Auvi-Q's return in 2017

     A while back the epinephrine auto-injector for severe allergic and anaphylactic reactions called Auvi-Q was taken off the market. The reason was a concern with it delivering the proper dose (0.15 or 0.3 mg) every time, across all the units that were made. The company that originally developed the Auvi-Q is now bringing it back to the market in early 2017 after extensive work to ensure that the units work just right.
     For years, the Epi-Pen and Epi-Pen Jr. have been the leading epinephrine auto-injector. When Auvi-Q was originally introduced, we applauded that it introduced competition to the marketplace (a good thing for consumers). Also nice is that a unit was introduced that would talk someone through the dosing of the injector, which in the frightening situation of a life-threatening allergic reaction may help caregivers or patients use the injector correctly. The size and shape of the Auvi-Q units also have appealed to many patients.
     With recent frustrations with the rising costs of many medications, including the Epi-Pen brand, I welcome the Auvi-Q return in 2017. Here is a link to the Auvi-Q website with further information about their product. Here is a link to the Epi-Pen website. Realize that even with the return of the Auvi-Q to the marketplace, different insurance plans cover these medications differently. Some plans may prefer Epi-Pen, others Auvi-Q. If you have questions regarding coverage, contact your insurance provider in 2017.

Safe Help for Teething in Infants and Toddlers

     Most infants get their first teeth at 5-9 months of age. For months before this, you may not see much happening at the gums (not puffy or swollen). But leading up to the teeth breaking through, many infants drool more than ever and chew more for comfort. Although some infants and toddlers cruise through teething without much pain and discomfort, other little ones are intermittently uncomfortable. The pain and the teeth actually breaking through do not always correlate well. In other words, your infant might be having a great week when a tooth actually breaks through, but the previous week was filled with fussiness. You may be wondering how to safely help with teething discomfort.
     Teething toys are a good option for teething discomfort. Teething rings, wet washcloths kept in the freezer for 10 minutes or so (we want them cold but not frozen), a favorite blanket or toy, and your fingers (can be a big ouch!) are all good options. The liquid filled teethers are thought to be unsafe as they can break open - so avoid those.
     Another treatment option for teething pain that you may have heard about is Amber Teething Necklaces. Here is a link to more information about these necklaces. We do not recommend them, as we feel they may not be safe and there is no scientifically sound information to show that they work.
     We have recommended the Baby Orajel and Ambesol for many years. These products contain benzocaine, a topical numbing agent. Recently recommendations have changed and the Federal Drug Administration no longer recommends the routine use of benzocaine because of the risk of methemoglobinemia, a rare but serious condition when the blood cannot carry the oxygen properly. In addition to possible safety issues with the benzocaine, anything massaged on to the gums washes away very quickly because of all the drool.
     We are asked about the use of acetaminophen (Tylenol) and ibuprofen (Motrin and Advil) for teething discomfort. The truth is we think these are safe to use on occasion for discomfort, but we do not think it safe to dose many times in a week. A safe guideline might be to "save it" for the 2-3 times a week when things are at their worst and nothing else seems to help. Daily doses of Tylenol or Motrin for teething given on a regular doses may not be safe for your liver or kidneys.
     I love referencing the Healthy Children website. They have so many good articles about so many issues in kid's health. Their page about teething found here has lots of good information. Ask your doctor at an appointment if you have questions or call during regular office hours. Good luck!

Baby Led Weaning

     I am getting more questions about baby led weaning recently. I must admit, the first time I heard the term, I was not sure what the parent was referring to exactly. If you are unfamiliar, baby led weaning is really baby self feeding, with infants 6 months and above offered the opportunity to feed themselves from the start of transitioning to solid (complementary) foods. There is much more detail here on a website all about it.
     Are there advantages and disadvantages to transitioning to solid foods this way? This is not easy to answer as there has been VERY limited scientific research into the area. My biggest three questions are: 1. Is it a choking hazard? 2. Will the infants who do self-feeding eat a well balanced diet that allows them to get all the nutrition, vitamins, and minerals that they need? 3. Are these children more or less likely to develop food allergies than a child who does another feeding strategy?
     Although the concern for this strategy leading to choking issues, this article reviews a recent study that showed it could be done safely. Having said that, I remain worried about infants choking with baby led weaning.
     The answer to the question about balanced nutrition is not answered yet. I have seen at least two 9 month old infants who have done a baby led weaning strategy who were anemic. I remain concerned, as do other pediatricians, that there may be some important things missing from their intake. Trusting that the baby's instincts will lead them to good nutrition makes me nervous. Toddlers, for instance, might eat bananas, cheese, and noodles all day if left to their own choices -- not bad nutrition, just not all that one needs.
     The answer to the food allergies question also is unanswered. We seem to be headed in the right direction by now introducing those foods most likely to trigger reactions. I would hate to lose this momentum. Items like the Osum Bamba Peanut Snacks are a terrific way to introduce peanuts into the diet for children who can self-feed.
     So much time and research has gone into pediatricians feeling confident about traditional transition to solid foods with purees. If you are interested in following a baby led weaning plan, I encourage you to keep the above issues in mind. Ask your pediatrician if you have more questions or concerns.

New HPV 2 Dose Schedule for 9-14 Year Olds

     We all like when an immunization shot schedule gets easier! The HPV (human papilloma virus) vaccine has been used since 2006 in this country. The current vaccine is "Gardisil 9" and offers excellent protection against HPV strains that can lead to cancer and other issues. Recent studies have looked at whether giving two doses of the HPV vaccine at the preteen age would provide very good protection versus given three doses. The study showed that the two dose schedule gave very good protection. The second dose was given 6-12 months after the first dose. In fact, the protection was so good for 9-14 year old receiving two doses, their protection was better than the 15-26 year olds receiving three doses!
     So you will likely find that we will recommending a different schedule for the 9-14 year olds receiving the vaccine. Discuss it with your doctor. When we routinely offer the vaccine in the pre-teen years, getting the first dose at one visit and another in 6-12 months should give your child excellent protection against HPV. This will allow us to give the vaccine in two consecutive check-ups, simplifying the schedule and reducing trips back to the office in between well visits.
     If you have felt hesitant about this vaccine, please know we feel it is very safe and very effective. My own three children have received the vaccine. Other than some arm soreness, they have had no side effects. And my wife and I can rest easier knowing that they and their spouse/partner are better protected from cancer and other issues.
     We hope this new schedule for those that start the vaccine before they turn 15 years of age will encourage everyone to start the vaccine at a younger age (11-13 year olds) when the protection they will receive from the vaccine will be at it's best. Please discuss with your doctor if you have questions or concerns.
     Here is a link to an article from the Centers for Disease Control and Prevention with more information.

Our office's patient portal.

     With our change about a year ago to our current medical software, we now have the capability to have a patient portal. Patient portals are secure, safe, online websites that give convenient access to personal health information. Many patient portals allow you to request well visits, request non-urgent appointments, access your health information, access your immunizations, ask non-urgent questions, request prescription refills, update contact information, and more.
     We know many of the families that have been in the office in the last number of months have provided information so that you can access our patient portal. The portal is located at https://health.healow.com//hilliardpediatrics.
     Our patient portal is currently set up so that you can request a well visit appointment, request non-urgent appointments, request prescription refills, ask non-urgent questions, access your child's immunization records, check your child's growth curves, check you child's upcoming appointment(s), and see a summary of previous visits.
     We plan to set up a link from our website at www.hillardpeds.com to reach our patient portal. We hope to make it convenient to access.
     An important note: our patient portal should not be used to reach us with urgent or emergency issues. The portal will be checked periodically during routine office hours (9:00 a.m.-noon Monday through Saturday; 1:00-5:00 p.m. Monday through Friday), but not when the office is closed after hours, on weekends (besides Saturday morning), or on Holidays when we are closed. Leaving an urgent issue on the portal for us to read later will delay when we will be getting back with you. As you know, for an emergency, call 911 or go to the emergency department at Nationwide Children's Hospital. For an urgency, call our office (after hours, call and leave a message) or go to Nationwide Children's Hospitals Urgent Care or emergency department.
     We look forward to your feedback.

Why do some medical offices not consistently have the flu vaccine this 2016-2017 year?

     In the Spring of 2016, the national organizations made the recommendation to not do the Flu Mist nasal influenza vaccine because of it's lack of effectiveness in the last 3 influenza seasons. This information was available for us soon enough to cancel our Flu Mist order for the 2016-2017 season and increase our order of the flu shot. However, this has happened all over the country and has increased the demand for the flu shot routinely used with children (there are some flu shots that are not used for all ages). This increased demand has meant that the makers of the flu shot have had some delays producing enough flu shots to keep all office's supplied at all times. Although we do not know when it will be received, we will keep you updated when we know more about our supply.
     We actually order the flu vaccine in the previous Winter for the next season. That means by February 2016, our order was placed for the 2016-2017 season. We added to our order of flu shots once it was known that the Flu Mist would not be used this year.
     A review of our recommendations may be helpful. We recommend the annual flu vaccine to all of our patients 6 months and above [there are some of our patients who cannot safely receive the vaccine -- the most common reason is a history of anaphylaxis (severe allergic reaction) to egg and egg protein]. The first year the vaccine is given, if the child is less than 9 years of age, they get the best protection if they receive two doses a month apart. Unless there are special circumstances some year (there were a few years ago when the H1N1 strain emerged), that is the only time a second dose is needed the same season.
     Years ago, it was thought the vaccine's protection against influenza only lasted a few months,  The current recommendation says to give the vaccine from when it is first available in July-September and it is fine to receive it, if not received previously that season, for as long as the flu vaccine supply is available (we have given it as late as January when it has still been available). It takes about 2 weeks for the vaccine to work well, and the typical season for influenza in the community is from October or November through February or March, so ideally the vaccine is received by October each year. In our experience, the vaccine continues to give protection throughout the season.
     Each year, experts pick the 3 or 4 strains of influenza in the vaccine for that year. As you may be aware, some years the match of what is in the vaccine as protection and what strain goes through the community can vary. Some years, the protection is terrific because there was a good match. Other years, many who received the vaccine may still become ill with influenza because the match was not a good one. We do not yet know this year about how well matched the vaccine strains will be with the virus strains in the community.
      To summarize: 1. we recommend the flu vaccine, 2. only the flu shot is available this year, 3. we are out of the vaccine right now but expect more doses soon, and 4. we will keep you up to date about our supply.

Dr. Greg Barrett's Pediatrics Blog -- An excellent essay on Parenting

     Dr. Greg Barrett, M.D. and I spent some time together growing up in Tipp City, Ohio. Our parents know each other well. We both have practiced general pediatrics for over 20 years in Central Ohio.
     Like myself, Dr. Barrett has an excellent blog for parents. I really enjoy many of his topics and essays. Here is an excellent one on parenting. I recommend reading it.

Baby walkers are not safe.

     Although baby walkers -- those contraptions with wheels that hold a baby up and support them -- were popular years ago. There is a picture of me taking on our babysitter's porch of me in a walker before my first birthday. But time has taught us that baby walkers do nothing to teach someone to walk. In fact research has shown they can delay motor (getting around) development. Most importantly, they are dangerous. Many injuries have occurred with infants and toddlers in walkers over the years, mostly from the walkers going down stairs. Although parents tell me they are a good option to partially corral their children, I am convinced the risks are too high to recommend using one.
     Despite them losing popularity some time ago, they seem to be making a comeback. And I highly recommend NOT using one. It is not worth the risk. Here is a link to an article written on Healthy Children's website (excellent resource for families!) that discusses this issue further.
     Again, I highly recommend that your child NOT use a baby walker.

Please Don't Pass the Nuts Blog

There is a terrific blog about living with food allergies: Please Don't Pass the Nuts Blog. This link includes an interview with the also terrific Dr. Dave Stukus, MD, allergist at Nationwide Children's Hospital in Columbus, Ohio. Check it out!

Nitrates in the Water Supply

     Nitrates are a normal in the water and in some foods. High levels in the tap water occur when Spring rains cause the fertilizer to run off into the water supply. Infants, especially very young infants less than 4 months of age, are at risk to develop a startling blue-ish color to their skin. The AAP (national organization of pediatricians) does NOT recommend worrying about breast fed infants receiving nitrates thru breast milk as it is essentially unheard of for moms to have any significant levels pass into the breast milk. However, for anyone less than 12 months of age, until the alert passes, anyone less than 12 months of age should be given bottled water. Methemoglobin causes an infant to turn blue. And this is not likely at all. We have never seen a case at Hilliard Pediatrics even though these alerts happen every couple years. However, if your child turns blue, take them to the Nationwde Children's Hospital emergency room immediately.
     Although the Dublin Road Water Plant reached an advisory level last week (about June 30th, 2016), the advisory has been lifted now -- as of July 6th, 2016. Here is the initial article about it in the dispatch. And here is the follow-up article about the level being lifted.

Mom Docs helping Moms on the go -- a great website

     I am more than happy to point families to other doctor's awesome websites. One of those that is well worth checking out is "Mom Docs helping Moms on the go", a blog on St. Louis Children's Hospitals website. It is located here and I recommend it!

Flu Vaccine Update for 2016-2017 Season

     We were made aware in the third week of June 2016 that the Centers for Disease Control was officially recommending that for the 2016-2017 flu season that only the flu shot be given, not the Flu Mist. This is based on the protection for the last few seasons. In these studies, the flu shot was much more protective than the Flu Mist. Although this information contradicts what we had been told from past years, the study was so convincing that it will greatly change what we do for the upcoming flu vaccine season.
     As of now, the last week of June, we anticipate only stocking and giving the flu shot. The Flu Mist may be used again in the future. We will keep you updated about this issue here and on our Facebook page in the coming months.
     We feel as distressed about this as many of you will feel.

Toilet Training Your Child

Introduction I talk to parents and children quite a bit about toilet training. It is a big accomplishment to finally be potty trained as a toddler. I know it can be a frustrating path to get there. I hope this information is helpful to you.

Signs of readiness

     Here are signs to look for to know your child may be ready for potty training:

- Your child is dry at least 2 hours at a time during the day or is dry after naps.

- Your child can tell you when they are about to urinate or a have a bowel movement.

- Your child can follow simple instructions.

- Your child can walk to the bathroom and help undress.

- Your child does not like wet diapers and wants to be changed.

- Your child asks to use the potty or toilet.

- Your child asks to wear big kid underwear.

First steps towards potty training

- Buy a potty. We generally suggest a potty that allows the child’s feet to reach the floor. But children with older sibs may prefer going on a toilet with a potty seat on top.

- Be a good role model. Many toddlers will follow you into the bathroom. Let them see you go on the toilet and wash your hands afterwards. You can help prepare them to use the potty by saying “You can sit on your potty too”.

- Decide which words you will use. When I was growing up, it was a naughty word to say “poop” in my house. But that is the word my kids used to describe bowel movements – we said “pee” and “poop”. You might say “urine” or “number 1” or another word that works for you. You might use “poop” or “BM” or “number 2” or “poo”. Try to avoid words that put a negative spin on toilet habits – keep it neutral – so it is best to avoid dirty, naughty, or stinky.

- Watch for the signs. Toddlers may grunt, look like they are concentrating, squat down, stop playing, or other signs before they have a bowel movement. You will learn your child’s signs. This is a good time to offer to have them sit on the potty. Signs of urinating are trickier – some children give you no signs. Occasionally kids will pat the front of or tug on their diaper.

- Teach proper hygiene. Show your child how to wipe. Girls should spread their legs apart while wiping and should wipe front to back. Wiping front to back helps prevent bacteria from spreading from their bottom to their bladder and vagina. Teach your child to wash their hands after the use the toilet.

- Make it part of the routine. Take your child to the potty when you see the signs of needing to use the potty, first thing after sleeping overnight or napping, and when your child is getting ready for a bath. Even if they do not use the potty or go right after getting up from the potty, do not stress – it takes time to do it right.

- Give lots of praise for successes. Everyone will be less stressed about potty training in your home if you can remember to offer praise, hugs, and high-fives when your child goes on the potty AND act as if it is perfectly fine if there are accidents, lots of sitting without any actual “potty business”, and other issues. Punishment will just make your child upset and can make it take longer to be successful at potty training. Many parents find it helpful to make a sticker chart, offer a small treat (raisins, animal crackers, an M&M candy), or put a penny in a piggy bank for successes on the potty. These kind of small rewards work best if you do it for each small step: sitting on the potty dressed, sitting on the potty without diaper on, peeing on the potty, and then pooping on the potty. Although some parents have good success with just praise, a special sticker on a chart or a special treat can go a long way to help encourage better interest in potty use.

Grandma swears you as a parent were potty trained when you were 18 months old and your child is 18 months old and not yet potty trained

     First: don’t let this stress you out. Nowhere on your child’s college application does it ask when your child was potty-trained. It will happen and everyone is on a different schedule.

     Second: don’t tell the grandparents, but their memory may be fuzzy for the details.

     Third: more kids had a stay-at-home parent years ago and some children had a good chance to potty training earlier.

 Potty trained but not potty motivated

     This is a common issue. Your child has shown signs of success, has peed and pooped on the potty, but will not do it regularly. This is the best time to practice patience. A researcher at the Children’s Hospital of Philadelphia studies potty training and did a study with potty resistant children. He had one group of these families regularly do sticker charts, encouraged the kids to regularly sit on the potty, made a plan for rewards for success, and talked about it regularly. The other group put the potty training “on the back burner” – the potty was there but they did not regularly talk about it, they did not plan to make trips to the potty regularly, and stopped any talk of stickers/M&Ms/pennies in a piggy for success. Three to six months later, the group that put the issue on the “back burner” was almost twice as likely to have their children now potty trained. The researcher (and I agree) said this was a classic “issue of control”. The child wanted to be in control over this potty training issue. Once the pressure was off, they chose to use the potty. So if a family says their child cannot start pre-school in 6 weeks because they are not potty-trained, the most likely thing to work is the put it on the back burner.

     Although peer pressure can result in bad things, watching an older sibling or a classmate in daycare use the potty well can be a powerful motivator.

Your child will pee on the potty but you are having no success with having them poop on the potty

     This is so common that for many children it is practically an official step in potty training (although some children skip this step). And helping kids through this is often a two part job: helping the child be motivated about pooping on the potty AND solving any constipation that happens. First off, constipation sure can happen because all of a sudden we are expecting the child to hold their poop until the go on the potty. Once they go, they may have waited long enough that it is a larger, harder to pass bowel movement and it is not as comfortable to pass as usual. This motivates many children to wait longer to have a bowel movement the next time. This cycle of waiting and then a less comfortable bowel movement pushes them into a stretch of constipation. Children at this age have a mind-set called Magical Thinking that can allow them to think “it hurt the last time so I am never going to poop again”. This is not how it works in real life obviously. Many of these children then need help from us to keep the bowel movements softer: more water and juice intake, more fiber (whole grains like oats and wheat), less of the foods that tend to constipate (bananas, cheese, and carrots – 3 staples of toddlers diets), and potentially Milk of Magnesia or Miralax® (see our Constipation protocol). After a few weeks of keeping the bowel movements (emphasis on weeks – this will take time) softer AND with encouragement, hopefully the cycle of putting off the bowel movements will be improved.

     Now let’s tackle how to encourage the actual pooping on the potty! Many of these kids will not tell you when they need to go or will but they will poop in their diaper or pull-up. Many times we will hear that a toddler will ask for a pull-up or diaper so they can poop in it. What to do as a parent? As you can tell, the child does have control over their bowel movements. They just are not going on the potty. Instead of letting that frustrate you, we can channel that into going on the potty. One strategy is to encourage small steps in that direction. Encourage your child (bribes may be needed) to go into the bathroom when they poop in their pull-up or diaper. Then when that is going well, encourage them to sit on the potty in their pull-up or diaper. When that is going well, encourage them to try sitting there without a pull-up or diaper on. This may take a few weeks to accomplish, but once it happens it is likely a big breakthrough. Make sure to give lots of praise and maybe a special surprise.

     Dr. Barton Schmidt, MD, a pediatrician in Colorado, recommends that if you cannot get past the stage where the child takes off the diaper or pull-up to poop on the potty to cut a vertical hole in the diaper (do not tell your child). When they are sitting on the potty and poop, the bowel movement will fall out of the diaper or pull-up into the potty and you can say “Hey, the poop must have wanted to go in the potty!” This has worked for a number of my patients.

Staying dry at night

     There is a whole handout on Bedwetting with more information. But realize many children take a while to stay dry at night even if they are dry and clean during the day. Although some kids become dry at night when they are potty trained during the day, do not let anyone at home stress about it – it will happen! Make sure your child empties their bladder and does not drink much before bedtime.

When do I buy pull-ups?

     Pull-ups are an odd piece of the puzzle. For some kids, they are a nice transition to big-kid underwear. For others, they are no more than a more expensive diaper. If your child is nearly there (keeps their diaper dry most of the time and poops sometimes in the potty) but when they are out playing or you are out running errands they have been known to have an accident, it is appropriate to try putting them in a pull-up during the day. Also kids who are doing great during the day who still wet at night will often do well with a pull-up. That way they can pull it on and off as needed if they use the toilet or potty overnight. If your child does not seem to treat the pull-up any different than a diaper and they are not independently running to the potty (with the pull-up being easier to take off by themselves so they can go potty), it will be cheaper to just use diapers.

Do I have my son stand up to pee?

     Yes. But realize that the little fella’s aim is not going to be so good. And get used to saying “Point your penis so that the pee goes in the potty” and cleaning up the pee that does not make it to the potty. Many boys start by sitting and then transition to standing later. Even while sitting to pee, you often have to say “Point your penis so that the pee goes in the potty”.

When should we put potty training on hold?

     Big changes in a family’s life (even happy ones) can mean emotional upheaval for everyone. Moving, a newborn at home, a major illness, or a death in the family are good examples. These are good reasons to hold off on or pause potty training efforts for a month or two.

Should I worry that my child is having accidents again when they were potty trained for months?

     The good news is that with patience, this phase often passes within a few weeks or months. If your child is not constipated and is not complaining of discomfort when they urinate, this will likely pass. We want to see children in the office if they are having pain with urination (to rule-out a bladder/urinary tract infection). If your child is constipated, treating the constipation can help with the accidents. It turns out that our bladder is right next to the lower intestines and the pressure on the bladder from being constipated can contribute to accidents. If you have questions about how to treat constipation, see the Constipation protocol.

Grandma says she can potty train my child in a weekend

     No offense to grandma, but this is probably not what you and I mean by potty trained. We mean a child who can and does go to the bathroom, can usually get their clothes on and off to use the potty, routinely pees and poops in the potty or toilet, and initiates the whole thing themselves (without you having to remind them all the time). What grandma will do is put them in underwear, take them to the potty every 30 minutes, give them lots of love and praise, and the child will keep their underwear clean and dry (except for maybe an accident or two). But then real life happens the next few days after this weekend, your child is probably not going to have magically turned the corner. See below.

When do I put them in underwear (no pull-up or diaper) and see how it goes?

     This is successful with a nearly-there toddler who has a lot of success but seems to not be able to get over the hump of routinely making it to the potty on time. The hope is the “ugh – this wet/dirty underwear feeling is gross” motivates them to regularly pee or poop in the potty. And it can work. Remember to give a big pep talk about “Spiderman/Elsa/Paw Patrol/the Princesses do not want pee or poop on them. We need to keep your underwear clean and dry!” If you and your child are quickly getting frustrated after a few hours or a few days of this strategy, stop and go back to diapers or pull-ups.

My child does great at daycare but then over the weekends we struggle with success going on the potty

     This is a common issue. Your child sees all their friends go at daycare and there is a routine a school. When real life and no awesome peer models (the other kids going on the potty is a huge motivator) interfere, many 2-3 year olds are not as motivated over the weekends or holidays. Hang in there. Keep up with the gentle reminders (avoid sounding as if you are desperate for them to go, even if you feel that way!) and a small reward for success (a star on a chart, a small treat, etc.).

Conclusion

     If you have questions or concerns that are not covered in the above information, do not hesitate to call during routine office hours to discuss with the nurses on the phones. Our number is 614-777-1800. Good luck! Your child will get there!

                                                                                                                   

New Meningitis Vaccine Requirements for Ohio Schools 2016-2017 School Year

     The Neisseria meningitis vaccine helps prevent the leading bacterial cause of meningitis in pre-teens, teens, and young adults. The vaccine we use is called Menveo (manufactured by GSK) and we have routinely been giving it to our 11 year olds and high schoolers (usually 16-18 years of age) for a few years. Although many colleges have required the vaccine (two doses), the middle schools and high schools have not required the vaccine in years past. That is now changing.
     For the 2016-2017 school year, the State of Ohio is now requiring that the first dose be given before the start of 7th Grade and the second dose be given before 12th Grade. Our office schedule has meant the vast majority of pre-teens and teens have been up to date for school, but there are some of our patients who were not receiving the second dose until 12th grade. If your child has not received the dose, they can either do it at a well visit before their senior year starts or come in for a shot-only visit this summer (call to schedule these ahead of time). We can print out their shot record for proof to the school that your child is up to date.

Melatonin Use In Children

     Problems with falling and staying asleep happen to about 1 in 5 children and teenagers. One of the dietary supplements available for help with this issue is melatonin. We naturally have melatonin in our system that is produced in the pineal gland. It helps regulate sleep onset, meaning it is released to help us fall asleep. We are still discovering other things that melatonin does in our system.
     By 3 months of age, melatonin in infants start to regularly be released in the evening. This helps the 3-6 month old infants sleep better at night. By the teen years, it is released later. This contributes to teens staying up later and sleeping in. By the senior adult years, it is released earlier. This contributes to senior citizens going to bed earlier and waking up early in the morning.
     Some people naturally make plenty of melatonin. Other people's body does not make enough melatonin for them to easily fall asleep and stay asleep. For those children (and adults), taking melatonin about an hour before sleep can allow them to fall asleep faster, increase the total number of hours slept, and decrease the number of night time awakenings.
     A number of studies have looked at otherwise healthy children, children with autism or autism spectrum, children with developmental disabilities, and children with mental retardation. All of these groups have shown improvement with melatonin if they had sleep issues. Side effects in the short term are limited. The most common feeling is a "fuzzy" or tired feeling in the morning and many people do not experience this side effect. Occasionally, people experience headaches, nausea, or dizziness after using the melatonin, but the chances of these symptoms is not greater than taking a placebo (sugar pill). Although long term side effects are still being studied, no alarming information is coming out of studies that have looked at 3+ years of use. Exceeding the maximum dose may increase the risk of heart arrythmias.
     Because melatonin is available over the counter as a dietary supplement, it is not tightly regulated by the Federal Drug Administration. Many manufacturers make a melatonin product. Because these products are not tightly regulated by the FDA, some of the products may be better than others. One major manufacturer's melatonin product was found to contain no melatonin! If you are taking an appropriate dose of a melatonin product and it is not helping, consider trying a different company's melatonin. It is available in many forms, all over the counter: liquid, pills, dissolvable tablets, and gummies.
     The usual dose range is from 1 mg to 10 mg. I recommend starting with the lowest dose. There are melatonin products that are 500 mcg (1/2 mg) -- although the dosage may be so low that it would not help with sleep, it is fine to try this lower dose first. Increase to a higher dosed if a lower dose is not adequately helping. It is fine to use the melatonin every night or just as needed. Give the melatonin 30-60 minutes before you want your child to fall asleep. Remember: not everyone will respond to melatonin. It may be a big success or you might not notice any difference at all.
     A personal perspective: we have used melatonin in my house. I have taken it occasionally if I was struggling with insomnia on a particular night (which I am lucky enough to not have very often). It works very well for those nights. I might feel a little more "fuzzy" or drowsy the next day, but then I did not fall asleep at my normal time. I have also taken melatonin if we were taking an over-night flight. It has also helped me sleep during those nights also. On a humorous note, I took it once in an airport before a flight on a family vacation. My family was not pleased when the flight was delayed by about 45 minutes. Their worry was that the melatonin I had taken would kick in and they would have to help me on the flight. As the melatonin kicked in, I was so sleepy that they did indeed had to assist me into the plane. One of my three sons is not our best sleeper. We have often said that he is "not wired for sleep". He has tried melatonin on occasion and it has not helped him. Admittedly, we have not increased his dose past 6 mg, but he has not thought that melatonin made him any more sleepy. So our family's experience with melatonin has been mixed.
     So who do I recommend try melatonin to help with sleep? Certainly a child with autism, ADHD/ADD, or developmental disabilities who struggles with falling or staying asleep may benefit from melatonin. Other children with difficulties with falling or staying asleep may also benefit from trying melatonin. If you start with a low dose and notice a nice improvement, you may continue the dose as needed. If you do not notice a difference, the dose may be increased to a maximum of 10 mg. If any dose causes side effects that bother you, decrease the dose or stop the melatonin. Call during regular office hours if you have questions or concerns.

New stimulant options for treating ADHD

     There are three new options for treating ADHD. Each of these are new forms of two stimulant medications previously available, methylphenidate and amphetamine. The new medications are Dynavel XR, Evekeo, and QuilliChew ER. All of these are Controlled (CII) Prescriptions.
     Dynavel XR is a liquid form of amphetamine. It is the first liquid form of the medication in Adderall, Adderall XR, and Vyvanse. It is taken once daily with breakfast. It is expected to last about 12 hours. A syringe and special bottle allow for accurate dosing. The medication is bubblegum flavored. We have found that children who responded well to an amphetamine product but struggled to swallow a pill previously needed to open up an Adderall XR or Vyvanse capsule and swallow the small beads in the capsule on applesauce. The availability of Dynavel XR allows these children to swallow a liquid medicine instead.
     Evekeo is a shorter-acting amphetamine tablet. It lasts 4-6 hours and most children will need to take it 2-3 times in a day: once in the morning, once at the lunch hour, and potentially once in the late afternoon so they can get through homework or other activities. The tablets are scored to that the 5 or 10 mg pills can be split into smaller doses of 2.5 or 5 mg. This allows for flexible dosing.
     QuilliChew ER is a long-acting chewable methylphenidate product. It is the same medication as in Quillivant liquid and Concerta tablets. The medication is expected to last long enough throughout the day that the average child will need just one dose. Occasionally, someone might need a second dose of QuilliChew ER or another medication to get them through homework or late-day/evening activities. QuilliChew ER is cherry flavored.
     These new medications add options for children with ADHD. Feel free to discuss these with your doctor if your child has ADHD.
   

Mouth Injuries in Children

Introduction

     Mouth injuries in children are quite common. For the first years after someone learns to walk, falling onto the mouth is quite common. Read further for guidance on when to watch at home or when to seek medical attention.

Injured frenum or frenulum

     You may be asking “What is that?” A frenum or frenulum is the fleshy connection between the inside of the lip and the gums. A frenulum is a small frenum. These have quite a bit of blood supply and bleed easily if injured. Why many people no longer have an obvious frenum or frenulum is that they very likely injured it a long time ago, it bled, and then faded away and shrunk as it healed.

     Because they bleed easily, it can frightening to see when the frenum or frenulum is injured. Most children will cry for a few minutes, the bleeding will stop, and the area will look better in a few days. It is fine to offer Tylenol® or Motrin® for pain. If it is particularly sore, offering a Popsicle® or applying a cold cloth to the area should help. It may help to avoid acidic foods and citrus (for example, tomato sauce and orange juice) for a few days.

     We have not had a patient have this torn or injured frenum or frenulum that has needed stitches in the past. Having said that, if the bleeding did not slow to just an slow ooze after 20-30 minutes, we would recommend either contacting us or having your child seen at the Nationwide Children’s Close to Home Center Urgent Care or Emergency Department.

Injured lip

     Swelling and bruising of the lip or lips are common after mouth injuries. The lip, like the frenum or frenulum, often bleeds quite a bit if a cut occurs. Applying a cold cloth or ice pack often helps the swelling, although do not stress if your child does not tolerate this for just a few seconds. It is fine to offer Tylenol® or Motrin® for comfort sake.

     A cut lip often happens when the teeth bite into the lip with a fall. A deeper cut or one that the edges gap open easily often will benefit from being stitched. We do not do stitching here in the office and therefore recommend having your child seen at Nationwide Children’s Close to Home Center Urgent Care or Emergency Department if that would be needed. A shallow cut that does not gap and stops bleeding quickly will usually heal well in a few days without needing stitches.

Biting the inside of the cheek

     It can be super painful to bite the inside of the cheek. With a fall or with chewing, it is easy to accidentally bite the inside of the cheek. These may bleed a little but the bleeding often stops quickly. If a child is quite uncomfortable after a few minutes (when the pain is the worst), it is fine to offer Tylenol® or Motrin® for the pain. It may be helpful to offer a cold drink (ice water or cold juice) or a Popsicle® for the pain. Encourage your child to chew on the other side of their mouth for a few days.  If your child is old enough for chewing gum, avoid it for a few days afterwards also. Spicy, salty, or acidic (for example: tomato sauce and orange juice) foods should be avoided for a few days.

     These injuries generally do not need to be seen in the office. However, if the pain cannot be managed with the above measures or the bleeding cannot be stopped as described above, your child should be seen.

Injuries to the tongue

     Bites to the tongue with falls or chewing can be painful and bleed for a few minutes. If a child is quite uncomfortable after a few minutes (when the pain is the worst), it is fine to offer Tylenol® or Motrin® for the pain. It may be helpful to offer a cold drink (ice water or cold juice) or a Popsicle® for the pain. Spicy, salty, or acidic (for example: tomato sauce and orange juice) foods should be avoided for a few days.

     As scary as an injured tongue can be, the good thing is they rarely need to be stitched. If the edges line up well and the bleeding stops in less than 15-20 minutes, it will very likely heal well on its own in a few days. A tongue injury that did need stitches would need to be seen at Nationwide Children’s Urgent Care or Emergency Department. In addition, some pediatric dentists, oral surgeons, and some ENTs (otolaryngologists) also can treat these as needed.

Injuries to the teeth and gums

     These injuries occur most often with falls, bike and car accidents, and sports-related injuries. We think of these tooth or teeth injuries as falling into three categories:

-Mild injuries                 
Injury to the tooth and gum without loosening or change in position of the tooth.

Treatment: Tylenol® or Motrin® for pain; soft diet for 2 weeks; follow-up with the dentist as needed.

                                          

Injury to the tooth and gum with loosening of the tooth but no change in position of the tooth. There may be bleeding at the gum line and tenderness at the tooth.

Treatment: Tylenol® or Motrin® for pain; soft diet for 2 weeks; follow-up in the next in the next few days with the dentist.

                                           

-Moderate injuries        
Injury to the tooth and gum with loosening and change in the position of the tooth.

Treatment: Tylenol® or Motrin® for pain; soft diet for 2-4 weeks; see dentist in the next 24 hours.                                                 

Tooth is pushed into the gums by the injury.Treatment: See dentist immediately if a permanent tooth. For a primary or “baby” tooth, see the dentist within a few days, sooner if the pain is hard to control with Tylenol® or Motrin®. 

Tooth is partially knocked out of the socket. 
Treatment: see dentist immediately.

-Severe injury            
Tooth is completely knocked out of the socket. 
Treatment: Do not replace a primary or “baby” tooth. See the dentist within the first 24 hours. For a permanent tooth, replace the tooth back in the socket, making sure to place it correctly (for example, the front of the tooth faces the front). If the permanent tooth cannot be put back in place, place it is cold low-fat milk or saline and see a dentist immediately.

If an injury happens after hours and your child’s dentist is not available, we recommend your child be seen at the Nationwide Children’s Hospital Emergency Department where a dentist is available 24 hours a day.              

What to do for your child's allergies?

     I know the allergy symptoms are bad this Spring. Although, I am on allergy shots, allergy eye drops, and a daily antihistamine, I have had to go back to doing a daily nasal spray too! You may have not discussed with us yet what to do if your child has symptoms of allergies. Here is a quick guide for what to do.

2-5 years of age

ANTIHISTAMINES (all over the counter)

Children’s Allegra Oral Suspension 5 milliliters by mouth every 12 hours

Children’s Claritin Syrup 5 milliliters by mouth every 24 hours

Children’s Zyrtec Allergy Syrup 2.5 milliliters by mouth every 24 hours

6-11 years of age

ANTIHISTAMINES (all over the counter)

Children’s Allegra Oral Suspension 5 milliliters by mouth every 12 hours

Children’s Allegra Meltable Tablets 1 tablet by mouth every 12 hours

Children’s Claritin 5 mg Chewables 1 by mouth every 24 hours

Children’s Claritin 5mg Reditab 1 by mouth every 12 hours

Children’s Claritin 10mg Reditab 1 by mouth every 24 hours

Children’s Claritin Syrup 10 milliliters by mouth every 24 hours

Children’s Zyrtec Allergy Syrup 5-10 milliliters by mouth every 24 hours

Children’s Zyrtec Dissolve Tab 1 by mouth every 24 hours

Zyrtec 10 mg Tablets 1 by mouth every 24 hours

STEROID NASAL SPRAYS (all over the counter)

Flonase Allergy Relief Nasal Spray 1 spray per nostril once a day

[Note: OTC ClariSpray® is the same ingredient and dosing as Flonase.]

Nasacort Allergy 24 Hour Nasal Spray 1 spray per nostril once a day

Rhinocort Allergy Spray 1 spray per nostril once a day

ANTIHISTAMINE EYE DROPS (over the counter)

Zaditor Eye Itch Relief 1 drop to each eye every 12 hours

12 years of age and up

ANTIHISTAMINES (all over the counter)

Children’s Allegra Oral Suspension 10 milliliters by mouth every 12 hours

Children’s Allegra Meltable Tablets 1 tablet by mouth every 12 hours

Children’s Claritin 5 mg Chewables 2 by mouth every 24 hours

Children’s Claritin 5mg Reditab 2 by mouth every 12 hours

Children’s Claritin 10mg Reditab 1 by mouth every 24 hours

Children’s Claritin Syrup 10 milliliters by mouth every 24 hours

Children’s Zyrtec Allergy Syrup 10 milliliters by mouth every 24 hours

Children’s Zyrtec Dissolve Tab 1 by mouth every 24 hours

Zyrtec 10 mg Tablets 1 by mouth every 24 hours

STEROID NASAL SPRAYS (all over the counter)

Flonase Allergy Relief Nasal Spray 2 spray per nostril once a day

[Note: OTC ClariSpray® is the same ingredient and dosing as Flonase.]

Nasacort Allergy 24 Hour Nasal Spray 2 spray per nostril once a day

Rhinocort Allergy Spray 2 spray per nostril once a day

ANTIHISTAMINE EYE DROPS (over the counter)

Zaditor Eye Itch Relief 1-2 drops to each eye every 12 hours

PLAN:

1. Do a daily antihistamine when your child has their symptoms. If one does not agree with them or does not work after a week or two, try a different one.

2. If you have tried the antihistamines, your child is 6 years of age or above, and there has not been a big improvement, add a nasal spray.

3. If the eyes are itchy despite doing an antihistamine (or antihistamine plus the nasal spray), add Zaditor eye drops.

4. If you have tried all of the above, your child would benefit from seeing an allergist. They can assist with knowing what your child is triggering the allergy symptoms. They also discuss with you other treatment options, including allergy shots. Call our office during regular office hour to discuss.

ANTIHISTAMINE NOTES

Allegra is the least likely antihistamine to make someone sleepy. If Claritin or Zyrtec makes someone sleepy, try taking it at night.

Each of the three antihistamines work for many people, but many people respond much better to one or the other. You may have to try 2 or 3 to see how someone responds.

Antihistamines work quickly – they should help within a few days of starting the medication.

STEROID NASAL SPRAY NOTES

The spray with the most scent: Flonase. If your child is bothered by the “flowery” smell, try a different brand.

The spray with the least amount of spray: Rhinocort. If another causes too much drip down the back of the throat after using it, try Rhinocort.

These sprays take a week or two to work at their best.

EYE DROP NOTES

If the drops causing stinging, keep them in the refrigerator.

These eye drops works quickly – they should help within a few days of starting the medication.

      As always, call during routine office hours if you have questions. Good luck!

Why is the 2015-2016 such a mild influenza season?

     This has been a busy winter with so many cold, coughs, vomiting and diarrhea illnesses! But remarkably, it has been a very mild influenza season. We have only seen a handful of cases since the start of the season. Many parents are asking me "Why, Dr. Tim?".
     Weather plays a part in many illnesses. The classic pediatric example is croup. The number of cases of croup we see is correlated with weather changes. The more the weather flip-flops around, the more cases we see. That has been true this cold and flu season. However, it is hard to say that this milder winter is changing our influenza season. The last really mild winter a few years ago was accompanied by a really bad influenza season! So, we cannot give credit to the weather this past few months.
     How many people are vaccinated with the influenza vaccine plays a part in the influenza season. I would love to say that this influenza season has been mild because we vaccinated so many kids with the vaccine in the Fall, but that is just not the fact. Due to the nationwide shortage of the FluMist (nasal spray influenza vaccine), we vaccinated about 1000 kids less than we usually do each year. Judging by that fact, we should be having a bad influenza season. But that is not the case.
     How well the influenza strains of the vaccine match the virus in the community plays a part in the severity of the influenza season. There are four (4) different strains in the injectable flu vaccine and the FluMist. Some years, the educated guessing game that the scientists play in picking the four strains is more successful that other years. This year, there is a very good match between what strains are out and about in the US and what was in the vaccine. So that is helpful, but probably not enough to help prevent the influenza as successfully as has happened.
     Why then are we having a mild season? I think the vaccine strains matching the strains in the community is helping. Plus we are just lucky enough to be having a good, mild year! Keep getting vaccinated!