Monday, July 30, 2012

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!

Wednesday, July 25, 2012

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!

Monday, July 23, 2012

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.

Wednesday, July 18, 2012

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.