Start Talking! program to reduce medication abuse.

     Start Talking! is a program from the State of Ohio to prevent over the counter and prescription medication abuse by children. It is aimed at reducing the misuse or abuse of these medications by informing the public and taking steps to ensure that parents and families are advised about these potential issues before filling a prescription. The website is here at Start Talking! Ohio.
     I think this program is terrific and it has a very real impact on our practice. When a prescription for an opioid is written for a child (often a prescription strength cough medication for pre-teens and teenagers), a form needs to be signed by the prescribing doctor and the parent. This form then is brought to the pharmacy where the prescription will be filled. We are required to do this step with the opioids now -- the doctor could lose their prescribing privileges for controlled medications if these steps are not followed.
     This above scenario most often applies to one of the hydrocodone-containing cough medications that are prescription-only, including Histussin, Hycodan, and generics (hydrocodone-homotropine). We used to be allowed to call the medication into the pharmacy. We cannot call this medication into the pharmacy any longer. If we do write the prescription in the office, it needs to be hand delivered by the parent to the pharmacy, along side the signed Start Talking! form stating that we have discussed the safe use of these medications as they can be misused and abused, and therefore are potentially dangerous. The forms are to be signed by the doctor and the parent dropping off the prescription.
     Although there are pain medications that contain the opioid hydrocodone (along with acetaminophen), such as Vicodin, it is very rare for pediatricians to prescribe these medications -- I can recall only prescribing them a handful of times in 21 years of being a pediatrician.
     I realize this is burden to families who "follow the rules" and the medications do not become misused or abused. However, the reality is we will need to follow these guidelines for the foreseeable future.

New Bacterial Meningitis Vaccine for Pre-Teens and Teens

     One of the scariest bacterial infections in children, adolescents, and young adults is bacterial meningitis. It can come on suddenly. It can quickly progress to a deadly infection. Our Menveo vaccine for bacterial meningitis helps prevent cases of Neisseria meningitis due to strains A, C, W, and Y. Approximately 30% of all Neisseria meningitis cases in the U.S. were due to strain B, which is not in the Menveo vaccine.
     The FDA has now approved a vaccine called Trumenba that helps prevent cases of meningitis due to this B strain. It is currently approved for 10-25 year olds. It is a three shot series given at a doctor's visit then 2 months and 6 months after the first. The side effects are similar to other vaccines given to adolescents: soreness of the arm, tiredness, and headache. Generally, the vaccine has been well tolerated. The Advisory Committee on Immunization Practices, the national committee of vaccine specialists that make the recommendations we follow, is going to make a further recommendation on the Trumenba's routine use in February of 2015.
     I anticipate that in 2015, we will start to routinely recommend the vaccine series. I will keep you updated. For now at least, we do not stock the vaccine. I will definitely want my three teenage sons to receive the vaccine.

Can these medications be given together for my child?

      We are commonly asked if different medications can be given together. This is an appropriate question to ask because there are medications that should NOT be given together. The good news is so many of the medications given to children can safely be given together.

All of the following medications can safely be given together:

Antibiotics including amoxicillin, cefdinir/Omnicef®, amoxicillin-clavulanate/Augmentin®, azithromycin/Zithromax®, cephalexin/Keflex®, and trimethoprim-sulfamethoxazole/Bactrim®.

Antihistamines including Benadryl®/diphenhydramine, Claritin®/loratadine, Zyrtec®/cetirizine, and Allegra®/fexofenadine.

Decongestants including pseudoephedrine/Sudafed®.

Cough suppressants including dextromethoraphan, the active ingredient in over the counter cough medications including Delsym®.  It also includes codeine-containing cough medications that are prescription-only, such as Hycodan® (hydrocodone and homotropine)

Fever reducers/pain relievers including acetaminophen/Tylenol® and ibuprofen/Motrin® and Advil®.

Antacids such as calcium carbonate/Tums®, aluminum carbonate/Maalox® and Mylanta®, ranitidine/Zantac®, omeprazole/Prilosec®, lansoprazole/Prevacid®, and esomeprazole/Nexium®.

Medications used to treat ADD and ADHD including Concerta®, Vyvanse®, Adderall® and Adderall XR®, Focalin® and Focalin XR®, Intuniv®, Strattera®, Quillivant®, Daytrana®, and Kapvay®.

Medications used to treat anxiety, depression, and obsessive-compulsive disorder including Prozac®, Zoloft®, citalopram/Celexa®, Welbutrin®, and Paxil®.

Medications for asthma including albuterol, montelukast/Singulair®, and inhaled corticosteroids such as Qvar®, Flovent®, Pulmicort®, and others.

Nasal steroids for allergies such as Nasacort®, Nasonex®, Rhinocort®, Flonase®, and others.

     Any of the above medications can be given together at the same time or on the same day.

Nationwide Children's Hospital Sports Medicine Update

     Now that the Nationwide Children's Hospital Hilliard Close To Home is open with expanded services, including an Urgent Care, other services are being added. The Sports Medicine department, which we have found very helpful for our parents. is going to be adding 2 half day sessions in Hilliard at the Close To Home. In addition, Jessica Buschmann, Clinical Dietician with the Sports Medicine Department, is offering one-on-one, group, and team services with patients. We can refer, upon your request, to Sports Medicine physicians or the Dietician. You may also call yourself to their clinic at #355-6000.

New FDA sunscreen recommendations.

     It is well known that sun exposure leads to skin damage. The skin damage raises the risk of skin cancer and premature aging. Sadly, despite this knowledge, the rate of skin cancer is growing rapidly. Melanoma, the most serious (dangerous) type of skin cancer, has had it's incidence (the number of cases in a given year in the group of people studied) increase. In fact, the number of cases are doubling every 10 years. Melanoma is the most common cancer in the U.S. It is thought 1 in 5 persons will be diagnosed with a skin cancer in their lifetime.
     Protecting everyone with sunscreen when they are sun exposed is an excellent way to help prevent skin damage. Reading labels on sunscreen can be difficult. The SPF on the label stands for sun protection factor. Originally, we were all informed that an SPF of 16 was twice as protective as an 8 -- it turns out this was not true. In fact, these are the new regulations:
1. The highest SPF you should see will be "50+".
2. There is no evidence that says that an SPF greater than 50 is more sun protective.
3. Sunscreens with SPF greater than 15 are more sun protective than those with an SPF of less than 15.
4. "Broad Spectrum" sun screens will need to have both UVA protection (against skin cancer and premature skin aging) and UVB protection (against sunburn).
5. The terms "waterproof" and "sweatproof" will no longer be allowed.
     My recommendations:
1. Use sunscreen with both UVA and UVB protection whenever you are being exposed to the sun.
2. Look for products with an SPF of 30 or above. But realize it is not likely you are getting more (or much more) sun protection if the SPF is over 30. If the higher-than-SPF-30 sunscreen is more expensive, consider purchasing the SPF 30 sunscreen instead.
3. Reapply sunscreen every 2 hours. Reapply more often if sweating or in and out of water.
4. Covering up with sunglasses, hat, and covering exposed skin helps limit sun damage.
5. Limit sun exposure from 10 a.m. to 2 p.m. when the ultraviolet rays are the strongest.
6. For infants less than 6 months of age: a. avoid sun exposure, b. dress infants with a hat and long clothing if out in the sun, c. if adequate clothing and shade are not possible, apply a small amount of SPF 15-30 sunscreen to small areas (exposed areas on the face, arms, or legs).
Resources used: FDA report and 'FDA's Sunscreen Recommendations' in October 2014 Contemporary Pediatrics by Mary Beth Nierengarten, MA.

Pediatric Psychiatrists

     We know many of our families battle mental health issues and have a need for the services of pediatric psychiatrists. There is a need for more mental health professionals in many communities in the U.S., including here in Central Ohio. Here is our list of mental health professionals we frequently refer to on our website.
     I just became aware of two pediatric psychiatrists that are accepting new patients. They are Drs. Nathaniel Johns, MD and Walter Stearns, MD. They are with UMCH Family Services at 1033 High Street, Worthington, Ohio. The office requests that we fax them a referral with the necessary information. If you are interested in a referral, contact our office during routine office hours Monday through Friday.

Chapped Lips and Rashes Around the Mouth

     We have entered the chapped lips time of year Fall and Winter. When the weather gets cooler and everyone turns their heat on in their home, our skin and lips naturally get more dry. Many young children lick their lips more often in reaction to the dryness. The excessively licking the lips results in even more dryness once the saliva dries on the lips and the skin around the mouth. Not drinking enough causes increased dryness. So try increase the child's water intake. Although there are many, many products that help dry lips, you will frequently hear us recommend Aquaphor Healing Ointment or the new Aquaphor Lip Repair by Biersdorf. More information is available on these over the counter items here. It is important to have the proper expectations about these products: you will likely have to apply them multiple times per day, remind your child to not lick (instead, ask for more lip ointment!), and do this for many days until the Spring season arrives. The peak years for this licking/chapped/licking/chapped cycle is 2-8 years of age.
     Being outside in the cold weather often makes lips chapped. In the coming months, when your children are out on cold weather adventures such as making a snowman, skiing, snowboarding, and sledding, putting on Aquaphor or another similar product ahead of time sure can help prevent chapped lips. Applying it again when your child arrives inside will also help. Older kids can put a stick of ChapStick or Blistex in their pocket of their coat so they can reapply when they need it.
     Thumb sucking and pacifier use increase the chances of having not just dry lips but a rash around the mouth. The rashes often look chapped and irritated. It is not likely, unless things have gotten more complicated (read below), that it will look scabbed, very red, or show much peeling. I personally do not think you should stress about this rash because it is so difficult to get it to look much better until your child cuts back or stops sucking their thumb or using their pacifier. It is fine to apply some Aquaphor Healing Ointment to this area. The small amount that your child might get into their mouth after you do this is not worrisome.
     There are times when just coating the dryness will not help. If the above measures do not help, especially if the rash around the lips is quite painful, itchy, peeling, blistered, or scabbed, we should see your child at walk-ins or a scheduled appointment to better assess what is going on and how to help. There are cases of yeast (or ringworm or fungal -- all mean the same thing here), bacterial (impetigo, others), or viral (herpes simplex virus) infections that will need further treatment. We also see some children who have eczema (atopic dermatitis) who have rashes around the mouth that need something besides just moisturizing the area.

Staying Safe in an Electronically Connected World

     I recently discovered a very helpful resource called "OnGuard Online" to help all of us stay safe in this electronically connected world that we live in. It has terrific information about many topics. Near and dear to a pediatrician's heart are the sections on Keeping Kids Safe Online. The full site is available at OnGuard Online. I hope you find it helpful.

Ebola Virus

     I have hoped to find an excellent resource for parents and families about the Ebola virus. I have found one here at the Healthy Children website, which is affiliated with the American Academy of Pediatrics. The information is excellent and accurate. In addition, here is a link to the Centers For Disease Control webpage about Ebola.
     As I said on Facebook earlier this week, there will very likely be more deaths this year in the U.S. from influenza than there will have ever been cases of Ebola. Although the chance of dying from Ebola is much greater (about 40-50% so far), there will be many more cases of influenza in this country.
     To limit the spread of the virus, it is very, very important to limit the contact someone with possible Ebola viral infection has with others. If someone has travelled to West Africa or had a known exposure to someone with Ebola virus AND has symptoms of fever, severe headache, muscle pain, weakness, diarrhea, vomiting, stomach pain, or unexplained bleeding or bruising, walking into a doctor's office, urgent care, or emergency room without letting them know ahead of time may needlessly expose many people to the virus. If your child or yourself have the symptoms and the possible exposure, CALL your doctor's office for advice. Because of the severity of the symptoms, children and adults with Ebola will need to be evaluated and cared for at the hospital.
     Remember that we are in the midst of the Fall cold and flu season (although we have not yet seen cases of influenza this Fall as of mid-October). Many people with no direct contact with Ebola will have the same symptoms of Ebola -- just not as severe -- this illness season in the U.S. Many of these are routine illnesses that will pass with routine care. Do your best to lessen your risk of becoming sick this illness season with wise, routine measures: 1. have you and your family receive the influenza vaccine, 2. make sure yourself and your children are up to date on other vaccines, 3. eat healthy, 4. get plenty of sleep, 5. stay active, 6. wash your hands with soap and water or use hand sanitizer regularly, and 7. avoid as best you can people how are sick.
     

NCH Hilliard Close To Home Center Moving to New Location, Adding Services

     On October 20th, 2014, the Nationwide Children's Hospital Hilliard Close To Home Center is moving from Brown Park Drive to 4363 All Seasons Drive, off Britton Parkway. This is just North of Cemetery Road in the same development as the new Giant Eagle and Rusty Bucket. Previously, lab services, x-ray services, as well as speech, occupational, and physical therapy services were available. These are still going to be available. The big news is that this location will offer urgent care services. Their hours for urgent care will be Monday-Friday 3-10 p.m. and Saturday-Sunday noon-8 p.m. Other services are available from 9 a.m. to 5:30 p.m. Monday through Friday. During the weekend, the lab and x-rays will be available during urgent care hours. In addition, sports medicine services will also be at this location.
     If your child needs an urgent care, we strongly recommend the Nationwide Children's Close To Home urgent care centers.

Calcium and vitamin-D for children.

     The national recommendations are changing about calcium and vitamin-D intake for children. Intake of these are not just important for strong bones for growing children but to prevent osteoporosis in elderly adults. Osteoporosis is a disease of the bones that causes the bones to be more fragile and to break easily. A healthy intake of calcium and vitamin-D in childhood helps build healthy bones ("bone mass"). Childhood and the teenage years are the best years to build these strong bones: by 18 years of age, about 90% of bone mass has already been made.
     Daily Calcium Needs:
1-3 Years of Age: 700 milligrams
4-8 Years of Age: 1000 milligrams
9-18 Years of Age: 1300 milligrams
     Note that there is about 300-400 milligrams of calcium in a serving of dairy products. A serving of dairy is considered to be 8 ounces of milk, 8 ounces of yogurt, and 1.5 ounces of cheese. Other foods rich in calcium: salmon, tofu, orange juice supplemented with calcium, broccoli, spinach, baked or white beans, sesame seeds, peas, almonds, and Brussel sprouts. See a link here for more info on good sources of calcium. So if your child only gets calcium from milk, a 1-3 year old needs 16 ounces a day, a 4-8 year old needs 24 ounces per day, and a 9-18 year old needs 3-4 servings per day. Note that you would need 4-6 cheese slices or sticks to get 700 milligrams a day (that is quite a bit!). Most cheese sticks are 1 ounces of cheese and the average slice of cheese has 0.6 ounces.
     Daily vitamin-D Needs:
Birth-1st Birthday: 400 IU
1-18 Years of Age: 600 IU
     Note that infants who are exclusively breast-fed or who take less than 16 ounces of formula per day should take a daily dose of vitamin-D. Formula fed infants do not need a supplement as the formula has vitamin-D. Baby ddrops(r) have 400 IU of vitamin-D in one drop. See more information here. Enfamil D-Vi-Sol(r) has 400 IU in 1 milliliter with more information here. There are other over the counter options.
     For older children who are allergic to dairy, struggle to get it in, or who otherwise need a supplement, it is the Viactiv(r) chews that we recommend. These over the counter chews have 500 IU of vitamin-D and 500mg of calcium. Therefore the dose would be 1-2 chewables per day, depending on age and other sources of vitamin-D or calcium.

Great information resource for information about influenza.

     The website Flu.gov is an excellent website with accurate, up to date information about influenza and the flu vaccine. If you want specific information about the illness, more information about the vaccine, and should receive the vaccine (almost anyone 6 months and above), and who should not (very few persons -- the most common is if someone has anaphylaxis to eggs (not just hives or vomiting)).

When to start fluoride toothpaste for your child.

     I have now been a pediatrician for 20 years. During that time, the amount and timing of giving fluoride to children to protect their teeth has changed every couple of years. Pediatricians have a hard time keeping up with the latest recommendations. We realize it can be difficult for parents to keep up to date about fluoride recommendations.
     Fluoride is a safe way to prevent "dental caries" or cavities of the teeth. However, too much fluoride can cause "dental enamel fluorosis", which is a spotty discoloration of the teeth that is permanent. Fluoride is in most public water supplies (it is added to help prevent cavities), so many people have tap water at home with a good source of fluoride. Here is a good source of information about whether your wattle supply has added fluoride to protect the teeth. Bottled water that you can purchase has some fluoride in it, but the amount can vary widely. Bottled water also very rarely lists how much fluoride is included. Well water usually does not have fluoride in, but occasionally it does. The water can be tested to determine how much fluoride is in the water. Here is more information from the CDC about fluoride in well water.
     We have recommended against using fluoride toothpaste for young children as they could easily swallow too much toothpaste, increasing their risk of the excessive fluoride staining the teeth. The previous recommendation was to wait on fluoride containing toothpaste until the child could spit out the toothpaste after brushing. We found this was often 2 1/2 or 3 years of age. The recommendation now is to use fluoride toothpaste for children as soon as the first tooth erupts (breaks through the gums). But until age 3, use just a "smear" or the size of a grain of rice. After age 3, a pea-sized amount of fluoride toothpaste is recommended.
     Our recommendation is to follow the above recommendations: Once your child has their first tooth, start using a grain of rice sized smear of toothpaste with tooth brushing. After the 3rd birthday, use a pea-sized amount of toothpaste. We will keep you updated as the recommendations change!

HEV 68

     HEV 68 is a human illness first recognized in 1962 as a cause of pneumonia and wheezing. It has occurred on occasion over the years since then but is being recognized as a major cause of respiratory illnesses in children in 2014 in the Midwest states. There was a cluster of cases in children in St. Louis, Missouri prior to the illness appearing in large numbers in August and beyond in Central Ohio. Cases are occurring throughout the Midwest as well. Children are more ill than adults with HEV 68. The peak age nationally has been 4-5 year olds, with an age range of 6 weeks of age to 16 years of age. Many children may have mild upper respiratory illness symptoms with HEV68, but some children will wheeze with the illness (even if they have never wheezed before) and show signs and symptoms of respiratory distress.
     The enterovirus family of viruses also causes hand-foot-and-mouth disease, aseptic meningitis, and paralysis, along with more milder illnesses with rashes or vomiting and diarrhea illnesses. The HEV68 also called EV-D68) has typically caused nose and throat congestion, cough, headache, chills, achiness, runny nose, sore throat and occasionally fever. Like other upper respiratory viruses, HEV 68 is believed to be spread by coughing, sneezing, and touching items after touching the face, nose, or mouth. Because it is a virus, antibiotics have no effect on the course of the illness. Although we believe all eligible children should receive a flu vaccine each year, the flu vaccine will not effect whether someone becomes ill with HEV68.
     What is causing hospitalizations with HEV 68 is respiratory distress and oxygen requirement. These children are breathing faster, coughing frequently, retracting (muscles of the chest, belly, and neck working to help them breath), and often wheezing such that you can hear it without a stethoscope. The cough sounds moist and mucousy, not dry and barky (such as with croup -- which is also going around). The wheezing and other breathing problems caused by HEV 68 have responded well to the same treatments that we use for asthma: albuterol and prednisone. The albuterol is often given as a nebulized or aerosol treatment. Some children, especially older children, will respond to albuterol treatments with an inhaler. The prednisone helps the breathing issues by fighting the inflammation in the chest. Children not responding to outpatient treatments with albuterol and prednisone may need to be hospitalized at Nationwide Children's Hospital for close monitoring, further treatments, and possibly oxygen.
     Since most children have milder symptoms, who needs to be seen promptly for respiratory symptoms? It turns out, the same signs and symptoms we would always caution you about:
1. Breathing rapidly (especially more than 50-60 breaths a minute).
2. Retracting (seeing the skin around the neck, chest, or belly sink in and move out with each breath).
3. Wheezing you can hear without a stethoscope.
4. Frequent coughing (if your child is coughing every 30-60 seconds, they need to be seen).
5. Blue lips or blue color around the nose and mouth.
6. Passing out because of difficulty breathing (if this occurs, call 911).
If these are going on, your child needs to be seen right away: call during routine hours, come in for walk-ins at 8 a.m., go promptly to Nationwide Children's Hospital, or to the emergency department at Nationwide Children's Hospital. So many cases have occurred at the hospital (and because it is acting like asthma), it is being referred to as "Asthmageddon".
     If your child has routine upper respiratory symptoms without the worrisome symptoms, watch carefully over the first few days or week of the illness to make sure the symptoms do not worsen as detailed above. The children we have seen so far seem to have milder symptoms for a day or two before worsening -- it does not take much time into the illness to notice worsening symptoms if they are to occur. Most of the children with worse symptoms seem to improve after about a week.
     Many things we do not know yet: How long this outbreak will last? Just how contagious is it? Will many families with one child with it have it spread throughout the house? Are most children in the community with "just a cold" ill with this virus? How many children are getting a fever with HEV 68? Will these children go on to develop further wheezing episodes or asthma down the road? We will know more in the coming months.

Tummy Gas

     I am often asked about gassiness. The gas in our stomach and intestines is both swallowed air and created in our gut as we digest things that we eat and drink. That is true with infants, children, and adults. The gas is normally passed from above (belching or burping) and below (flatus or farting). Many times the gas does not cause any significant pain. So what is important is whether the gas causes pain. Many times the stomach discomfort happens first and we do not know that is the culprit is gas until it is relieved. A full, uncomfortable belly in a toddler that is relieved by passing gas or an infant that fusses for 20 minutes until they pass gas then calm down are good examples. Babies that pass gas frequently but are not uncomfortable are thought to be just fine -- we do not consider that gas to be a problem. In that case, the swallowed gas or created gas is just moving through their system.
     Is there anything we can do to reduce or relieve the gas that is swallowed? Yes. (1). For breastfed infants, a good latch helps them swallow less air. For bottle fed infants, the nipple and bottle combination may make a difference. Sadly, there is not one perfect bottle for every baby. In fact, if the bottle/nipple combination your infant is using is not working for them, you may have to try a few. Some brands that may be helpful: Dr. Brown's, Evenflo Pure Comfi, Playtex with drop-in liners, and Bare Air-free. (2). For infants bothered by the gas they swallow, making sure you do your best to burp them well after the feedings. Young infants may need to be burped after each breast or ounce of formula or pumped breast milk. (3). Simethicone (as generics and name brands such as Mylicon©, Gerber©, and others) gas drops can help some infants. The simethicone breaks up the gas into smaller, more comfortable gas bubbles. For infants, the dose is 0.4 milliliter by mouth as often as every feeding. Simethicone is very safe and can be used every feeding for as long as your child needs the drops. 2-11 year olds, the dose would be 0.4 milliliters per dose.
     Is there anything we can do to reduce and relieve the gas produced in the intestines? Yes. (1). Here is a terrific recent article in our Columbus Dispatch that has a great review of the issue with a chart of the low-FODMAP foods and beverages (I realize you may need to be a Dispatch subscriber to fully access this article). Another good source of information is here from Stanford. If your breast-fed infant has troubles with gas, the most common food and beverages we suggest avoiding for the mother are milk and dairy, asparagus, peas, and cabbage. But as you can see from the FODMAP information, there are MANY foods that may cause more gas. You will likely need to do some detective work at home to discover what you eat or drink that causes more gassy discomfort for your infant. Dramatically reducing or stopping your intake of those things that bother your infant should help your infant. (2). For infants who are formula fed, there are many infants bothered by gas who improve with a formula change. Similac Sensitive©, Similac Total Comfort©, and Similac Soy Isomil© are the formulas that I would recommend if you are going to try something different, in that order. Give a new formula at least 5-7 days to see how it works because it takes 3 days for the previous formula to get out of their system.(3). Massaging a baby's tummy can help if they are crying with gas. Gently massaging in a clock-wise motion is recommended. You can use some baby oil to lubricate your fingers.
     For toddlers and older children bothered by tummy gas, consider these things to help: (1). Encourage chewing with the mouth closed. (2). Encourage your child to eat slower. (3). Avoid carbonated beverages, such as sodas. (3). Consider changing the food and beverages that your child takes in -- especially milk and dairy. Check out the FODMAPs data for other ideas of foods to reduce or eliminate. As said before, it can take some significant detective work at home (consider a food dairy) to figure out what aggravates their tummy and what helps. (4). Consider the simethicone gas drops. Just 0.4 milliliter by mouth every 4 hours or every meal may help reduce the gas pain.
     Call during regular office hours if the above measures are not helping your child or you have other questions not answered here.

Flu vaccine update August 2014

     The current recommendation is that everyone 6 months and above receive an annual influenza (flu) vaccine each year unless they have a medical contraindication (such as immunodeficiency or anaphylaxis to eggs). We have ordered the flu vaccine for at least 24 years. We order the vaccine the Winter before it is needed. We typically receive the FluMist (nasal spray for 2 years and above in children who do not have asthma or other high-risk-for-complications-with-influenza-illness medical conditions) in mid-August. And the flu shot typically within a few weeks later. We generally then routinely give the vaccine at visits to the office and walk-in flu vaccine clinics until our supply is gone, usually late November or after.
     Although we have ordered the vaccine in our usual way and they did not change the vaccine from last year (same 4 strains of influenza virus in the vaccine), our supply has been significantly delayed. We do not have any control over the vaccine being sent to us. We have yet to receive the injection (flu shot) vaccine -- honestly, we are grumpy about this -- especially when the large pharmacies in town have the flu vaccine. However, we are happy to say we just had our FluMist vaccine arrive today (8-27-14).
     We will update the website and Facebook page as we get updates and receive the flu shot. We still expect that our patients will be able to receive the vaccine in an appropriate time this year through our office. However, if your child has the opportunity to receive the vaccine somewhere else and needs the flu shot  -- health department, Nationwide Children's Hospital specialty clinic, or pharmacy -- that is fine.
     We will await the flu shot being available in the office before scheduling our flu vaccine clinics. We anticipate starting them September or October. 

September is the "perfect storm" time for asthma problems.

     A surprising fact for many families who have a child with asthma is that the peak month for asthma visits to the doctor's office, urgent care, and emergency department is often September. Why? It does not seem that it should be September -- the weather is still nice and the school year just started (and can the germs be that bad?). But the combination of the weed pollen season (mid August through late October), exposure to lots of germs as kids are back in the classroom, and the weather changes make September the worst month for asthma most years.
     What can you do to prevent problems? The most important thing to do is to have your child regularly take their controller medication to prevent flare ups of the asthma symptoms. Many families let their guard down at this time of the year with asthma. Many children have gotten out of the habit of using their controller medication (steroid inhaler or Singulair, most commonly). As these medications need time to work in your system (weeks), many children are more vulnerable at a time when those factors mentioned above make this a bad time of the year for asthma.
     So what to do? If your child has asthma triggered by allergies or illness (these are the big causes for the vast majority of the kids we see) and you realize your child has not regularly used their preventative medication(s), start back right now. If you want to further discuss your child's asthma care, follow-up with your pediatrician, allergist, or pulmonologist. And if you need medication refills, for both albuterol when your child does wheeze or for controller medications to prevent the asthma, call your child's doctor's office.

Switching from Summer to School Sleep Schedule.

     When the calendar turns to August, there are many things to do to get ready for the new school year. One of the many things to do is to get your kids (and possibly yourself) back on the "school schedule". For most families, this means waking up earlier and going to bed earlier. This causes some stress around most households. I know part of it in our house is the "summer is over?!" feeling.
     How is the best way to do it? Part of the answer to that question is based on the fact that most folks take about a week or two to get settled in to a new schedule. Some families do not change their schedule at all until the first day of school. I think that guarantees that for the first days of school your child will be tired. And it will take a few days or more to get settled into the new schedule.
     A better way to do it is to take 10-14 days and gradually get up earlier and go to bed earlier. It will be not so jolting for your family if you do it in 15-20 minute increments. Also, sleep specialists will tell us that the most important part is to wake up a little bit earlier each day. If you plan "well, I will just go to bed a little earlier" but you do not get up any earlier, you will not be tired enough each night to fall asleep soon after going to bed.
     So if your 14 year old is sleeping until 11 a.m. but will need to get up at 6:30 a.m. (that is what is happening in my house), note that the difference is 4 1/2 hours between when they are getting up and when they need to get up for school. If you divide that into 20 minute segments, that comes out to about 14. So if 14 days before school starts, you get up 20 minutes sooner each day and go to bed each day 20 minutes earlier, you will end up on schedule when the school year starts. Note that this means maintaining this through the weekends.
     Getting your child back on to a good sleep schedule for school will help your child get off to good start for the school year. Good luck!

Iodine Deficiency in Pregnant and Breastfeeding Women

     The American Academy of Pediatrics has just come out with a Policy Statement about iodine deficiency in pregnant and breastfeeding women in the United States. A good review of the issue is here. Iodine is needed for your thyroid gland and for normal brain development. Ideally, pregnant and breastfeeding mothers would take in 230 micrograms of iodine per day. Make sure your prenatal vitamin contains at least 150 micrograms per day -- it will say on the label. Not all do. The rest of the iodine will come from foods that we eat. Here is a good article listing foods that contain iodine.

The Fearless Formula Feeder blog

     I just discovered the Fearless Formula Feeder blog by Suzanne Barston. I am an advocate for the health benefits for babies who breastfeed and their mothers. However, I totally "get" why Suzanne Barston has written a book and writes this blog. Families who formula feed their infants can feel a lot of flack from others. I appreciate the support that Suzanne Barton is giving these families. I know many families who would also appreciate that support.

Teething

     Teething in children occurs when the child drools more, chews on things, and fusses when their teeth develop under their gums. The average infant starts between 2-4 months with teething. On average, the first tooth breaks through near the center of the lower gums at between 6 and 7 months. However, it is normal to have teeth pop through anywhere between 2 months and 18 months. Once the teeth starting coming in, they will usually come in the following pattern and timing: 6 months -- 2 center bottom teeth. 8-12 months -- 4 top center teeth. 12-14 month -- 4 first molars come in. 15-18 months -- 4 eye teeth (canines) come in. 20-30 months -- two year molars come in. There is a great variation between children in when the teeth come in. We see 2 and 4 month olds in the office with baby teeth. We also see children who come in at the 15 month visit with no teeth.
     Like other conditions in children, how much it bothers each child is different. Some child sleep poorly, do not eat well, and fuss around excessively off and on. Other children seem to breeze through the teething. One of my children seemed to have an easy time with the front teeth but molars really bothered him.
     Over the years, we have been asked many, many times "Does teething cause ______?". Fevers, diarrhea, coughs, congestion, runny noses, throwing up, and rashes are often blamed on the teething. Teething does NOT cause a fever. Remember, we mean temperatures over 100.5 degrees. When a large study looked at children with fevers who were in that teething age (6-24 months), they found an illness (cold virus, ear infection, throat infection, etc.) in virtually all of the infants and toddlers. We think the excess saliva can cause more than usual spitting up, an eating change from teething pain could make the bowel movements more runny, and a little bit of congestion or an occasional cough. Truthfully, I think it bothers us as parents when our children become ill. We feel that somehow we have failed to keep them healthy. That drives us to blame something we cannot control -- "It must be the teething!". That way we feel better and we can better justify the symptoms. Also, it makes us feel like the child is not contagions. Also, realize that the symptoms of teething would last from 4 months until you were past your second birthday.
     So what to do for the teething? Each child seems to respond to different teething treatments, so you may need to try different things when your children are fussy with teething. Realize if they are drooling and chewing but not fussy, you need to do nothing but wait for the teeth to pop through. Many children will feel better if they are chewing on teething toys -- some children will want hard plastic toys, some will prefer the soft toys (even chewing on stuffed animals or a blanket), and some will like the teething helpers that you keep in the freezer or refrigerator to keep them cold. We think it is safe to use the occasional dose of Baby Oragel or Anbesol which contains benzocaine. Although there is a danger in over-use (it can numb the throat if small amounts are not used and this could lead to choking) and the rare chance that someone has methemoglobinemia and will react to benzocaine (as well as other medications), we have not had anyone have a dangerous reaction to these products over the years. We want you to be cautious about Tylenol or Motrin use for teething. If you use 2-3 doses in a week, I think that is fine. Daily, regular use for teething is not good for the stomach or kidneys(ibuprofen/Motrin) or liver (acetaminophen/Tylenol).
     One tricky issue is that many children will tug on their ears at the time of teething. If the child also has a runny or congested nose from a viral upper respiratory infection and is tugging on their ears, it is possible it is caused by the teething pain and not an ear infection. We are happy to see your child during walk ins or a sick appointment to confirm it is not an ear infection.
     Last but not least: here is a link to the Healthy Children website's info on teething. Call with questions!

Proper use of hydrocortisone and other steroid creams.

     Hydrocortisone and other steroid creams are used for itching and rashes with inflammation (eczema, seborrheic dermatitis, poison ivy, etc.). The 1/2 and 1% hydrocortisone creams are available over the counter. The stronger steroid creams are only available by prescription.
     Although these creams can be very helpful, they also have some side effects. They can thin the skin, lighten the pigment of the skin, and make the blood vessels under and in the skin look more prominent. The tricky thing about lightening the pigment is that the conditions that we treat with steroid creams also cause the same thing: eczema and poison ivy patches often cause so much irritation to the skin that the pigment of the skin looks lighter. The good news about this lighter pigment is that it tends to improve as the months go by once the eczema or poison ivy are gone. However, make sure to use a good sun block with titanium dioxide and zinc dioxide to help protect from sun damage when out in the sun. The pale areas have a harder time recovering their pigment if allowed to become sun burned.
     So how should you safely use these creams? One rule to follow is to use the weakest cream that works. That means that if improvement is seen with over the counter hydrocortisone cream, use that instead of moving to something stronger. Remember we are looking for improvement after using the creams over 3-5 days. Even if eczema comes back after you stop using it after 3-7 days of hydrocortisone, we still think of the hydrocortisone cream has successfully helping.
     If the rash looks much better after 3-7 days of a steroid cream, stop using it for a while and see how the rash does without it. Eczema will likely need another round of a few days to a week of the steroid cream periodically, but poison ivy rashes will likely improve and you will not need to re-use the cream soon. Ideally, for every number of days you used these creams, you should avoid them for the same length of time. For instance, to help your child's eczema if you normally will do the steroid cream for 5 days in a row, follow that with at least 5 days without the steroid cream before using it again.
     If an over the counter hydrocortisone cream is not helping, we will want to see the rash. We can decide whether a prescription strength cream is needed. This can done at a walk-in visit during walk-in hours, a scheduled ill visit, or a well check.

Cradle Cap and Seborrheic Dermatitis

     Seborrheic dermatitis is a skin condition with red patches that can be divided into two types: cradle cap (infants) and seborrheic dermatitis (older children and adults). For infants, it will often start within the first month or two of birth and last until the infant is somewhere between 6-12 months of age. Older children that develop this find it happens late in or after puberty. There is a genetic component: it does tend to run in families.
     "Seborrheic" means "runny or seeping oil" and the rash is often accompanied by yellowish oily film or scaly crust. The rash in infants is most often just on the forehead, but there may be a rash in many other areas. This rash may be red and in splotchy areas or be many fine small "pimple" looking spots. There may be an oily or crusty appearance to the top of the smaller rashy areas. Seborrheic dermatitis can be itchy but is not always.
     What to do if your child has cradle cap? For infants where there is not much cradle cap and it does not cause your infant to scratch at the area, it is fine to just watch. The first step in treatment is to massage baby oil into the area 20-30 minutes before a bath. Then wash the hair with the usual baby shampoo that you use. After the bath, gently brush at the area with a soft-bristled brush. Do this regularly (2-3 times a week or more) until the cradle cap improves and the flakes are removed. Then repeat as needed in future weeks. Remember that the baby oil will not cure the cradle cap, just keep it calmed down until the cradle cap improves as the months go by.
     For those infants and children that the baby oil and brushing is not effective, we recommend trying using one of the over the counter medicated shampoos: Head 'n' Shoulders, Selsun Blue, or Neutragena T-Gel. Note: these are the same ones you and I would use. They do not make "infants" or "kids" forms of these. All of these can sting the eyes so be cautious about rinsing them out while keeping them out of the eyes (tilt the head back and pour the water front to back). These shampoos can be used daily or a couple times a week. If the cradle cap improves over a couple weeks, you may just need to use the medicated shampoo once a week. The baby oil can still help get the oily scales off the scalp.
     Most of the infants are not itchy with the cradle cap. However, for those infants that are itchy and the above measures are not helping, it can really help to use the over the counter 1/2-1% hydrocortisone cream (such as "Cortaid"). Apply a thin layer to the cradle cap once or twice a day. Ideally, this is only done when the itching is bad and for 3-7 days then off for the same amount of time.
     For older children with dandruff, itching, and seborrheic dermatitis, we recommend they use one of the three shampoos (Head 'n' Shoulders, Selsun Blue, or Neutragena T-Gel). If using that on a regular basis does not help, we can discuss here in the office -- there are prescription strength shampoos that can really help. If despite even the prescription medication your child's medication is no better, we would have them see a dermatologist.

Water Safety and Swimming Lessons

    The American Academy of Pediatrics found for many years that it was difficult to answer the question of "Is my child less likely to drown if they have taken swim lessons?". That might seem like the answer would be "Of course they are safer if they have had swim lessons." However, for a long time, it was not known for sure if that was true. And a long time worry has been whether parents and guardians could drop their guard about the child swimming if the parent and guardian knew that the child had swimming lessons.
     Here is the Healthy Children's website about drowning prevention and swim safety. And here is another good webpage about the same subject. From the same website, here is an audio piece to listen to about infant and toddler swimming lessons. One last link -- this directly from the American Academy of Pediatrics.
     So I do think swim lessons are fine for young toddlers. Formal swim lessons for children 4 years of age and above are a good idea. BUT never let your guard down. Even with good swimmers. Do not assume someone else is supervising your child while they are in the water.
    

2014 Mumps Outbreak in Central Ohio

     Mumps is a viral infection that causes swelling of one or more of the saliva (spit) glands, usually the parotid glands (in your cheeks in front of the ears). About one of three cases of mumps show no obvious symptoms. Mumps can cause swelling of the testes, ovaries, or breast tissue one week after the parotid gland swelling. These are more common with young adults and adults with mumps. Mumps rarely causes much in the way of cough, runny nose, and congestion. It commonly causes achiness, low grade fever, tiredness, and decreased appetite. Mumps is spread person-to-person by sharing cups, utensils, kissing, etc. Children with mumps are contagious for a few days ahead of the symptoms starting and 5 days after the swelling of the parotid glands.
     The vaccine for prevention of the mumps became available in the 1960s and by 1977 was a routine part of the vaccine schedule in the United States. Since then, the chances of getting mumps in this country has plummeted to a low "normal" of 200-300 cases across the country each year. In some years there have been as many as 1000-6000 cases, especially amongst college students. Although those children and adults who are not vaccinated are more prone to develop the mumps, in outbreaks many of those that develop have been vaccinated. The vaccine provides very good but not perfect protection.
     Because of the success of the vaccine, we have never had a confirmed case of the mumps seen by Hilliard Pediatrics. That continues to be true as April 15, 2014 -- despite the recent outbreak in Central Ohio. Currently the recommendation is to not change anything about the timing of the two mumps vaccines -- giving in combination with the measles and rubella vaccines at 12 months of age and 5 years of age. Although the recommendation would be for those with just one MMR vaccine and past the age of 5 years to receive a second dose now, no other recommendations are made at this time.
     We do want to see children with symptoms that could be mumps. There is testing available that can confirm that it indeed is mumps. The symptoms of sore throat and fever are treated, but generally the illness passes on its own without other complications.
     Keep vaccinating your children.

     UPDATE: As of May 21, 2014, we do have a teenager in the practice that we are highly suspicious that he has mumps. He attends a Hilliard high school.

As of May 30, 2014, we have now seen two cases of mumps. Initially, the lab work to confirm that it was mumps was paid for the CDC or NIH. Now it is not. And the testing costs as much as $400-600 and takes 10-14 days to come back. So we are not gong to routinely test to confirm that the cases we see are indeed the mumps.

February 2014 update on the HPV (cervical cancer) vaccine.

     I am excited that there is very encouraging information about how safe and effective the human papilloma virus (HPV) vaccine is for pre-teens and teens. Although I know this article has some "technical" words and information that might be confusing, but the data is very encouraging. The safety remains very good. The numbers of pre-teens and teens receiving the vaccine in this country is still less than 50%, but hopefully the number increases over time. This will allow everyone to be better protected.
     I still strongly support the vaccine. I have had my own three sons vaccinated. They tolerated the vaccine well (except for one of them with some arm soreness afterwards for a day or two with the first shot). I have posted before about the HPV vaccine -- here is a link to the most complete of the posts on the vaccine.

Underarms, sweating, odor, and hyperhidrosis.

     Not a very glamorous topic, but one that bothers quite a few of our patients and about which I get lots of questions.
     First, I get a lot of questions about when to start deodorant with kids. There are many 7 and 8 year old girls and 8 to 10 year old boys that (years before puberty starts) will need deodorant because they develop underarm body odor. If your child is grumbling around about using deodorant remind them that every one gets to a point where, as they grow up, they need to use it. It is fine to use any deodorant at a young age (it does not have to be a "teen deodorant"). As with any deodorant, if it causes irritation, try a different brand (see below). The average child starts using deodorant when they are a little older than the ages above, but if your child needs it at a younger age, encourage them to do so.
     When to start an antiperspirant, you ask? If it is an odor issue and not an issue with excess sweating, it is fine to use just the deodorant. If your child sweats through shirts (even a little bit), make sure it is a product with both a deodorant and antiperspirant.
     Some teens and adults are so sensitive to different antiperspirants and deodorants, that they need a fragrance-free deodorant and antiperspirant designed for sensitive skin. Common ingredients that cause reactions include the fragrance, propylene glycol, essential oils, parabens, vitamin E, and lanolin. Dr. Matthew Zirwas, M.D., a dermatologist at the Ohio State University, did a study on antiperspirant and deodorant allergy. He reported that the leading products with low likelihood of causing local allergic reactions include the following:
Almay Hypo-Allergenic Fragrance Free Roll On (antiperspirant and deodorant)
Certain Dri (antiperspirant)
Crystal Roll-On Body Deodorant for Sensitive Skin (deodorant)
Crystal Stick Body Deodorant for Sensitive Skin (deodorant)
Mitchum Roll-On Deodorant (antiperspirant and deodorant)
Secret Soft Solid Platinum Deodorant Unscented (deodorant)
If your child is having an issue with rashes, irritation, or itching with antiperspirant and deodorant use, consider one of these products. They are available in stores and on-line. If the itching is an issue or a rash is forming, it is fine to use over the counter 0.5 or 1% hydrocortisone cream once or twice a day for a few days to calm the itching and rash down.
     What is hyperhidrosis? It means excessive sweating. Some folks sweat excessively compared to others. Sometimes, it is multiple areas. Other times it is just it one place or two, such as hands, feet, head, or underarms. Although there are some medications (stimulants for ADHD) and conditions (hyperthyroidism) that can cause increased sweating, the vast majority of kids and adults with hyperhidrosis do not have a specific medical reason for the issue. I remind teens that caffeine can cause excessive sweating. If someone has excessive sweating and drinks caffeine, they should try cutting back or stopping their caffeine intake to see if that helps reduce the sweating. Genetics can play a part -- many times this runs in families (not something you would wish to pass on, however).
     If your child struggles with excessive sweating at their feet, try doing more breathable socks and shoes (less leather shoes and more athletic shoes or sandals; Drymax or CoolMax socks). For sweaty feet that need something more, consider using an underarm antiperspirant on the feet every morning.
If usual antiperspirants do not work, consider a "Clinical Strength" antiperspirant such as Gillette (for guys) and Secret (for girls). If that does not help decrease the sweating, try the over the counter Certain Dri Antierspirant Roll-On on the feet at bedtime. Then use the Clinical Strength antiperspirant on the feet in the morning. One more step would be to continue the Certain Dri Antiperspirant Roll-On at bedtime and do Certain Dri A.M. in the morning.
     If your child struggles with excessive sweating at the underarms, start with a "Clinical Strength" antiperspirant. If that is not helping, add the Certain Dri AntiPerspirant Roll-On at bedtime. One more step would be to try the Certain Dri A.M. in the morning. If those are not helping, we can discuss at a check-up or appointment other options, including trying prescription medications including Xerac AC or DrySol. If we are not having good success with these options, the next step is to see the dermatologist -- they are the hyperhidrosis specialist.
     What to do for sweaty hands? Try the Certain Dri AntiPerspirant Roll-On each evening, applying to the palms of your hands. If that helps, continue the Certain Dri. If that does not help, we can discuss at a check-up or other appointment other options. These include the Xerac AC and DrySol. See below.

Use of prescription Xerac AC or DrySol solution:
These medications are used to reduce the sweating from an area. They are applied to the area before bedtime and allowed to stay over night. They can cause irritation or redness at the site. Ironically, it can help to reduce the sweating if it has caused some irritation. If the irritation or redness is too much, wipe it off early with a warm, wet washcloth. For irritation afterwards, apply some Aquaphor Healing Ointment or over-the-counter 1% hydrocortisone cream. It may take 1-2 weeks of using it every night to notice a difference with how much that area sweats. If it is helping, we recommend using it for 2-3 weeks total then see if simply continuing the morning antiperspirant is working. Even if you have a good 3-6 weeks of less sweating even after stopping the medication, the sweating will likely return. At that point, you may need to do it just 3-7 nights in a row to reduce the sweating for a number of weeks. If working, continue in this way. If not helping, let our office know during a visit or call during routine office hours.
    

What to do when you think your child may have ADHD.

     I realize that I have written long handouts about ADHD and its treatment, but it might not be quite clear what to do if you suspect your child has ADHD. First, look at this list of the symptoms that fit for ADHD. If a child is 6 years old or above and the symptoms on the form are interfering with home, school, and other activities and it has been going on for more than 6 months, we should look into the possibility of ADHD. That does not mean that all of those children have ADHD or need medication. In fact, over the years many families where this question of whether or not their child has ADHD comes up, most of the times the child does not.
     If they are showing symptoms of ADHD and do not have ADHD, what could it be? Whole books have been written about this topic. A short list: hearing loss, learning disability, vision problems, absence seizures, medications, and thyroid disease. I have had patients who have had classic ADHD symptoms (but something seemed different about the story) where we found they had profound hearing loss, hyperthyroidism, or a medication side effect causing the symptoms. In addition, there are children with some of the ADHD symptoms who do not quite fit the diagnosis of ADHD that in the "gray zone" between "no ADHD" and "ADHD". Many of these children will be watched to see how they do over the coming months and years. We can re-evaluate things depending on how they do in school and at home.
     For children who have symptoms that we want to further check into, we have you the family and the school fill out the Vanderbilt form for Teachers and the Vanderbilt form for Parents. It is very helpful to have each teacher complete the form. At home, having each parent complete the form is helpful. For teens, they can complete one also. When those forms are returned to us by you, the doctor will review the forms and we will get back with you shortly (usually within a couple days and sometimes sooner). At this point, if the scores on the Vanderbilt forms show that we should have a discussion about the diagnosis of ADHD and possible treatment for it, we set-up a saved time appointment (these can take 30--45 minutes) sometime soon to discuss it in the office. Is it helpful to have your child there at this appointment? It depends. For many young kids, they may feel that so many people have gotten frustrated with their symptoms, that hearing their parent(s) and pediatrician discuss it may be stressful and not productive. For older kids, it can helpful to be part of the discussion. Based on the scores on the Vanderbilt forms, the history of the problems, and our discussion in the office, the diagnosis can be made of ADHD. We can discuss medication treatment for ADHD, which I can tell you has about a 80-90% chance of making a big impact on the symptoms. Why is it the doctors talk about stimulant medications? Because they work. Although special diets, cognitive-behavioral therapy, and specialized computer training has all been tested, there is less than a 20% chance of these helping by themselves. Please see my blog post on ADHD and diet here.

Formula changing their calorie count.

     For many years, infant standard formulas have had 20 calories per ounce. This was based on the fact that breast milk averaged 20 calories per ounce. However, many formulas (including formulas such as Similac and Isomil) are changing to 19 calories per ounce. The ongoing research shows that although the average mom's breast milk contains 19 calories per ounce in the US, the range is from 11 to 35 calories per ounce. To try to be as close to breast milk as possible, the formulas are changing. Research has showed that although there are 5% less calories per ounce, the infants fed about the same amount each day AND grew just fine. My take on this is that it makes sense to try to match the calories of breast milk and the infants should do fine. If you have questions, ask at your child's appointment time or call us during routine office hours.

Raw Milk

      Pasteurization of milk heats the milk to a specific temperature and then cools it down. This process kills harmful bacteria. If the milk is then stored properly (40 degrees or less), it is dramatically less likely to pass dangerous bacteria to someone drinking the milk.
      Milk sold in stores and breast milk from milk banks is pasteurized. What is called "raw milk" is not pasteurized. Raw milk does not have proven benefits AND it is NOT safe: the bacteria that are in raw milk are dangerous. Although raw milk and unpasteurized breast milk is available on some "secondary markets" (such as Craigslist), do not offer it to your children.
      I would strongly recommend that raw milk never be consumed by anyone, but children and pregnant women are at most risk. Please see these links at Healthy Children for more information here and also here. 

Tamiflu and Influenza in Children

     So far this 2013-2014 influenza season, the H1N1 influenza strain is what is circulating in the United States. That was included in both the flu shot and the FluMist (flu spray) vaccine this year. It has also been circulating the last few years. This means that between having had the vaccine or the illness in the recent past, many folks will be protected against the major strain this year. Despite that protection, many kids and adults will get influenza, some worse than others.
     What our grandparents would have said about influenza years ago is still true: you need rest, plenty of fluids, eat bland foods as you can, and treat the fever. Those things are still what I tell families battling influenza. A late fever (especially if there was an initial fever, none for a day or two, and now there is a fever again), a worsening cough a few days into the illness, or poor intake with less than three times urinating in 24 hours are worrisome signs or symptoms for the two most common complications of influenza in children: pneumonia and dehydration. And remember that the fever with influenza is often higher than many other illnesses: 106-107 degrees. Even with those high temperatures, what is important is whether your child perks up when the fever is coming down.
     I am certainly all for children 6 months to 18 years of age (that do not have some reason they cannot get the vaccine) receiving the flu vaccine each year. Since the recommendation changed a few years back (now saying everyone would benefit from the vaccine each year), we have routinely had my three sons vaccinated. One of my twins had influenza in first grade (he is now in 8th grade) before he ever received the flu vaccine. He felt like he got run over by a truck (very achy), had a fever up to 106.3 for 4-5 days, a sore throat, and a cough. Luckily, he did not get dehydrated or a case of pneumonia. He recovered well with rest, plenty of fluids, and fever reducers.
     So what about the antiviral medications, including Tamiflu? (a). These medications can shorten the course of influenza from 5-6 days to 4-5 days (shortens the illness by 1-2 days) if started in the first 48 hours of the illness. They also can prevent someone with a direct exposure to influenza from developing it, if it is given early after the exposure. (b). They are fairly expensive prescriptions -- we recently had a family that decided against filling the prescription for Tamiflu as the co-pay was over $100. (c). The supply of the Tamiflu liquid was in short supply early this flu season. The supply is better at this point (1-21-14). (d). Almost 40% (2 out of 5) of children taking Tamiflu will have stomachaches and nausea from the medication. Every year, we have people ask if they can stop the Tamiflu early because of the stomach symptoms. (e). There are no new promising antiviral medications under development that will be available soon. That means that when the influenza strains evolve and become resistant to the Tamiflu, we will have limited or no options for treating or preventing influenza. Since I began medical school in 1987, at least two prominent antiviral medications are no longer used because the influenza strains are resistant to the medications. (f). Tamiflu can lessen the chances of an ear infection, pneumonia, hospitalization, or death from influenza. (g). Very few people experience these issues, but some adolescents and adults have had self-injury or delirium while being on Tamiflu. These issues, interestingly, have been most prominent in persons in Japan with influenza who have been treated with Tamiflu.
     So when do I recommend Tamiflu in children? 1. A confirmed case (with the rapid influenza test which can be done in the office or at urgent care or emergency department) of influenza in a high risk (asthma, diabetes, heart disease, and some others) patient AND in the first 48 hours of the illness. 2. A confirmed case of influenza with severe symptoms that suggest someone is so ill they may require hospitalization for dehydration or pneumonia, especially if in the first 48 hours of the illness. 3. The rare case when a very high risk patient could not receive the flu vaccine (because of a severe egg allergy, for instance) but has a known direct exposure to influenza (such as a family member having the virus).
     I actually only prescribe Tamiflu a few times each year. I want to use it when it is appropriate. However, I also want to have an effective, safe antiviral medication for real emergencies and urgencies when the medication is truly needed. Now and in the future.

Probiotics and Prebiotics

     Probiotics are supplements or foods that contain live bacteria that change the types and number of healthy bacteria in our system. Prebiotics are supplements or foods that contain an ingredient that stimulates the growth or activity of healthy bacteria in our system. Breast milk contains prebiotics
     I am often asked what I think of probiotics. I will try to summarize what we know scientifically about probiotics and prebiotics. Most of what I know about them is from the "Clinical Report -- Probiotics and Prebiotics in Pediatrics", Dec. 2010, by Drs. Thomas and Greer and others.
     Realize that when things are scientifically studied, the gold standard for studies about probiotics or prebiotics are randomized clinical  trials (RCT). With RCTs, the patient and the doctor do not know whether they are getting the "real treatment" or the placebo. That way, when answering the "Was it really better because of the treatment?" question, the doctor, patient, and family are not biased by knowing what they were taking. If I think probiotics really help with diarrhea as a side effect from antibiotics, I may be more likely to say "Yeah, that diarrhea really was better that time I took the probiotics with the Augmentin!". That is why it is so much more helpful to know that "80% of kids on antibiotics have less diarrhea if they take SuperPro [I am making this up as an example]" than "my sister's friend's child took SuperPro while on an antibiotic and they did not have any diarrhea".
     A few things to know from the start: 1. Probiotics are available over the counter without a prescription. 2. There has not been enough studies to help us say "this is the brand to buy!" and feel super-confident about it. 3. Probiotics and prebiotics positive effects only last as long as you take them. If you stop taking a probiotic, the "good bacteria" benefits quickly get out of your system. 4. The top three bacteria in available probiotics are Lactobacillus, Bifidobacterium, and Streptococcus. These bacteria are believed to be the most helpful based on current research. 5. It makes sense that the health probiotic bacteria will help more if more of them are alive. Some probiotic products are kept refrigerated, potentially keeping the bacteria at their best. However, we still do not know for sure if these probiotics are necessarily more effective.
     By 2-4 days of age, vaginally delivered infants have millions of bacteria in our intestines. Breastfed infants have more "healthy" bacteria in their system, even by 7 days of age. After infancy, the average person has 10,000,000,000,000 (!!) bacteria in their intestines, the vast majority being healthy bacteria. These healthy bacteria play a vital part in our immune defense system. Science is still studying all of the particulars of how these bacteria interact and play a role in our immune system.
     Because of where probiotics work (in the intestine), the most hope for probiotics are diseases or illnesses that occur in or are effected by the intestines and its immune system. That means that diarrhea, eczema, inflammatory bowel disease, irritable bowel disease, colic, and constipation are the conditions studied in children with regards to whether probiotics have had an effect.
     So far, the research shows probiotics can 1. help prevent some cases of viral "stomach flu" (acute viral gastrointestinal infections) in children in child care, 2. reduce how long (by about a day and a half) rotavirus diarrhea illness lasts, and 3. reduce by about half the diarrhea associated with antibiotic use when started when the antibiotic is started. Probiotics may be helpful in eczema prevention, treating inflammatory bowel disease, infant colic, and constipations, but we need more large RCTs to know for sure. In addition, large studies on side effects of probiotics have found them to be well tolerated with no significant side effects.
     Foods that include can or do contain probiotics include yogurt (look for the Live & Active Cultures seal), kefir, and aged cheeses (cheddar and Gouda). In addition to foods that include probiotics, many over-the-counter brands are available. To emphasize, there has not been a well done head-to-head study comparing these probiotic brands against each other. In addition, the Federal Drug Administration does NOT evaluate the "this is how helpful we are" claims by probiotics. Therefore, the "helps" and "supports" words used to promote probiotics need to be taken with a grain of salt.
     A good friend of mine exercises every day, eats healthy, does not smoke, and does many other things well to take care of his general health. For a long time, he claimed why he was so healthy was the $80-100 worth of vitamin and mineral supplements he took every month. This is despite the fact that he was getting all he needed of vitamins and minerals from what he ate. This is a thousand dollars a year of unnecessary expense. Realize when zinc supplements (again, not evaluated by the FDA) claim to "support your immune system" that the immune systems that are likely respond to zinc supplements are those folks with zinc deficiency. And zinc deficiency is quite rare.
     Commonly available brands include:
Culturelle Kids Packets or Chewables (contain Lactobacillus)
Dosing for age 1-3 years of age: 1 packet once a day. If using for diarrhea: 1-2 packets every few hours with a maximum of 7 packets in 24 hours.
Dosing for age 3 and above: 1 chewable once a day. If using for diarrhea: 1 chewable 4 times a day.
BioGaia ProTectis Chewables or Drops (contain Lactobacillus)
Dosing: one to two capsules once a day or 5 drops daily.
Florastor for Kids Capsules or Powder Packets (contain Saccromyces and lactose)
Dosing: one to two capsules or packets twice daily.
Florajen4Kids Capsules (can be opened and powder sprinkled on food; contains Bifidobacterium and Lactobacillus; best if refrigerated)
Dosing: one capsule once a day.
     Based on all of the above information, if you are going to try a probiotic for your child, here is what I would recommend.
For colic: BioGaia ProTectis Drops 5 drops daily. If no change in 1-2 weeks, you are not likely to notice a change for the better after that first couple weeks. If it is helping, continue until 3-4 months of age.
For diarrhea: Culturelle, Florastor, or Florajen4Kids. Dosing as above. Start as soon as the diarrhea begins and continue until significantly improved.
For prevention of diarrhea while taking an antibiotic: Culturelle, Florastor, or Florajen4Kids. Dosing as above. Start taking when you take the antibiotic and continue for the full 10 days of antibiotic.
For constipation or irritable bowel symptoms: Florajen4Kids, Florastor, or Culturelle. Your child will likely need to continue the probiotic for 4-6 weeks or more to be able to tell if it is helping. If it does help, feel free to continue the probiotic.
     Summary: 1. Probiotics may be helpful to treatment or prevention of some conditions. 2. Probiotics are very safe and free of side effects when used with the proper dosing. 3. Many more scientific studies need to be completed to know all we need to know about probiotics. 4. If you chose to try a probiotic for your child, I would recommend following the above information.
     Good luck and call if you have questions.

Teen driving

     I have a responsible 18 year old son who had a scary car accident last year. The car was totaled. Thank goodness no one was significantly injured. Teens, for many reasons, are more likely to be involved in accidents and other driving incidents than young and older adults. Improving their skills at driving can save lives, save money, and give us all peace of mind. Although I am grateful that my children are all terrific about using their seatbelts every time they are in the car, I am also grateful that was reinforced when the police officer that responded to the crash told my children they would have had serious injuries if they were not using their seatbelts. When I was in middle school, my best friend died in a car accident when the teen driver of the vehicle drove recklessly.
     There are many resources available to you in helping your child be a safer driver. One is the Check Points Program through the Young Driver Parenting website. Here is the website where this information is available. I think this program has an excellent chance at enhancing the safety of teen drivers. Please check it out!

Wind Chill and Frostbite

     Today (January 6th, 2014) schools in Central Ohio are closed due to the very cold conditions. The wind chill will be talked about frequently this week and beyond. The wind chill is the temperature it "feels like" outside. The windier it is, the faster the skin and the rest of the body cools. The wind chill dropping makes frostbite more likely. Frostbite is an injury due to frozen body parts. Exposed extremities including fingers, toes, ears, and the nose tip are the most likely to be injured by frostbite. Frostbite causes white, numb skin. See this link to the Healthy Children website for more information. Here is the National Weather Service's brochure on Wind Chill. It includes the updated Wind Chill Chart. This is how the temperature and wind speed are used to calcite wind chill. It is also possible to see how many minutes until frostbite will occur.
     So dress warmly, dress in layers, keep extremities covered, and stay indoors as much as possible. Stay warm out there!