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.
Tuesday, May 17, 2016
Monday, May 16, 2016
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.
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.
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.
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
Tooth is partially knocked out of the socket.
Treatment: see dentist immediately.
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.
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.
Friday, May 6, 2016
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!
Monday, February 8, 2016
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!
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!
Saturday, November 21, 2015
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.
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.
Wednesday, September 23, 2015
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!
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!
Subscribe to:
Posts (Atom)