When to see an allergist.

     Allergies are a big topic in my life. I have allergies. My wife and children have allergies. I have many family members and friends with allergies. As a pediatrician, I see many children with allergies of all sorts. My wife is a pediatric and adult allergist. A common question is when to see an allergist. The American Academy of Allergies Asthma and Immunology has a good website here with lots of excellent information, including when to see an allergist. Our website at www.hilliardpeds.com has a handout about Allergic Rhinitis. My wife's practice is Midwest Allergy. Their website is here and has a list of conditions in which it is recommended to see an allergist. Here is the list:

Anyone who has reacted to a food

Anyone who has reacted to a stinging insect

Anyone with moderate to severe eczema

Anyone with persistent asthma (on a controller medication)

Any asthmatic who requires more that one course of systemic steroids per year or who requires more than one canister of albuterol per year

Anyone with rhinitis who fails pharmacotherapy or desires to minimize medication use

Anyone with chronic or recurrent sinusitis/otitis

Anyone with recurrent infections of any type

My list of reasons to refer includes:
1. Allergic rhinitis symptoms that do not respond well to over-the-counter or prescription medications.
2. Allergic reactions to foods.
3. Allergic reactions to stinging insects (bees, wasps, hornets).
4. Difficult to treat eczema that may be triggered by allergies.
5. Persistent or difficult to control asthma.
6. Recurrent or unusual infections that may be a sign of an immune problem.
7. Recurrent sinusitis that does not respond to other treatments.
8. Finally, if someone is struggling with allergy symptoms that may be from a pet (cat, dog, gerbils, hamster, etc.) and would consider having the pet live somewhere else, I would confirm the allergy with testing first.

Certainly discuss with your primary care physician if you have concerns about the above issues.

2012-2013 Seasonal Flu Vaccines

     Many offices, including our own, have received the seasonal influenza (flu) vaccine for the coming season. The Centers for Disease Control has excellent information about the flu vaccine here. It is now routinely recommended that all children 6 months to 18 years of age receive the vaccine each year. We have both the nasal spray and the shot available. For children less than 24 months of age and those with a history of asthma, heart conditions, diabetes, and kidney disease, it is recommended to do the flu shot (not the spray). Children less than 9 years of age, if this is the first year they have received the vaccine, it is recommended to received two doses of the vaccine one month apart. We offer the flu vaccine at both well visits, sick visits (if not "too sick" -- we can discuss it), and walk-in flu vaccine clinics. The dates for our flu vaccine clinics are on our website here. It is not too soon to start receiving the vaccine now -- the CDC site has good information on that topic (when to receive the vaccine).

Swine flu and the fair

     As reported in the Dispatch, pigs from the Ohio State Fair have tested positive for the swine flu. There are at least 41 cases (almost all in children) of swine flu confirmed in fair-goers. The basic message is a common one: wash your hands or use hand sanitizer after touching animals. Especially before you eat (where you can pass germs from your hand to your mouth through the food)!
     Remember that despite all the different names for different types of "flu" (influenza), they essentially cause the same classic flu symptoms: fever, aches, cough, cold, stomach upset, and sore throat. Here is a good review of what to watch for with the swine flu and common symptoms.
     Bottom line: your mother was right -- wash your hands!

Sudden Cardiac Death among young athletes

     An ongoing discussion in this country amongst physicians, families, insurance companies, and others involves how to better prevent sudden cardiac death among young athletes. Many times these teenagers collapse suddenly and die unexpectedly on the playing or practice field. Since someone with a heart condition that would predispose them to this often has no symptoms and a normal exam, the question then is: Can we prevent these tragedies? It is possible to find these athletes before tragedy strikes with an electrocardiogram (EKG) and echocardiogram (ultrasound of the heart). One major issue is the expense and who will pay for it. These tests are not cheap and can cost more than $1000. If they are done for screening (not because there is already a problem -- dizziness with exercising, fainting with exercise, family history, etc.), insurance companies often do not cover the expense. One study estimated it would cost over a million dollars of money spent screening many athletes to prevent one episode of sudden cardiac death amongst young athletes. As much as it is easy to feel as a caring parent that this expense should be covered by insurance, remember insurance works as "shared risk" -- the more routine tests, the more expense for everyone. And with health care so expensive at this point, more of the cost of "not everyone needs that test" will fall on the people that use that care.
     One intriguing new option is mCore. There was an article in the Columbus Dispatch this week discussing the issue and mCore's ability to provide cost-effective screening. I think this is an exciting option. I hope these kind of screenings allow us to prevent more episodes of Sudden Cardiac Death.

Pediatricians and formula samples.

     Last week, the American Academy of Pediatrics Committee on Breastfeeding issued a "resolution" to encourage pediatricians to stop distributing formula samples at prenatal visits and upon discharge from the hospital. There are good studies that show that these samples decrease the number of infants fed breast milk exclusively and the number of infants fed any breast milk. The specific resolution is here.
     I and my partners at Hilliard Pediatrics have mixed feelings about this issue. As much as we want infants to successfully breast feed, we know many families find the samples helpful. We want to do what we can to encourage infants to have breast milk the first year of life. We also want to encourage infants who are going to receive formula to receive the best formula.
     We will continue to discuss the issue here at the office. I suspect there is going to be an ongoing discussion for many in the coming months and years. I will keep you posted!

Getting your child to take medication -- part 2

     Over the years, we have found getting children to take medication is not always easy. And sometimes it takes a major amount of effort! The following are a number of tips to try to help you get your children to take their medicine.
     First, there are some scenarios where it is not necessary for your child to take any medication to get better. Although we as adults may agree that your child would feel better if we got their 102 degree temperature down with a fever-reducer, that their stomach would feel better if they chewed up a chewable antacid for their stomachache after eating spicy food for dinner, or their nose would not run so bad if they would take an allergy medication. However, with these issues, they "will be okay" without taking the medication. Consider in these situations simply not stressing over the medications. One Christmas morning in the Teller household, we had our son vomiting with a fever of 102-103 degrees. He declined any fever-reducer (which stressed out his grandmother) because, in his words, "that will make me puke". So he just laid on a cool tile floor in the bathroom and rode out his fever. If he would have been more lethargic, we would have pushed the issue. It was a 24 hour viral illness and was better the next day.
     There are some instances when it is essential that the child take their medication. There are bacterial infections, such as pneumonia or staph skin infections, when it is very important for the medicine to be taken in full, each dose. In these cases, we worry that a child could end up quite ill and in the hospital if they do not do well taking in their medications.
     One issue with children taking their medication is "issues of control". Even nice children will test their parents. They may think they can refuse to do something their parent wants them to do and exert some control over the situation. Although it does not always work, sometimes these children can be convinced to take the medication with small bribes -- a small treat, a coin to put in their piggy bank, a special privilege. Do not hesitate to say "You will need to take your medicine now." Although giving them a choice (in a dosing cup or in a syringe?) may help, it is best to stay unemotional and matter of fact.
     A common issue is taste of the medication. Sometimes there is more to do about this than others. Thankfully, the pharmacist can often add flavoring (which may really help) to a medication if your child will not like the initial flavor. For better or worse, there is no flavor every child loves. One study showed that the 30% of all children would take even the worst tasting commonly-prescribed antibiotic (Vantin(r)) and only 80% of all children would take the best tasting (cefdinir/Omnicef(r)). With over-the-counter medications, you often have some choice over taste. I think you can assume that name-brands taste better than generics (although not always). Many times with a taste issue, "chasing" the medicine with something to eat or drink (a favorite juice, a lemon-lime soft drink, etc.) may help. Remind your child "As soon as you drink the medicine, you can have your juice".
     We are asked many times whether the medication can be added to something the child regularly drinks -- milk or juice. Keep in mind, you want to add enough beverage to cover the taste, but not so little the child can clearly still taste the medication. Also, if the medication is put into something to drink, they have to drink it to get the dose. If you drink half of the medicine, you probably got half of the dose if you mixed it up well. So proceed cautiously!
     It certainly helps to eliminate issues with the flavor of medication if the child learns to swallow a pill. The average child learns at about 12 years of age, but we see grade-schoolers who can swallow a pill and teenagers who cannot swallow a pill. I try to remind the "big kids" they swallow food pieces much bigger than the pill size. One good way to work up to swallowing pills is to try swallowing small pieces of candy and gradually increase the size of the piece. For instance, if your child can swallow Nerds(r) candies then move on to Tic-Tacs(r). The good news is that if your child fails to swallow it, they can always just chew it up. Reward your child's success with allowing them to have more of (and to eat it normally) the candy they just successfully swallowed.
     I hope this information helps!

Tick bites

     Tick bites are common during the warm weather months. The two most common ticks in Ohio are deer and dog ticks -- the deer ticks are smaller and the transmitter of Lyme disease. Dog ticks are larger and do not spread Lyme disease. There is an extensive review of deer ticks here and there is extensive information about management of ticks here. It has been shown to be helpful to take a shower within 2 hours of being outdoors, using DEET insect repellent while outdoors, wearing long sleeves and pants, and do tick checks when back indoors.
     When I practiced in Wisconsin for 2 years, I saw hundreds of ticks that I removed -- at check-ups and sick visits. So many of our families spent a lot of time outdoors and would get dozens and dozens of ticks every year. Although the chances of being exposed to a Lyme disease-carrying tick was thought to be about 1 in 100, I only saw a few cases of Lyme disease. The ticks were probably removed (by a shower or the family removing it at home -- or me doing it in the office!) before they had a chance to feed long enough for the germ to pass to the person. Most the kids who did have Lyme disease had the classic symptoms or Lyme disease arthritis. In that 2 years there, I did not, thankfully, run into any cases of difficult to treat, "bad" Lyme disease. So in a state, such as Ohio, where it is much less likely to get Lyme disease from a deer tick bite, we are very unlikely to see cases of Lyme disease.
     Tick removal is best done with fine-tipped tweezers. This is an excellent guide to tick removal from the CDC. To prevent a skin infection at the site after removing the tick, clean with soap and water or with hydrogen peroxide. Apply a small dab of Neosporin(r) to the site. Watch for redness, drainage, fever, or rash -- see us if this occurs in the next two weeks after you have removed the tick.