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!

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.