that this happens when your immune system's reaction to the illness spills over in your body and triggers your allergy system to react. The hives typically last for a few days to two weeks.
     The majority of times, oral over-the-counter diphenhydramine (Benadryl(r)) offered every 6 hours while awake will treat the hives. Although food allergies and bee sting allergies can trigger off a life-threatening allergic reaction (anaphylaxis), it is extraordinarily unlikely an illness or antibiotic would trigger a scary allergic reaction. If someone did have throat tightening, difficulty swallowing, hoarse voice, or lip or tongue swelling with hives, it is a medical emergency and 911 should be called so that your child can receive immediate medical attention.
     You may ask "What is the big deal? Why not just call it an allergic reaction to the antibiotic?" The issue is: we really only have 4 good antibiotic groups for kids (penicillins, cephalosporins, macrolides, and sulfa). If we start crossing off groups we will no longer use for your child, we have less good choices when your child needs an antibiotic. And sadly, there are no new terrific antibiotics being developed for use in common childhood illnesses for the near future.
     So what to do? We want you to call us if your child is on an antibiotic and develops hives. We want to help guide you through what to do in this situation. Based on the situation, we may change the antibiotic. Other times, we may continue the antibiotic and have you do diphenhydramine
 for a few days.

The common cold and its treatment

     We are in the middle of the common cold (viral upper respiratory infection) season. Runny nose, cough, and congestion are the common symptoms. It is hard to go anywhere at this time of the year without being exposed to the virus.
     The over-the-counter medications are available in the stores and are tempting to use to reduce the symptoms. Millions of dollars every year are spent in the U.S. on these medications. Although there is much information about these medications available elsewhere (including on Hilliard Pediatrics website at http://www.hilliardpeds.com/), I want to provide an update on some of the latest medication information.
     Antihistamines such as chlorpheniramine and diphenhydramine are often labelled as for sneezing and runny nose. Although they can cause drowsiness, these are quite safe. And most studies have shown they are the most effective over the counter medication for cold and cough. They probably help a cough by slowing down any drainage that is causing the cough. Another thing folks find helpful about the antihistamines is simply that you may sleep better as a side effect (and getting more rest is a good thing).
     Expectorants increase mucous production -- that does not sound like a good thing, does it? While these medicines can help you cough and clear your mucous (and reduce congestion in the sinuses), they will not help you cough less. As a matter of fact, they generally increase how frequently you cough. The
expectorants do not taste good and can cause an upset stomach. They are probably best used during the day to help clear mucous. Good scientific studies do not demonstrate much benefit to kids with using expectorants.
     There is some good scientific research that shows that acetaminophen (for fever and achiness) suppresses a normal immune response our body has to an upper respiratory virus. This can result is worse nasal symptoms and a longer period of being contagious to others. So be cautious about routinely using acetaminophen for the pain or achiness of upper respiratory infections.
     Both echinacea and zinc are commonly used at the beginning of a "cold" to keep from getting worse and to get better faster. However, every scientific study done with children has not shown any benefit. That does not mean to stop these if your family finds it helpful. If you have found them helpful, it is quite possible that the illness was just going to be less severe and shorted that illness.
     I recall having Vicks(r) VapoRub slathered on my chest and under my nose during colds. However, I have been not often recommended the menthol vapor rub to my patients because no good scientific study had ever shown any promise -- until now. In 2-11 year olds with a cold and cough, there was improved sleep, less cough, and less congestion when compared to children who just used petrolatum or no treatment. So using these products may certainly help you fight your child's symptoms while they have a cold.
     We still like to recommend using saline drops and nasal suction for the infants and vaporizers for all ages to help reduce the cough and congestion by mouisturizing the air.
     Good luck. I hope you find this information helpful!

Health care costs

     Health care costs have become so expensive. One area that does get discussed at times is the cost of medications. Unfortunately, you often do not know the cost of the prescription until you pick it up at the pharmacy. For most conditions that require a prescription, there are less expensive alternatives available. Sometimes these alternatives may be generic forms of medications, they may be 2 or 3 times a day instead of once a day, and they may be a little less likely to work. But they can be free or $4 or otherwise very reasonable. There are many name-brand-only medications for children that are $70-150 for a 10 day or one month supply.
     The technology exists to be able to do something amazing with the prescriptions. What if the doctor could tell you, based on the medication, your insurance, and the pharmacy, how much the prescription was going to cost? No more surprise at the pharmacy. I think this could take a minute or so with a computer. Both the doctor and you the family could make a more informed choice. And it would be natural to pick something cheaper if it was otherwise "just as good". Many programs do this on the Internet when you are searching for a DVD or a coffee maker.
      An added benefit to having this ability is that it would likely push everyone to use more generics. With many antibiotics, that is a good thing. Because the older antibiotics are often not the "big guns", we would all be encouraged to use the "weakest thing that is likely to work". That would help us keep the bacteria from becoming more resistant over time.
     Although I think a computer program that provided this information would save this country millions and millions every year in medical care costs, it sadly will not come to exist anytime soon. The reason is that the pharmceutical companies and the pharmacies will lose money. But I think pediatricians and the families that they serve would love this ability. Maybe some day....

Childhood Obesity

     Childhood obesity is an increasing problem in the United States. A combination of less activity, large portion sizes, less healthy food, and other factors have more than doubled the cases of childhood obesity in the last twenty years. Many things can be done to help fight obesity, although many of these actions are not easy and are not going to be popular. But to help make our children physically, socially, and psychologically healthier, these are important things to work on as a family. Tackling a few of these to begin with is a good start.
     The American Academy of Pediatrics recommends: eating 5 fruits and vegetables per day; getting 1 hour of physical activity per day; limiting screen time to less than 2 hours per day; limiting consumption of sugar sweetened drinks; eat breakfast daily; switch to low-fat dairy products; regularly eat family meals together; limit fast food, take out, and eating out; prepare foods at home as a family; eat a diet rich in calcium; eat a high fiber diet; and breastfeed exclusively until 6 months and maintain breastfeeding after introduction of solid foods until 12 months of age.
     Annual checkups are important for many reasons. Getting feedback about your child's growth is important in making sure they are maintaining healthy growth. If your child is overweight or obese, they can help you make a plan to make positive changes in their diet and their activity level. Set a healthy example for your children by making healthy choices yourself.
     Do not get too discouraged about this issue. As families, as communities, and as a nation, we can help our children lead healthy lives.

New information on fever reducers

     Medications such as acetaminophen and ibuprofen have been available over the counter for some years now. They are commonly used to treat elevated temperatures and pain. They are quite safe at the recommended doses and at the recommended intervals. Acetaminophen is metabolized by the liver and large over-doses can result in severe liver damage and death. Ibuprofen is metabolized by the kidneys and large doses over time can cause kidney damage.
     In recent years, studies have looked at how acetaminophen use may affect you in other ways. It has been common practice to recommend that infants receiving their vaccines that day be dosed beforehand with acetaminophen. One study looked at how this affected how immune the child was in the coming months to those vaccines. The infants who received acetaminophen on the day of their vaccines were LESS immune. It is believed that the acetaminophen dulled the infant's immune system's ability to make good protection. However, the study was done in Europe with a small number of infants.
     In addition, a number of recent studies have showed there is a correlation between acetaminophen use and developing asthma. At least two possibilities explain this. One is that the effect the acetaminophen has on your immune system may in some way make the asthma more likely. The other possibility is that respiratory viruses that can aggravate your lungs lead to asthma. And since a common symptom of a respiratory virus is a fever, the treatment of the fever with acetaminophen happens more often with those kids and adults who develop asthma.
     More research into how these medications affect us will happen. We all look forward to having more information on this topic. Stay tuned. And in the mean time, ask your physician and their staff about their recommendations for safely using these medications.

Children who are sick all the time

     One of the most common questions that we are asked as pediatricians is about children who are "sick all the time". Many of these children are in daycare, preschool, or grade school. Many of them are in the first few years of being exposed to common childhood infections: colds, flus, pink eye, etc. Many of these children do not naturally do a very good job of avoiding other germs: they touch the world around them then touch their face, eyes, nose, and mouth. They do not avoid playing with a toy the other 2 year old just played with and he has a runny nose and a cough. They will pick up a spoon just used by their recently ill sibling and put it in their mouth. And the vast majority of children will build up a better immunity to these germs through these early illnesses. Down the road, these children often are rarely sick as they do a better job of avoiding the illnesses and they have a better immunity to fight them off if they are exposed.
     My three sons went through a similar story. Each was in daycare around many other children. Each of them went through dozens and dozens of illnesses: upper respiratory viruses, stomach flus, pink eye, ear infections, bronchiolitis, croup, roseola, hand foot and mouth disease, and fifth's disease. My oldest son was in a small, private daycare his first year. My wife and I circled the calendar date that year if he did NOT have a cold or cough that day. By the end of the year, we had only circled 5 days! Now that they are 16, 12, and 12, they are much healthier with an illness being a rare thing.
     Although some children who are "sick all the time" do have an underlying problem with their immune system, most do not. And the children that do have a "immune deficiency" often have unusual bacteria cause their infections or have unusual infections (for instance, a joint infection when there was no injury to that joint before the infection). The most common immune deficiencies are self-limited -- they require no special treatment and will resolve on their own.
     If you have concerns about your child and their infections, discuss it with their doctor.