Infants with Acid Reflux

     I am in the process of completing my pediatric boards re-certification. This process ensures that doctors keep up with current medical recommendations and put in place steps to improve medical care within their practice. One of the activities I have been working on focuses on acid reflux, especially in infants. One of my sons had acid reflux during his first year of life.
     As part of my focus on acid reflux in infants I have found some good resources for parents with infants with acid reflux. I want to share them with you. This is a link to from GI Kids about coping when your infant has reflux. There is lots of good information here. Another good resource is here, also from GI Kids, that includes a checklist of common symptoms. GI Kids main page on Acid Reflux can be found here. My own handout (protocol) on Acid Reflux is here on our website, Hilliard Peds.
     I hope this information is helpful. If you have questions or concerns about acid reflux and your child, call during routine office hours.

Croup

     When the school year has begun and the weather starts flip-flopping from cold to warm, we see a big increase in the number of cases of croup. This is a viral illness caused by parainfluenza virus. It is transmitted from one person to another the way other respiratory viruses are transmitted: being near someone who has coughed, spread their cough or nasal germs on to some surface someone else touches, etc.
     Although it is the cough that sounds like a barking seal that tells us it is croup, what worries us about the illness is when the breathing is difficult (noisy, tight, or wheezy) in between the coughs when the child is breathing. See our protocol here for more information. Many of the hoarse voice (laryngitis), sore/scratchy throat, barky cough illnesses in the community are this illness.
     Stay healthy!

Prepare Now for Start-of-the-School-Year Asthma Issues

     Every year, pediatricians notice that there is a big surge in asthma issues early in the school year. It happens before the big stretch of "winter viruses" hit. It happens often when the weather is still nice. And it catches many families off guard. Read more so you can be prepared.
     It is thought that three things happen during September to make these asthma issues much worse. Mid August brings a surge in the weed pollen, especially ragweed pollen here in Central Ohio. The pollen can trigger asthma issues. Back to school time suddenly increases many children's exposure to viral upper respiratory illnesses. It may not be as severe as into the cold weather months, however these viruses can trigger asthma issues. In addition, the weather changes that start in September, with some cooler days then warmer days, can also trigger asthma issues. These three things can work together to dramatically increase the chances of asthma flaring up early in the school year. In the 2014-15 school year, there was such a surge of asthma issues that folks at Nationwide Children's Hospital were calling it "asthmageddon". We had quite a few patients whose asthma worsened during that time period last year, with many admissions to the hospital and visits to the office or urgent care.
     The other big reason asthma worsens at this time of year, and the reason I am writing this blog post, is that many families let their guard down with asthma prevention. It is human nature to get out of the habit of using the daily asthma prevention medicine during the "well time of the year", summer time. If the inhaled steroids or Singulair (montelukast) is not in their system, children's asthma may quickly worsen if one of the above triggers (or all three) occur. And please remember that these medicines are much less effective if they are started when symptoms start -- cough, wheezing, difficulty breathing. They are most effective when given for weeks ahead of time and continued on a daily basis. We are only about 6-8 weeks from this time period, so NOW is the time to start these preventative medicines if your child has been off the medicine during the warm weather months. If you have questions about this, contact us during routine office hours.

Changes in Central Ohio for emergency behavioral and psychiatric evaluations.

     Behavioral health services are evolving frequently. Nationwide Children's Hospital and Ohio State University are collaborating to provide psychiatric and behavioral emergency evaluations for Franklin County children and adolescents. The Emergency Department of Nationwide Children's Hospital will provide the evaluations for children 14 years of age and under. The Emergency Department at Ohio State University Hospital will provide evaluations for teens 15 years of age and above. An organization called NetCare that previously did psychiatric and behavioral crisis evaluations and hospitalizations will not longer provide these services for children and teens.
     More information is on the www.cap4kids.org/columbus website under the Behavior/Counseling/Addiction section.

Medications for Anxiety, Depression, and OCD in Children and Teens.

     Many of our patients suffer from issues with anxiety, depression, and obsessive-compulsive disorder. These conditions may respond to time and counseling, but if the symptoms are routinely interfering with everyday life, we will often discuss further treatment with medications. The medications used are the same medications that are used with adults, the dose is just adjusted. Despite these all being different conditions and diagnoses, the medications used are the same. These medications work on the neurotransmitters (brain chemicals) to help balance how they affect our emotions.

 

Types of and Commonly Used Medications:

Name                                 Usual Dose           Dosing Forms                Usually Given   

SSRIs or selective serotonin reuptake inhibitors

Prozac® (fluoxetine)       10-40mg               Capsule, tablet, liquid    In morning        

Side effects: Brief nausea when starting.

Zoloft® (sertraline)          25-100mg            Tablet, liquid                   In morning       
Side effects: Brief nausea when starting.

Celexa® (citalopram)      10-40mg              Tablet, liquid                   In morning      
Side effects: Brief nausea when starting.

Dopamine-Reuptake Blockers

Wellbutrin (bupropion)   150-450mg          Tablet                             In morning        
Side effects: Not likely to cause stomach upset or weight gain. 

 

Serotonin/Norepinephrine Reuptake Inhibitors

Effexor® (venlafaxine)  37.5-150mg         Tablet                                In morning       
Side effects: Brief nausea when starting. If causing drowsiness, take in the evening. 

Tricyclic Antidepressants

Elavil® (amitriptyline)     25-100mg            Tablet                             At bedtime       
Side effects: Likely to cause side effects -- weight gain, constipation, dry mouth, urinary
retention, blurry vision, drowsiness, and dizziness.

      For those medications that can cause some nausea and stomach upset once the medication is started, these symptoms usually improve significantly over the next 2-4 weeks. Making sure the medication is taken with food helps. As with any of the above medications, if your child is taking the medication each morning and is drowsy during the day, switch to taking the medication in the evening. In fact, for those children who are anxious or depressed who struggle with falling asleep, taking the medication in the evening may very well help with falling asleep.

     Just as with other medications, it is often hard to tell what the right medication is for any individual. If someone in the family has taken one of these and had a good or bad experience with it, that can be helpful. We often start with one of the SSRIs then try something else if that medication is not helping. There are children and teens who will benefit from seeing a psychiatrist to manage and prescribe their medication. This is especially true if we are unsure of the diagnosis, if there may be another diagnosis (such as bipolar disorder), we are having issues finding the right medication for that person, or the symptoms are more severe. We have a list on our website at www.hilliardpeds.com

     Symptoms of anxiety or OCD tend to respond to the medication within just a week or two. Depression symptoms often take longer to respond, often 3-6 weeks. If we change doses, it may take less time to notice a difference. If we change medications, it will likely take this long to notice a difference.

     None of the above medications require any type of monitoring lab work. Although there are anti-depressants that require blood work to be checked, these above medications do not. Many children and adults take one of these medications for years. We have every reason to believe this is safe.

     If a medication is stopped, we recommend weaning off the medicine instead of stopping it suddenly. Stopping it without weaning can cause a very rocky emotional stretch and we want to avoid this from happening. Many times, we will have someone take half of their normal dose once daily for a week than half of their normal dose every other day for the following week before stopping. We will discuss with you if you will need to wean off a medication. This is most important when going from one group of medications to another (such as SSRI to dopamine-reuptake blocker).

     For children with depression, it is important to talk about suicide risk. Over the last 20 years, there has been much discussion of this issue. Children and adults with depression are certainly and sadly at risk for suicidal thoughts, suicidal attempts, and suicide. Some very depressed persons are so down and sad that they are not taking care of daily living activities – sleeping, eating, showering and hygiene, etc. When they start an anti-depressant, they often will have “activation” or more energy and desire to take care of these issues. This often happens more quickly than the help from the medication with the sadness and depression. If someone has been thinking of suicide and has been so down without the help of the medication that they have not acted on it, sometimes that “activation” of their “get up and go” to do something happens before they feel better. That would mean they may attempt or commit suicide. So the medicine did not cause the suicide or suicide attempt, but it had not helped yet with how sad and desperate they feel. This all emphasizes that it is important to ask the tough questions: Are you thinking of hurting yourself? If so, do you have a plan to do it? Someone with a specific plan to hurt themselves or others needs more evaluation and often hospitalization for further help. Note: it has not been shown to increase suicide risk by asking someone about it.

     A “no one’s favorite topic” is the SSRIs and sexual side effects. It is unfair for teenagers to not hear about the potential side effects, as almost half of the people taking SSRIs experience these side effects. Because these things are difficult to discuss with the doctor, many patients will simply stop taking the medication to avoid these side effects. These side effects can be discussed in the office. If they do occur and are bothersome, discussing a change in medication is appropriate.

    

    

    

                                                                                                                                                               

                                                                                                                                                                               

 

               

 

 

 

Listeria, ice cream, and your health.

          Listeria is a bacteria that can enter our system through contaminated food. There are about 1600 cases per year of illness from Listeria each year in the US. Nine out of 10 people who become ill with the bacteria will be pregnant women, their newborns, persons older than 65 years of age, or adults with weakened immune systems. Most infected people will require in-hospital care and about 1 in 5 persons with the illness will die due to Listeria infection.
     For adults with a Listeria infection, the symptoms often are fever, muscle aches, and diarrhea. Sepsis (a life-threatening whole-body inflammation due to an infection with fever and lethargy) and meningitis (infection of the lining over the brain and spinal cord with a fever, miserable headache, stiff neck, and lethargy) are how older adults, adults with a weakened immune system, and newborns present with Listeria infection.
     Listeria has been in the Central Ohio news recently due to the issues Jeni's Ice Cream, where the company found that the Dark Chocolate ice cream was contaminated with Listeria. Here is Jeni's Ice Cream recall statement. I applaud Jeni's for being so responsible about this issue! I like them even more now.
     So the chances of any of our patients becoming ill with Listeria is quite low. And if you presented to the emergency department with fever, stiff neck, and lethargy, the doctors would find the Listeria while testing for other bacteria also. As a matter of fact, those symptoms would likely be caused by some other bacteria.

Keeping your family safe from botulism.

     You are likely aware of the botulism outbreak in Lancaster, Ohio. It appears tied to contaminated food from a potluck dinner at a Lancaster church. Botulism can be deadly, as we have seen during this outbreak. The bacteria that causes botulism, called Clostridium botulinum, is most often transmitted from fruit, vegetables, seafood, and honey. The Dispatch has an excellent article about protecting your family from botulism and it can be found here. If you have difficulty accessing that article, the Centers for Disease Control (CDC) has an excellent page dedicated to information about botulism and its prevention. That page can be found here. Stay healthy!

Spring 2015 Allergies

     As Spring is in full bloom in Central Ohio, allergy season is in full bloom also. Here in the middle of April, the trees are pollenating, the grass is pollenating (a little early this year), and the mold counts are quite high. The molds are a tricky one. There are molds that prefer dry conditions and molds that prefer wet conditions. During the Spring, when it rains for a few days then warms up and is sunny and windy (something that has happened frequently this last 4 weeks), the mold counts are high.
     There is an excellent website that gives frequent updates about allergy counts. It is the AAAAI site, a national professional allergy group. The closest reporting station is in Dayton, Ohio and here is the link. If you are wondering "What is out there today, allergy wise?", this is an excellent resource.
     Although years ago everything was by prescription only, now the vast majority of allergy medicines are over the counter: the big three antihistamines (Claritin, Zyrtec, and Allegra), two of the top nasal sprays (Nasacort and Flonase), and the allergy eye drops Zaditor and Patanol. The doses are on the package or check our website.
     If you are having problems keeping the symptoms under control, contact us to discuss what further needs to be done to help.

Measles Update

     As you have heard in the news, there has been an increase in the number of cases of measles in the United States this past year. Nearly 75% of them are linked to an outbreak at Disneyland in California. Sadly, this outbreak, along with the recent increases in the cases of whooping cough and mumps, is related to fewer persons being immunized. This lowers the immunity of a group of people and leads to outbreaks such as what is being seen. None of the doctors at Hilliard Pediatrics has seen a case of the measles. We hope it stays that way!
     People who have received two doses of the vaccine of the measles, mumps, rubella vaccine are very well protected. The majority of the people that have been infected in the recent outbreak have not received both doses. Of the more than 100 California residents infected, only 6% had received both doses!
     Like many other illnesses, the signs and symptoms of measles are common ones. It is the exact symptoms that help us decide when a patient has measles. Eight to 14 days after exposure a fever, cough, cold, and spots in the inside cheeks of the mouth (Koplik spots) occur. A rash begins on the face and head and spreads downward, becoming widespread and obvious on the legs and buttocks on the third day of the illness. Common serious complications are encephalitis and pneumonia.
     It appears this recent outbreak is winding down. As always, we recommend you have your children vaccinated at 1 year of age and 5 years of age. This two-shot series safely provides excellent protection against measles, mumps, and rubella.

January 2015 Illnesses in Central Ohio

     We at Hilliard Pediatrics had a historically busy Decembers in 2014. Although Influenza virus gets a lot of press, we are seeing quite a variety of viral illnesses right now.
     Influenza with fever (often 102-106 degrees), cough, cold, sore throat, headache, nausea, and achiness. The illness often lasts 4-6 days. Because of "antigen drift" (the viral strain evolving), even those that got the flu vaccine this season are becoming ill with the "flu". Remember what gets people hospitalized with influenza are dehydration or pneumonia. The pneumonia usually presents just as the initial few days of fever has broken, the cough improves, and then the cough worsens and the fever is elevated again.
     RSV causes cold and cough symptoms in older children and bronchiolitis in infants and toddlers. These young children wheeze with the virus. See the Bronchiolitis handout for more information.
     Rhinovirus is a respiratory virus that causes cough, congestion, runny nose, and sometimes a fever. The illness can cause a lingering upper respiratory illness for 2 weeks. Check our handout about coughs, colds, and other respiratory symptoms for more information about treatment.
     Croup is a viral respiratory illness with a barky cough (like a barking seal), sometimes a fever for a couple days, sometimes nasal congestion, and a hoarse voice. When it becomes more worrisome, there will be noisy, raspy breathing in between the coughs, especially when taking in a deep breath. This is called stridor. Please check our croup handout for more information.
     There seem to be two major "stomach flus" or viral gastro-enteritis illnesses going through town. One causes frequent, intense vomiting for 6-12 hours, less vomiting for another 12 hours or so, then usually loose stools for another couple days. Another virus causes vomiting for 2-3 days then diarrhea for 4-7 days afterwards. Check our website here and here for more information on treatment of vomiting and diarrhea.
     We are also seeing viral sore throats, Strep throat, bacterial pink eye, a lot of viral pink eye, and a number of other illnesses. I hope this is helpful! We hope you and your family stays well!

Miralax for children with constipation and questions about it's safety.

     Miralax is an over the counter powder used to treat constipation. It previously was a prescription product and has been prescribed or recommended by pediatricians since the late 1990s. The active ingredient is polyethylene glycol 3350 ("PEG 3350"), which works by pulling water into the intestines. This softens the bowel movements and makes them more likely to happen regularly. Over the years, many of our toddlers, children, and teens have used Miralax to help with constipation. It is the most frequently recommended laxative for children by both pediatricians and pediatric gastroenterologists. One of my own sons took the medication regularly (essentially daily) for many years. He found it so helpful and was a normal part of his routine that he referred to it as his "Magical Pooping Powder".
     Despite the years of use and how often doctors recommend it for persistent (daily) use, it is not technically FDA approved for that use. Is that a problem? I would tell you probably not. We have an odd way of approving medications for use in this country. Many medications used for years in this country that have a good, safe "track record" have not been FDA approved for a certain use. A good example is amoxicillin use for sinus infections. It is used all the time, is recommended by the specialists, and has been safely and effectively used for years. It is not approved by the FDA for this use. Does that mean it has not been safe? No. The companies manufacturing the amoxicillin would need to spend hundreds of thousands of dollars to do the research to submit to the FDA to have this approval happen. Why don't they do that? It is so expensive and it would be unlikely to change how it is used by the doctors, so there is very little motivation to spend the time and money.
     In fact, at one point it was estimated that nearly 80% of the medications commonly used by pediatricians were not used "just" according to FDA approval. They may be used at different ages (clotrimazole states not to use on a diaper rash without it being recommended by a physician -- we do so all the time), for different diagnoses (approved for ear infections but used for sinus infections), for longer amounts of time (over the counter antacids are approved for use up to 14 days but are taken all the time for daily use), and other variations. The truth is pediatricians have so much good experience with these medications that we fill very comfortable recommending and prescribing them.
     There was an article in the New York Times in 2012 about this issue and Miralax. A link to it is here. My worry is that a safe, effective medication will no longer be used when the other options become more frequently used after concerns are raised. And despite 15 years of its use, no good studies have raised any worrisome concerns. I am always skeptical of individuals or groups blaming side effects on a medication or treatment and then it getting over-blown. Also, it is always important to remember that if a symptom or health issue starts while using a medication or undergoing a treatment, it does not mean the medication or treatment caused it.
     So further study into the safety of Miralax and PEG 3350 is going to occur. Here is another recent New York Times article about it. In the meantime, based on 15 years of experience and my reading, I will continue to recommend Miralax as I have found it safe and effective for my patients and family members who need it. If you are concerned about using Miralax at this time, there are other options listed on my "Constipation" protocol on the Hilliard Pediatrics website, available here.