New back to school recommendations for strep throat!

Many years ago I heard about research showing that throat cultures clear within 12 hours after the first dose of antibiotic for strep throat. I’ve been waiting since then for a change to our recommendation that kids must stay home from school for 24 hours after starting antibiotics. Guess what? The new Red Book (an infectious disease book from the American Academy of Pediatrics) is out and the back to school recommendations for strep throat have changed! This can help many parents get back to work when their kids can return to school and daycare earlier. But it doesn’t mean you should rush in to demand antibiotics for every sore throat!

Redbook return to school strep guidelines, 2018.
Red Book return to school strep guidelines, 2018.

I have summarized the Clinical Practice Guideline for the Diagnosis and Management of Group A Streptococcal Pharyngitis: 2012 Update by the Infectious Diseases Society of America previously. These official guidelines have not been updated, but the Red Book represents the AAP official recommendations.

What is Strep throat?

Strep throat is not just any sore throat. Many viruses can cause sore throats but strep throat is caused by group A streptococcus bacteria, also known as Streptococcus pyogenes.

Strep throat is not common in kids under 3 years. The incidence of strep throat peaks in young childhood and is less common in teens and adults.

A strep test is needed to diagnose strep throat in kids. Physicians and other healthcare providers can use Centor Criteria for adults, but a clinical diagnosis alone is not recommended in children.

Strep throat typically causes a sore throat, fever, swollen tonsils, and swollen lymph nodes (gland) under the jaw. Some kids will get a sandpapery rash on their trunk. When this happens, it is called scarlet fever. I also see a significant number of kids who get a stomach ache and vomiting with strep.

Pos strep
Strep throat sometimes causes white patches on the tonsils. This is called exudate.
Streptococcal pharyngitis
Red spots on the roof of the mouth is considered very specific for strep throat.

Does strep throat need to be treated?

Most parents and kids want antibiotic treatment so that the miserable symptoms of strep go away faster, but do we need to treat strep?

You might be surprised, but antibiotics are not prescribed to treat strep throat symptoms. Antibiotics are used to prevent serious complications from the strep bacteria. Pain relievers, such as acetaminophen or ibuprofen, can be used to treat the fever and sore throat symptoms. School aged children, teens, and adults can also use throat lozenges for sore throats. (Do not use these in kids who are still at risk of choking.)

So the simple answer is we don’t always need to treat strep with antibiotics. In the days before antibiotics, most people got better. Even now there are some people who don’t go to a clinic when they’re sick, so they recover on their own.

Use antibiotics wisely

There are a lot of reasons to use antibiotics only when necessary.

One major reason is to help delay antibiotic resistance.

Some people have allergic reactions or side effects to antibiotics, so we should not use them lightly.

They also can increase total healthcare costs. Although penicillin and amoxicillin (which are recommended for strep throat) are inexpensive, treating strep throat does increase healthcare costs. The sheer number of illnesses that present to clinics for evaluation, the cost of testing, and the cost of the treatments can all add up. Of course, returning to work a day earlier can make an impact on our economy as well.

If your child has symptoms not characteristic for strep and is not otherwise high risk, you can monitor and treat for a few days at home.

But antibiotics make us feel better faster, right?

Antibiotics tend to shorten the symptoms by about 16 hours.

They have been shown to prevent serious consequences of strep infections, but those are rare, so the risk/benefit ratio may not support treating every case of strep. (Though I still do treat strep when I see it.)

Look at risk/benefit ratio for all treatments

If you want to read an example of the risks/benefits of treating strep throat, see this (slightly technical) case report.

Remember that this report simply highlights one case, it cannot be generalized to everyone with strep throat. It shows how doctors work through the risks and benefits with everything we treat. We don’t always state things like this out loud, but they go through our mind as we develop treatment plans.

It’s common in medicine to have case reviews such as this. Any one case does not change our treatment guidelines, but they can help us start to understand issues. They often serve to initiate further studies.

Are there risks to not treating?

Untreated Strep infections can lead to complications.

The character Beth in the classic book “Little Women” died of heart complications after scarlet fever.

(If nostalgia hits you, you can get the entire series of the March family on Kindle for less than a dollar!)

Complications from untreated strep can include tonsil abscesses, ear infections, sinus infections, arthritis, heart damage, and kidney damage. While some of these can be severe, thankfully the more severe complications are rare, even without treatment.

There is also a condition called PANDAS (pediatric autoimmune neuropsychiatric disorders) that some experts think is related to strep. This can involve the sudden onset or worsening of tic disorders, obsessive compulsive disorder, mood changes, and change in quality of school work. Throat swabs can be normal, but a blood test can help to identify a recent strep exposure. Testing is not recommended for everyone with tics or OCD, but talk to your pediatrician if symptoms start out of the blue and you’re concerned.

Don’t let the new recommendations make you rush in…

Strep throat is rarely an emergency. Don’t rush to the ER after business hours to have your child checked as soon as you notice symptoms. You can use pain relievers as well as cold drinks, smoothies and popsicles to manage the symptoms at home initially. Just because the back to school recommendations for strep throat allow return 12 hours after antibiotics start, coming in too soon might not help in the long run.

The test commonly used to identify strep is most accurate after symptoms have been there for awhile. This is because it tests for the antibodies your body makes against the strep bacteria, not for the bacteria itself. A culture done at the same time may grow the strep bacteria in a few days, but antibiotics are not recommended until either the rapid test or culture is positive, so you’re not getting a head start on antibiotics if the initial rapid test is negative.

Do not use telehealth to get your sore throat treated. In children it is not recommended to diagnose strep throat without a throat swab test. This should be done in a medical clinic to avoid inaccurate testing.

Treating early in the course might diminish the opportunity for your body to fight strep off the next time it’s exposed. Yes, treating may allow a return to work, school or daycare in 12 hours, but if you can prevent the next occurrence (of course no guarantees…) wouldn’t you want to?

When should you not test or treat?

Kids under 3 years old

Strep throat is not common in kids under 3 , so it’s not recommended to test them.

I admit that if an older sibling or caregiver has strep and they have strep symptoms, I will test 2-3 year olds.  The recommendation is to not bother. Even if they have strep, treating does not tend to alter their course. Kids in this age group tend to not develop the severe consequences of strep like older kids, even when not treated.

Viral symptoms

Although both viruses and strep bacteria can cause fever and sore throat, there are clues that it is not strep. When strep carriers get sick, they can have a false positive throat culture. The strep that shows on testing is not the cause of their symptoms and leads to over treatment.

If there is a cough or runny nose, the sore throat is most likely a viral illness. A strep test is not recommended.

When there are blisters in the mouth or a characteristic hand, foot, mouth rash, they have a viral illness. A strep test is not recommended.

Recent strep

Because the rapid strep test looks at antigens the body makes in response to strep and not the bacteria itself, recent strep can affect rapid strep testing. The antigen can remain in the throat for a time after treatment, so a strep culture is recommended for several weeks after treatment of strep throat.

It is not recommended to do a throat culture after treatment unless a person is high risk for complications, such as rheumatic fever.

contacts of someone with strep

It isn’t recommended to test people who have been exposed to strep unless they have symptoms. If they do not have symptoms, a positive test is more likely to be a falsely positive (not true) test. It could lead to unnecessary antibiotics.

If a sibling over 3 years of age develops symptoms, it is recommended to test and not just treat.

Pets?

Pets do not get strep, so no need to swab your pet!

Why not just test every sore throat?

Studies show that 1 in 4 kids can have strep in their throat at any given time. They are simply carriers, but not truly infected with strep. Contrary to popular belief, strep carriers are not likely to spread strep infections.

If a strep carrier has a viral illness, they can have a positive test but the strep is not the cause of their illness. Antibiotics are not needed for this at all. A positive test leads to using antibiotics that are not needed, which can increase the risk of side effects and allergic reactions. They give a false sense of security of treatment, but if it’s a viral illness, antibiotics are not treating anything. Kids can be sent back to daycare or school while still contagious simply because they’re “being treated.”

“My child always has a negative rapid test but the culture is positive. Can’t we just treat?”

There are many reasons this can happen.
One of the reasons is that the child is a strep carrier, so has no strep disease. In this situation, there aren’t antigens to make the rapid test positive, but the culture will grow the bacteria. If you recall from above, carriers do not need to be treated with antibiotics in most cases. I often find that these kids continue to feel sick several hours after starting antibiotics for strep. Most kids with strep feel better really quickly after antibiotics are started!
It’s also possible that the child is brought in for testing early in the course of illness each time so the antigens have not yet developed. This is one reason to not rush in at the first sign of possible strep. Let the body do its thing first.

My back to school recommendations for strep throat:

If your child has some of the symptoms of strep (sore throat, fever, tender bumps in the neck, vomiting, or rash) consider strep throat.

Symptoms of typical viral illnesses make strep less likely. These might include runny nose, cough, red goopy eyes, or diarrhea. No testing is recommended.

It can be difficult to tell if a runny nose from allergies despite the strep throat or if the runny nose is part of the viral illness that includes a sore throat, so if in doubt, bring your child in for evaluation. The doctor can determine if testing should be done. Do not use telehealth for this. I recommend seeing your primary care physician during normal business hours.

If there is strep throat, penicillin or amoxicillin are the preferred treatments unless there is documented allergy.

Your child may return to school 12 hours after the first dose of antibiotic if they are otherwise well. (If they are not feeling great, they likely have something else going on!)

 

Is Miralax Safe?

Constipation is one of the most common problems that affects kids. Sometimes it’s mild and changes to diet and routines can help sufficiently. Those are of course the ideal treatments. But if it’s more severe or if kids are resistant to change, Miralax is my go-to treatment. Several parents have asked me about its safety due to what they’ve seen online. I know many more are probably worried but just haven’t asked. With all the concern, I thought I’d share some of the concerns and reasons that I still recommend it.

What is Miralax?

Miralax has been used since 2000, and since I finished my pediatric residency prior to that, I can remember the alternatives we used previously. Many of them were difficult to get kids to take due to poor taste or grittiness. When Miralax was first available, treatment of constipation improved significantly due to the tolerance and acceptance by kids. It was initially available by prescription only and expensive – thankfully both of those hurdles have been removed.

Miralax is the brand name for polyethylene glycol 3350 or PEG 3350. It is now available as an over the counter medication, so no prescription is needed. Generic versions are available. It has been used by many kids over many years, often for long periods of time, to treat constipation.

Is it a laxative?

PEG3350 is a stool softener, not a laxative (despite the name).The molecule binds to water, but is too large to be absorbed through the gut so it passes through the gut and carries the water with it. It works by increasing the water content of the stool. The more PEG taken, the softer the stool.

PEG is not a laxative and should not cause cramps. It is not habit forming. As mentioned above, it is not absorbed into the body it just goes through the GI tract and leaves with the stool.

How is it used?

PEG 3350 is a tasteless powder that dissolves in liquids. It often needs to sit for a few minutes and re-stirred to fully dissolve.

It may be dissolved in water, with a slight change to its taste, but is palatable. Be careful of adding it to drinks high in sugar (even juice), since your child may be on it for a long time, and they don’t need the added sugar. Consider making flavored water with your child’s favorite fruit. Simply put cut up fruit in water in the refrigerator for a couple hours. Infused water tastes great and is a healthy base for your Miralax mixture – or anytime your kids need a drink and don’t like plain water.

I don’t recommend adding it to carbonated beverages.

I recommend mixing a capful of powder in 8 ounces of water and titrating the amount given based on need. My office website discusses this in detail.

Why do we need medicine?

Constipation is common.

Very common. It causes pain, poor eating habits, fear of toileting, and sometimes even leads to ER trips and CT scans. It can last months to years in some kids, so it is not a minor issue when kids suffer from it.

Diet changes are hard – especially in kids!

Kids are often constipated because they have a diet that is poor in water and fiber. They need to eat more fruits, vegetable and whole grains. Many kids drink too much milk and eat too much cheese.

Changing habits is very difficult in strong willed kids. When it comes to food, they’re all strong willed! Dietary changes of course should be done so they are healthier on many levels, but if their stomach hurts all the time, they are unlikely to get out of their comfort zone with foods. Habits change too slowly to help the constipation if used alone.

I encourage first changing the diet to help constipation, but if that fails, or if it is too significant of a problem, PEG 3350 is my first choice. I have recommended it for years without any known side effects or complications, other than the kids who have frequent watery stools on it. This usually responds to continuing the medicine to release the large stool mass that has built up. Some kids just need to decrease the dose a bit.

What’s the concern?

I was quite surprised in 2015 to see that researchers were starting a study on the drug. It surprised me not only because I’ve never heard valid concerns about the safety or efficacy of the medicine (I have seen some really weird stuff online, but nothing that is valid), but also because I’ve never seen headlines that a study is starting. Usually headlines report results of studies. Why did it hit the press before the study was even done? I have no idea.

Even more interesting… it seems the study hasn’t started yet. Three years later. Not a high priority, apparently. Which fits with the low level of concern I find among general pediatricians and pediatric gastrointestinal specialists.

Yet parents still ask about the risks.

What was the proposed study?

Initial reports stated that they were going to look at the safety of other molecules in the PEG 3350.

PEG 3350 itself is a very large molecule that isn’t absorbed by the gut, but there are concerns that smaller compounds could be found as impurities in the manufacturing process of PEG 3350 or formed when PEG 3350 is broken down within the body.

The question is if these smaller compounds are absorbed by the gut and accumulated in the bodies of children taking PEG 3350.

Some families have reported concerns to the FDA that some neurologic or behavioral symptoms in children may be related to taking PEG 3350. It is unclear whether these side-effects are due to PEG 3350 since neurologic and behavioral symptoms can lead to constipation.

What are the recommendations?

The 2014 guidelines for constipation diagnosis and management from the European Society for Pediatric Gastroenterology, Hepatology, and Nutrition and the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition support the use of PEG 3350: Evaluation and Treatment of Functional Constipation in Infants and Children: Evidence-Based Recommendations From ESPGHAN and NASPGHAN.

These guidelines basically state that not many studies are required to diagnose functional constipation after a thorough history and exam. This means that we don’t need to do expensive tests to make the diagnosis.

The common things we recommend (fiber, water, probiotics) don’t have any proof that they work. There is evidence that PEG 3350 works.

Why does the label say it’s for adults?

As a pediatrician I know that many (if not most) of the medicines we use in children are not tested in children before they come to market.

Historically once something is approved in adults, physicians start to use them in children. Companies generally don’t invest money in studies to expand uses after approval because they know that the products will be used in broader ways without the specific indication. They don’t want to spend money they don’t need to spend, which makes sense from a business perspective. It’s also more difficult to do studies in minors.

New rules encourage pediatric testing, but all the drugs previously used in children will not need to undergo this testing. Because they’ve been used for years, we rely on post-market safety data.

Are there studies in children?

Many of the news articles say that studies have not been done in children, but this isn’t true.

This 2014 research article reviews the history of PEG 3350 and compares to other medicines used in pediatric constipation. It also shows safe blood electrolyte levels while on PEG 3350 long term.

In 2001 a study was published showing safe and effective pediatric dosing.

2003 studyshowed safety and better tolerance than previously used medications for constipation.

A study specifically looking in children under 18 months of age showed safety.

2009 Canadian study shows its safety in children.

If you look at the references of any of these studies, you will find more. The only side effects noted are related to diarrhea, cramping, bloating — all things that would be expected with a large stool mass blocking the new, softer, water filled stools from coming out. Once the large stool mass is out, these symptoms resolve.

For what is PEG approved?

PEG is used in many products, not just stool softeners. It is found in ointments and pills to allow them to be more easily dissolved in water. PEG can also be found in common household products such as certain brands of skin creams and tooth paste.

PEG 3350 is approved for treatment of constipation in adults for up to 7 days. Approval is based on studies available at the time a medicine is approved. Many commonly used medications are not specifically FDA approved for use in children less than 16 years due to difficulties and expense in testing drugs on minors.

How do we know it works?

There have been several studies in children and the collective experience of pediatricians around the world showing improved tolerability over other treatments for constipation because PEG 3350 has no taste, odor, or texture.

It has been shown to be either as effective or more effective than other constipation treatments. See the links to these studies above. Until children can keep stools soft with adequate amounts of water, fruits, vegetables, and fiber, long term use of PEG is well tolerated.

How long can PEG be used in children?

This is a very difficult thing to study because the longer a study follows their subjects, the more subjects are lost to follow up.

There have been studies of up to 30 months that showed safe use. Blood electrolytes, liver and kidney tests were all reassuring that PEG is safe during the study.

Pediatric gastroenterologists and general pediatricians have often recommended even longer periods of time without any known side effects.

If my child has taken PEG 3350, should I worry?

Is miralax safe?
Is MiraLAX safe?

I cannot stress enough that the studies that have been done all support the safety and efficacy of PEG 3350.

After years of experience using PEG 3350 with many children, I have not seen any neurologic or behavioral problems caused by PEG 3350. I do see many kids with baseline neurologic and behavioral problems become constipated, so they often end up on PEG 3350, but if the issue is carefully assessed, the problems start prior to the treatment.

Generally if the stools are softer, you can more easily work with the behavioral issues that cause the constipation, such as loss of appetite/poor diet and failure to sit on the toilet long enough to empty the stool from the rectum.

If you decide it is time to stop the medicine, be sure to discuss this with your child’s doctor to keep them in the loop about how things are going!

Hand, Foot, and Mouth Disease

Hand, foot, and mouth disease is a very common illness, but there is a lot of confusion about it. It is caused by several different viruses in the enterovirus group. It can make kids (and some adults) miserable, but like most viruses we don’t have a specific treatment to fix it. There are things we can do to help kids stay more comfortable and to decrease spread.

Daycares in my area often make unreasonable demands of when to let kids return, which makes me aware that they aren’t aware of how it’s spread and how to control the spread as much as possible. Do they realize that many adults can have the virus and spread the disease without having any symptoms themselves?

How can you recognize hand, foot, and mouth?

Hand, foot, and mouth disease can look different in different people.

Of course the name gives a clue: there’s often a rash on the hands and feet, and in the mouth. If there is  a classic rash, you’ll know what you’re dealing with. The rash can look like red spots or blisters, classically on the palms and soles, but it can extend up the arms and legs. I often call it hand, foot, mouth, and butt disease because bumps in the diaper region are common. You might not recognize the blisters unless you can get a good look in their mouth to see blisters on the gums, tongue, or throat.

Some kids will be fussy and eat less than normal.

Many, but not all, will have a fever. Don’t fear fever.

This photo shows typical blister-type lesions around the mouth of a toddler. Notice the drool at the chin. Many kids have these blisters on their throat, which makes it painful to swallow. They often refuse to eat or drink – or even swallow their saliva!

Hand Foot Mouth Disease

Are there any serious complications?

Most kids recover completely within a week or so, but some can have a more significant illness.

Some kids refuse to eat or drink and may require hospitalization for dehydration.

A rare complication is viral meningitis, an inflammation around the brain. Symptoms can include fever, headache, stiff neck, and irritability. Viral meningitis might require hospitalization to help with comfort measures or to treat with antibiotics while ruling out bacterial meningitis.

Even less commonly children can get encephalitis or a polio-like paralysis. Encephalitis is an inflammation of the brain. Symptoms include fever, seizures, change in behavior, confusion and disorientation, and related neurological signs depending on which part of the brain is affected.

One consequence I tend to see every few years is fingernails and/or toenails falling off weeks after recovery from hand, foot, and mouth disease. While this is not serious and the nails eventually grow back normally, it can be distressing to parents. Simply knowing that this might happen can hopefully stop your worry before it starts!

How is it spread?

Most enterovirus infections in the US are during the summer and fall. Enterovirus infections are common worldwide. Most kids have been infected by the time they’re school aged. Pets do not get infected with enteroviruses.

The virus easily spreads from person to person. This happens through contact with saliva, nose and throat secretions, fluid in blisters, or stool of an infected person. The virus can spread from mother to infant prenatally and in the newborn period.

Enteroviruses may survive on environmental surfaces for periods long enough to allow transmission from fomites.

Respiratory tract shedding usually only occurs for 1-3 weeks, but the virus can exist in the stool for months after infection. Careful hand washing after all diaper changes is essential. In most cases it is not possible to keep kids home from daycare until they are “no longer contagious.”

Infection and viral shedding can occur without signs of clinical illness, especially in adults. This means many parents and daycare providers can unknowingly spread the virus to susceptible infants and children.

The incubation period (time from infection until symptoms show) for enterovirus infections is typically 3 to 6 days.

What treatment can be given?

Because this is caused by a virus, there is no specific medicine that is needed to make it go away.

Fluids are very important. Some kids refuse to swallow due to pain, so they are at risk of dehydration. Giving pain relievers, such as acetaminophen or ibuprofen, can help to decrease the pain and improve how well they will drink. Offer cold drinks, smoothies, and popsicles if age appropriate.

Older children and adults can use throat lozenges or mouth sprays that numb the pain.

Magic Mouthwash

A mixture of liquid diphenhydramine (a common antihistamine) and a liquid antacid, such as Maalox, in a one-to-one ratio can help alleviate pain. Give the amount that equals the diphenhydramine dose per weight.

For example, if a child’s dose is 2.5 ml of diphenhydramine, mix 2.5 ml diphenhydramine with 2.5 ml of the liquid antacid. If a child can swish, gargle, and spit the mixture, it can help numb the sores. When younger children swallow the mixture, it may also help if it coats the sores in the mouth adequately.

Control measures to prevent hand, foot, and mouth disease

Hand washing, especially after diaper changing, is important in decreasing the spread of enteroviruses.

Don’t share foods or drinks. Avoid contaminated utensils.

Wash toys and disinfect surfaces regularly.

Chlorination treatment of drinking water and swimming pools may help prevent transmission.

Can kids get this more than once?

Since there are several different viruses that cause hand, foot, and mouth disease, it is possible to get it more than once. Keep washing those hands, toys, and surfaces!

Antibiotic Allergy or Just a Rash?

During the winter months more people get sick, so more people are treated with antibiotics. While antibiotics can help treat bacterial infections, they do carry risks. One of those risks is an allergic reaction. This is one of the reasons pediatricians avoid using antibiotics liberally. Most of the time our bodies can fight off the germs that cause illness and antibiotics don’t help treat viruses at all. How do you know if it’s an antibiotic allergy or just a rash?

Rashes are common

When someone is on a medicine and they develop a rash it can sometimes be hard to sort out if symptoms are part of the illness, a non-allergic drug reaction, or an allergic reaction.

There are many people who had a rash while taking an antibiotic as a child and were told that they are allergic to that antibiotic, but really aren’t. Unfortunately this can lead to more expensive and broader-range antibiotics being used inappropriately and unnecessarily.

Drug rash

About 2% of prescription medications (not just antibiotics) cause a “drug rash”. The rash usually begins after being on the medicine for over a week (earlier if there was previous exposure to the medicine), and sometimes even after stopping the medicine.

It can look different in different people.

Some get pink splotchy areas that whiten (blanch) with touch.

Others get target-like spots, called Erythema Multiforme.

Often the rash seems to worsen before it improves, whether or not the medicine is stopped.

Skin can peel in later stages.

It can itch but doesn’t have to.

Some people have mild fever with these symptoms.

Adults vs kids

In adults this type of rash is often a sign of allergic reaction, but in kids a rash is most often a viral rash – meaning they have a virus that causes a rash but they happen to be on an antibiotic (or other medicine).

This is why diagnosing allergy versus drug reaction is tricky.

These symptoms can mean allergy to the drug, but (especially in kids) is often just a symptom of a virus (or some bacteria, such as Strep or Mycoplasma).

Penicillin

Up to 10% of children taking a penicillin antibiotic (which includes the commonly used amoxicillin and augmentin) develop a rash starting on day 7 of the treatment. (It can be earlier in people who have had the antibiotic previously.) This rash tends to start on the trunk, looks like pink splotches that can grow and darken before fading. It does not involve difficulty breathing, swelling of the face or airway, or severe itching.

Because of this reaction many people live their life thinking they have an allergy to penicillin, even though many of them don’t.
amoxicillin rash
Amoxicillin rash 3 hours after the 17th dose. https://commons.wikimedia.org/wiki/File%3AAmoxicillin_rash_3_hours_after_17th_dose.JPG
amoxicillin rash
Amoxicillin rash 11 hours after the 17th dose of amoxicillin. https://commons.wikimedia.org/wiki/File%3AAmoxicillin_rash_11_hours_after_17th_dose.JPG

 

 

 

 

 

 

 

 

 

Why does this happen?

We don’t know for sure. But it can cause a very significant rash, especially with the virus that causes mono.

Up to 80 -90 % of people who have mono develop a rash if they are treated with a penicillin antibiotic (like amoxicillin).

This is common since symptoms of Strep throat and mono are very similar, and penicillins are the drug of choice for Strep throat. Some people with mono have a false positive test for Strep throat, meaning they do not have Strep but the test is positive.

This is why it is very important for the medical clinician to take a careful history of symptoms and do an exam, even with “classic” Strep symptoms. (If I had a dollar for every parent who says the symptoms are just like all her kids when they get Strep, can’t I just call it in…) Always be sure to get a Strep test and full exam to evaluate if it is really Strep or possibly mono. Blood tests for mono can be ordered if clinically indicated.

Never treat a sore throat without a full evaluation.

Amoxicillin rash that developed several days after starting amoxicillin with mono. Image from Ónodi-Nagy et al. Allergy, Asthma & Clinical Immunology 2015 11:1   doi:10.1186/1710-1492-11-1

How do we know if it’s a real allergy?

Doctors will take a careful history of all symptoms of the illness, the timing of when the rash developed during the illness and when the medicine was given.

If it is a classic viral rash, nothing further needs to be done. If there are symptoms (see below) that help identify a true allergy and make a clear diagnosis, then avoidance of that medication should be done.

Be sure all your doctors and pharmacists know of this allergy.

If it is not clear then further evaluation can be done. Allergists can do skin testing to see if there is a penicillin allergy, but most antibiotics do not have testing available so an oral challenge (in a controlled setting) is used if there were no clear allergy symptoms with a rash.

Mild to moderate allergic reactions can have the following symptoms:
  • Hives (raised, extremely itchy spots that come and go over a period of hours)
  • Tissue swelling under the skin, often around the face (also known as angioedema)
  • Trouble breathing, coughing, and wheezing
Anaphylaxis is a more serious allergic reaction and can include:
  • Difficulty breathing or wheezing
  • Swelling of the face, tongue, throat, lips, and airway
  • Dizziness
  • Loss of consciousness
  • Shock
  • Death

Final Take Away

As you can see, rashes that develop while on medications can be quite a conundrum. If one develops, be sure to get in touch with your doctor.

We usually cannot diagnose rashes over the phone, so an appointment may be necessary.

Improper use of antibiotics: Don’t take the risk!

Improper use of antibiotics is a problem on many levels. It’s easy to get the wrong prescription for an illness if it is improperly diagnosed or if the healthcare provider is trying to keep a patient happy. By taking an antibiotic that isn’t necessary, we increase the problem of Superbugs and even put our own health at risk.

Risks of improper use of antibiotics

Improper use of antibiotics increases risk unnecessarily. Use antibiotics wisely.
Improper use of antibiotics increases risk unnecessarily. Use antibiotics wisely.

Not only is an antibiotic NOT needed for viral illnesses, but taking them when not needed can increase problems.

Risks of antibiotics involve diarrhea, yeast infections, allergic reactions, and more.

Every time we take an antibiotic, we assume the risks associated with the antibiotic. If we have a significant bacterial infection, the risk is warranted. But if we have an infection that the antibiotic will not kill, it is an unnecessary risk.

Dr. Oglesby has a great series on antibiotics, covering general facts on antibiotics (such as how they work), how resistance spreads, and when antibiotics may be needed.

Superbugs

Most of us have heard of superbugs, but there is a misconception about how they work.

Using antibiotics inappropriately can allow bacteria to learn to evade the antibiotic, which makes it ineffective. This means that new antibiotics need to be used to treat infections, which increases the time of illness, the cost of treatment, and the risk of untreatable illnesses. Some bacteria develop resistance to all known treatments, which can lead to death.

“The Last time amoxicillin didn’t work and we had to use something else. Can we use that one again?”

A lot of parents think that if one antibiotic failed with a previous infection, they need a different one. This is not true.

The bacteria develop resistance to an antibiotic. Bacteria can share their genetic material with other bacteria, leading to the quick spread of resistance.

Even someone who has never used an antibiotic can be infected with a resistant bacteria, which makes it harder to treat their infection.

Unfortunately, without a bacterial culture it is impossible to know what the best antibiotic is for any specific infection. We use the type of infection and the bacterial resistance pattern of the area to make the best choice.

It’s not the person that becomes immune to an antibiotic

Very often parents request a different antibiotic because “amoxicillin never works for my family.”

A person does not become immune to a type of antibiotic.

Start with an antibiotic that has a narrow coverage usually

A first line antibiotic is an antibiotic that covers the type of infection that is present, but isn’t so broad that it includes more bacteria than needed. It can also be called narrow-spectrum.

One infection with a superbug might require a strong antibiotic, but the next bacterial infection in the same person might respond well to a first-line treatment, such as amoxicillin.

It’s always wise to start with the first line antibiotic for the type of infection unless a person’s allergic to that antibiotic. It doesn’t matter if it worked the last time or not.

Broad spectrum antibiotics are needed for some serious infections

Remember that broad-spectrum antibiotics that have great killing power can increase the risk of killing the good bacteria that your body needs.

If you have a serious infection, they might be needed. In this case the benefit outweighs the risk.

Each new infection is a new bacteria.

The type of infection will determine the most likely bacteria. A culture from the infection (if possible) will specify exactly what bacteria is the cause and which antibiotics will work.

First line antibiotics are chosen based on type of infection as well as local resistance patterns. Upper respiratory tract bacterial infections tend to use different antibiotics than urinary tract infections or skin infections because different bacteria cause different types of infections.

Allergic reaction

Most people can tolerate antibiotics, but allergic reactions can be serious. It’s not worth the risk if the antibiotic isn’t needed in the first place.

Many people think they’re allergic to an antibiotic when they’re not.

Talk to your doctor about any drug allergies you suspect your child has and why.

Diarrhea

Many kids will get loose stools when they take antibiotics.

Probiotics can help re-establish a healthy amount of good bacteria in the gut and slow the diarrhea most of the time.

Unfortunately there is a type of bacteria commonly called C. diff that can overpopulate after antibiotics and cause severe diarrhea. C. diff causes thousands of deaths every year in adults and children, most often following antibiotic use.

If diarrhea develops during or after antibiotic use, talk to your doctor’s office during regular office hours for advice. If there are signs of dehydration, severe pain, blood in stools, or other concerns you should have your child seen quickly.

Gut flora

Antibiotics kill not only the bacteria causing an infection, but also the “good” bacteria (gut flora) in our bodies.

Our bodies are a habitat for healthy bacteria and yeast. I know this seems unnatural or unhealthy to many people, but we need these bacteria and yeast in a healthy balance.

Gut flora is made of many types of healthy bacteria. These bacteria help us with many functions, such as digestion and weight regulation. Good bacteria make products that lower inflammation in the intestines. They also make neurotransmitters which affect our mood.

Different “good” bacteria can be affected depending on which antibiotic is used.

Yeast infections

As mentioned above, our bodies are an ecosystem of bacteria and yeast. When bacteria are killed off with an antibiotic, it throws off the balance and allows the yeast to overgrow.

Yeast keeps the digestive system healthy and helps our immune system. It can help our body absorb vitamins and minerals from food. Despite what you read online, yeast are very beneficial to us – as long as they remain in healthy balance.

There are a lot of people selling products to treat overgrowth of yeast, which is said to cause all kinds of problems. These types of overgrowth are not recognized as true overgrowth by most physicians, but there are true yeast infections.

Yeast can cause infections of your skin (ringworm), feet (athlete’s foot), mouth (thrush), and penis or vagina (yeast infection). At risk people can develop blood infections with yeast. These can be life threatening. Serious yeast infections tend to occur in diabetics, immunocompromised people and those who were treated with antibiotics.

If you suspect a yeast infection, talk to your physician.

Risk vs benefit

When antibiotics are needed to fight a bacterial infection, it is worth the risk of taking the antibiotic.

The balance flips if you have a common cold – don’t take the risk for something that isn’t needed or beneficial.

Antibiotics do not and will not help treat a cold. Ever.

Don’t try to use an antibiotic to prevent a cold from developing into something else.

Improper use of an antibiotic simply has too many risks and will not help, so there is no benefit.

Prevention is key!

If you’re not sick, you don’t even think about looking for an easy fix for a viral illness.

Use proper handwashing, vaccinate against vaccine preventable diseases, and stay home when sick!

 

Spring is here and it brought the pollen! Control allergies and enjoy the outdoors.

Spring is a beautiful time of year. The flowers bloom, the birds chirp… it’s like we’re all awakening after a long, cold winter. But with the flowers (and birds) comes pollen. And with pollen comes allergies. I don’t want anyone to be afraid to enjoy the beautiful outdoors, so learn to control allergies.

Why treat allergies?

I often hear parents say that they don’t want to give their kids medicine to treat allergies because, well, it’s medicine. They prefer to be natural and the symptoms don’t seem “that bad”.

Before you decide if the symptoms require treatment or not, be sure to recognize all the potential consequences of allergies. It’s not just a runny nose and sneezing.

Allergies can impair sleep (leading to all the problems associated with not enough sleep) in addition to the annoying symptoms of itching, coughing, sneezing, runny nose, and watery eyes.

Some kids get a crease across their nose from wiping – AKA the “allergic salute”.

Others get purple circles under their eyes called allergic shiners.

For people with asthma, allergies are a known trigger. It’s especially important that people with wheezing tendencies keep up on allergy prevention and treatments.

Some will chronically mouth breathe, which can affect the growth and development of their jaw, lead to bad breath, and increase the risk of cavities. Dr. Deborah Burton, an ear, nose, and throat specialist, discusses these and other consequences of mouth breathing in one of her DrMommaSays blogs.

How do you know it’s allergies?

Learn to diagnose allergies, what to do when you have them and what you risk if you don't treat them.
Learn to diagnose allergies, what to do when you have them and what you risk if you don’t treat them.

Allergies can cause runny nose, headache, congestion, sneezing, watery eyes, itching eyes, sore throat, itchy throat, and itchy skin. Not all symptoms need to be present.

An upper respiratory tract infection (AKA common cold) can also cause a runny nose, headache, congestion, sneezing, watery eyes, and sore throat. The difference is the cold symptoms tend to not last as long as allergies. There also could be a fever, body aches, and a general feeling of “not well” with viral infections.

Seasonal allergies tend to follow a seasonal pattern, so they can be easier to recognize than allergies to indoor allergens.

These days it’s easy to track pollen counts online. If you realize that every day the counts for one type of tree or grass is elevated you have symptoms, that’s strong support that you’re allergic to that plant.

Of course, it’s possible to get a cold on top of your allergies, which adds to the confusion sometimes.

Treatments to control allergies

It is best to treat before the symptoms get bad. Treatments include not only medicines, but also limiting exposure.

Use what you can to prevent and treat allergies, which most often means using more than one of the following treatments.

Limiting Exposure:  

Limiting exposure can help decrease symptoms.

Avoid Bringing allergens into the Home

Remove clothing and shoes that have pollen on them when entering the house to keep pollen off the couch, beds, and carpet.

Keep the windows closed. Sorry to those who love the “fresh air” in the house. For those who suffer from allergies, this is just too much exposure!

Beloved pets cause unique issues

If someone’s allergic to animals or suffers from year long symptoms, learn if your family pet is a problem.

When you have pets that go outdoors and then into the home, bathe them regularly.

Don’t let pets on the couch or beds and keep them out of the bedrooms of allergic sufferers.

If you know a family member is allergic to an animal, don’t get a new pet of this type!

If you already have a loved pet someone in the home, consider allergy shots against this type of animal. Talk to your pediatrician and consider a trip to an allergist.

Wash and clean

Wash towels and sheets weekly in hot water.

Vacuum and dust weekly. Consider cleaning home vents. Consider hard flooring in bedrooms instead of carpeting.

Wash stuffed animals and other toys regularly and discourage allergic children from sleeping with them.

There are many types of air filters that have varying benefits and costs. For information on air filters see the Environmental Protection Agency’s interactive page on indoor air quality.

Smoke is a “no”

Keep smoke away. Smoke is an airway irritant and can exacerbate allergy symptoms.

Remember that the smoke dust remaining on hair, clothing, upholstery, and other surfaces can cause problems too, so kids can be affected even if you don’t smoke near them.

And for those of you who vape, it’s not better. We’re still learning the risks  of e-cigarettes because vaping is relatively new, but early data supports staying away from e-cigs!

Wash it off of you!

Wash hair, eyelashes, and nose after exposures — especially before sleep. They all trap allergens and increase the time your body reacts to them.

Learning to rinse your nose

I have found the information and videos in Nasopure.com‘s library to be very helpful. You can teach kids as young as 2 years to wash their noses. Note: I have no financial ties to Nasopure… I just love the product and website!

I am an Amazon Affiliate member, so if you buy from this Amazon link, I do get a small percentage.

If you wear contacts

If itchy eyes are a problem for contact lens wearers, a break from the contacts may help. Talk with your eye doctor if eye symptoms cause problems with your contacts.

Medications

I don’t want kids with outdoor allergies to be afraid to go outside, so taking medicines to keep the symptoms at bay while out can help.

Antihistamines

Antihistamines work to block histamine in the body. Histamine causes the symptoms of allergies, so an antihistamine can help stop the symptoms.

Some people respond well to one antihistamine but not others, so sometimes you must use trial and error to find the right one.

In general I prefer the 12-24 hour antihistamines simply because it’s very difficult to cover well with a medicine that only lasts 4-6 hours, such as diphenhydramine (Benadryl) and they’re less sedating. Long acting antihistamines include loratadine -Claritin (24 hour), fexofenadine- Allegra (12 hour for kids, 24 hour for teens and adults), and cetirizine- Zyrtec (24 hour).

Different antihistamines work better for some than others. Personally loratadine does nothing for me, fexofenadine is okay, but cetirizine is best. I have seen many patients with opposite benefits. You will have to do a trial period of a medicine to see which works best.

If they make your child sleepy, giving antihistamines at bedtime instead of the morning might help.

Prescription antihistamines are available, but usually an over the counter type works just as well and is less expensive. Insurance companies rarely cover the cost of antihistamines these days.

Antihistamine and decongestant combinations

Antihistamine and decongestant combinations are available but are not usually recommended. Decongestants can cause dizziness, heart flutters, dry mouth, and sleep problems, so use them sparingly and only in children over 4 years of age.

Once control of the mucus is achieved, a decongestant isn’t needed. Giving a medicine that isn’t needed just increases the risk without increasing the benefit.

If you need a decongestant initially, you can use one with your usual antihistamine.

Most decongestants on the shelves are ineffective. If you ask the pharmacist for pseudoephedrine, it is available behind the counter. It was replaced by phenylephrine years ago due to concerns of methamphetamine production, but works a little better than phenylephrine.

Decongestants do NOT fix a cold, they only dry up some of the mucus.

Nasal spray steroids and antihistamines

Nasal spray steroids and antihistamines are available over the counter or as a prescription. An office visit to discuss the value of these for your child and proper use is recommended.

Nasal steroids are often the preferred treatment based on effectiveness and tolerability.

If your child resists nose sprays

You can help your kids get used to nasal sprays with saline sprays. Saline is simply salt water, so it is okay to let your kids practice with these without risking any overdose of medication.

Eye Drops

Eye drops can help alleviate eye symptoms.

They are available both as over the counter allergy drops and as prescription allergy eye drops. If over the counter drops fail, make an appointment to discuss if a prescription might help better. Most insurance companies don’t cover prescription allergy eye drops well, so you might want to check your formulary before asking for a prescription. This is usually available on your insurance website after you log in.

If your child resists eye drops

Tips to administer eye drops include washing hands before using eye drops, put the drop on the corner of the closed eye (nose side) and then have the child open his eyes to allow the drop to enter the eye.

Montelukast

Singulair (Montelukast) works to stop histamine from being released into the body.

It helps control both allergies and asthma and is best taken in the evening.

Once a person has been on montelukast for a couple of weeks, they usually don’t need an antihistamine any longer.

Montelukast is available only by prescription, so make an appointment to discuss this if your child might benefit.

Steroids

Steroids decrease allergic inflammation well. These include both oral steroids for severe reactions (such as poison ivy on the face or an asthma attack) and inhaled corticosteroids for the nose (or lungs in asthma).

The nasal steroids are discussed above and are highly recommended for kids and adults who tolerate putting a spray in their nose.

Other steroids require a prescription, so a visit to your provider is recommended to discuss proper use.

What if all of the above isn’t helping to control allergies?

Maybe it’s really not allergies.

There are many things that can seem to be allergies but aren’t. If proper treatment is not working, reconsider the diagnosis.

It’s possible that the allergy treatment is working, but you caught a cold on top of the allergies. Both are common, so they can occur together.

Allergies to things other than foods are rare before 2 years of age. If you’re treating allergies in an infant or toddler, be sure to keep your pediatrician in the loop.

I’ve known people who are treated for years by an allergist for allergies, but when they’re tested due to a poor response, they have no allergies. They might have frequent infections or other irritants like smoke exposure. Learn to control these issues too, starting with good hand washing, avoid touching your face, and avoiding smoke.

Allergy testing

Allergy testing is possible by blood or skin prick testing, but can be costly. Not to mention the fact that kids tend to not like needles, which are used with most testing.

Allergy testing isn’t recommended for most allergy sufferers. It can be used to guide allergy immunotherapy, which involves routine allergy shots. Most suffers don’t need allergy shots, but if you think your child would benefit (and allow them), talk to your doctor.

In most cases I don’t find test results very helpful for environmental allergens because you can’t avoid them entirely. You can limit exposures as discussed above, regardless of test results.

Tracking patterns and symptoms to identify allergies

By tracking seasonal patterns over a few years can identify many of the allergens. You can still treat as needed during this time. Reports of pollen and mold counts are found on Pollen.com.

Rather than testing, note animal exposures and household conditions and any symptoms seen with exposures.

Write symptoms and exposures weekly (or daily). It often doesn’t take long to see patterns. Testing is important if allergy shots are being considered.

Need help tracking allergy symptoms? There’s an app for that! Here’s one review I found of allergy apps. I don’t have any personal experience of any, so please put your favorite in the comments below to help others!

Wrong medicine or wrong dose.

Some people have more severe allergies and need more than one treatment. I personally use eye drops, nasal spray, and an oral antihistamine in addition to nasal washes and daily (sometimes twice daily) showers when my allergies flare.

Switching types of medication or adding another type of medicine might help. If you need help deciding which medicines are best for your child, schedule an office visit with your PCP for an exam and discussion of symptoms.

Some kids outgrow a dose and simply need a higher dose of medicine as they grow. Talk to your pharmacist or physician to decide if a higher dose is indicated.

Is Nothing working?

Consider allergy shots (immunotherapy) to desensitize against allergens if symptoms persist despite your best efforts as above.

Schedule an appointment with your pediatrician to discuss if this is an option for your allergy sufferer.

Learn to diagnose allergies, what to do when you have them and what you risk if you don't treat them.
Learn to diagnose allergies, what to do when you have them and what you risk if you don’t treat them.



Don’t look for quick fixes for your cold! There’s no quick fix

We all have been sick and wish for a magic cure. Sometimes it seems we find the right fix, but it was just coincidental. I see many people who want antibiotics to fix a viral illness because “it always works” but I want to try to show why this isn’t usually the case. Using antibiotics for most colds and coughs isn’t necessary and can lead to problems.

My urgent care experience

This blog is generally about pediatric health, but sometimes the principles are similar in adult medicine, so I’m sharing a personal story.

I was visiting my parents out of town and came down with fever, chills, and a sore throat. Due to the fatigue and shaking chills, I wasn’t sure if I’d be able to drive the 4 hour trip home the following day. I decided to go to a walk in clinic to see if there was a treatment to help get me on my feet again.

Although it’s less common for adults to get Strep throat, I wanted to have my throat swabbed because I had been exposed to just about everything at work.

If it was just a viral illness, fine. I’d tough through it with fluids and a fever reducer for the body-shaking uncomfortable chills.

But a child had gagged and coughed in my face earlier that week when I was doing a throat swab – and he had Strep. If I had Strep (as I hoped), then an antibiotic would treat the cause and I’d be back in shape in no time.

I could technically call out an antibiotic for myself, but I didn’t want to do that. That is poor care and I would never recommend treating anyone with a prescription without a proper evaluation.

I followed my own advice and went to a walk in clinic since I was out of town. If I was at home, I would have gone to my primary care physician because I believe in the medical home.

The provider walked into the exam room looking at the nurse’s notes saying it sounded like I had a sinus infection. (I use the term provider because I don’t recall if he was a physician, NP, or PA.)

What?

He hadn’t even examined me or gotten any history from me other than answers to the cursory questions the nurse asked. Not to mention that my symptoms had just started within the past 24 hours and didn’t include any form of nasal congestion or drainage.

I’m a physician and know that sinusitis must have persistent symptoms for much longer than 24 hours. But I kept that thought to myself for the moment.

He did a quick exam and started writing a script to treat my sudden onset of fever without cough/congestion.

He literally started writing the script as he was telling me, once again, that I had a sinus infection.

Now I couldn’t stay quiet any longer.

antibiotics are not a quick fix for virusesI said I really just wanted a throat swab to see if it was Strep. I didn’t want an antibiotic if it wasn’t Strep throat.

He argued for a bit about the validity of rapid Strep testing.

I argued that I did not meet the criteria for a sinus infection and that the rapid strep tests are indeed fairly reliable (not perfect).

As a pediatrician I won that argument easily. In the end I was swabbed.

The test was negative. I most likely didn’t have Strep throat after all.

He still gave me a prescription for a commonly used antibiotic called a Z-pack, which I threw away.

avoid unnecessary antibiotics
Antibiotics are not a quick fix for viruses and carry risks.

Did I get better?

I felt better the next day, so if I had just taken the z-pack, I would have thought it worked.

Ironically, the Z-pack is not a very good antibiotic against Strep, the one reason I would have taken an antibiotic. Resistance rates are high in my area, so unless a person has other antibiotic allergies (which I do not) I would not choose it for Strep throat.

But my body fought off an unnamed virus all by itself. That’s what our immune system does. Pretty cool, right?

No. Not cool.

Well, yes… it is cool that we can get better with the help of our immune system and no antibiotics. But not cool that a less knowledgeable person would have taken the prescription without question.

Unfortunately, I think many people trust the medical care provider, even when he or she is wrong.  Even smart people don’t know how to diagnose and treat illnesses unless they’re experienced in healthcare, so anyone could be fooled. Especially since we’re vulnerable when we’re sick. Even more so when our kids are sick. We want to do anything to help them.

False security in an unnecessary treatment.

Many parents come into my clinic wanting an antibiotic for their child because the child has the same symptoms as they have and they’ve been diagnosed with a sinus infection, bronchitis, or whatever. They’re on an antibiotic and are getting better, so they presume their child needs the same.

Most of the time they both likely have a viral illness, and the natural progression is to get better without antibiotics, but it’s hard to get buy in to that when a parent’s worried about a child. Even harder when the parent is certain that their antibiotic is fixing their viral illness.

Confirmation bias.

Confirmation bias is the tendency to process information by looking for, or interpreting, information that is consistent with one’s existing beliefs.

A false belief is reinforced when we think we get better due to an antibiotic. It doesn’t prove that the antibiotic worked, but our minds perceive it as such.

We want to believe something works, and when it appears to work, it affirms our false belief.

The wrong treatment plan.

In my example, not only did I not have a sinus infection, but if I did have a false negative Strep test and actually needed an antibiotic for Strep, the Z-pack wasn’t a good choice.

False negative tests mean that there is a disease, but the test failed to show it. False negative tests are the reason I usually do a back up throat culture if I really think it is Strep throat and not a virus.

If the wrong treatment is given, not only do you fail to treat the real cause, but you also take the risks associated with the treatment for no reason.

Doesn’t the doctor (or NP or PA) know the antibiotic won’t work?

Yes, they know (or should know) how antibiotics work and when they’re indicated. But unfortunately, there are other factors at work when quick fixes are chosen.

Top 3 reasons that lead to patients getting unnecessary prescriptions:

1. Time

One problem is that it’s much easier to give a prescription rather than taking time trying to teach why a prescription isn’t needed.

The faster they see a patient, the more patients they can see and the shorter the waiting time is, which makes people happy.

I see many unhappy parents who follow up with me because their child is still sick and the “last doctor” did nothing. I have previously blogged about the Evolution of Illness so will not go into it in depth here.

2. Experience

Sometimes it’s hard for physicians, NPs, and PAs to not try something to make a sick person better. After all, that’s why we do what we do, right? We want to help. We’ve all heard of patients who get progressively ill because an infection wasn’t treated quickly and we don’t want to “miss” something.

While missing a significant illness can happen, it’s not common. Common is common. Most upper respiratory tract infections are viral. It’s knowing how to recognize worrisome symptoms that comes from experience.

Physicians (MD, DO)

Physicians spend years of not only classroom training, but also clinical training to learn to recognize warning signs of illness. Even a brand new physician has at least 2 clinical years during the total 4 years of medical school. Then they spend at least 3 years of residency seeing patients in a supervised capacity before they can work independently. That’s at least 5 years of 60-80 hour work weeks.

The physicians in my office, including myself – now 18 years in practice – still ask for help if we feel it could be beneficial. Sometimes a second set of eyes or putting our heads together helps to put things into a clearer picture.

Trust that if we say it’s a virus, it’s a virus. We know that bodies can still be significantly sick if it’s Just A Virus, but most of the time you can manage symptoms at home. Listen to what we say are warning signs that indicate your child should be reassessed. Bring your child back if symptoms worsen or continue longer than typical. Symptoms can worsen, but taking an antibiotic does not prevent that progression in most cases.

Be sure to question if you do not understand or agree with an assessment or treatment plan, as I did in my example above. It is essential to have this type of communication for the best care.

Nurse Practitioners (NPs) and Physician Assistants (PAs)

I love the NPs in my office. They do a fantastic job and make patient access easier. They see a lot of sick kids and do a great job treating when needed and giving “just” advice when that is what is needed. (That’s usually harder, trust me.)

They are always able ask questions if they don’t know what to do or for a physician to see a patient if a parent wants a second opinion.

I do not want this to become an argument if NPs and PAs are good. They are needed in our healthcare system to help patients get seen in a timely fashion. I welcome and appreciate them as part of the healthcare team.

But I do want to acknowledge that the training and background can vary widely, and I think it’s important to know the experience of your provider. It is not as regulated to become an NP or PA as it is to become a physician.

Many NPs have years of work experience before returning to school to get their advanced degree. But newer online programs do not require much clinical experience. At all.

If they then begin working independently without much supervision, they learn as they go and may or may not learn well. I’m not saying they’re not smart, but I also know how lost I felt those first months as a new physician after many supervised hours, and I know they have a small fraction of those supervised hours. I can’t imagine doing that as a new grad!

This is why I think that all new practitioners should work with others who have more experience, so they can learn from the experience of others. I worry when inexperienced people work alone in clinics, with no one to bounce questions off of.

Learn more about the training of healthcare providers in What kind of doctor is your doctor?

Patient experience and the 6th sense as a parent

Experience as a parent (and patient) matters too.

We can’t see what your child experienced last night if we’re seeing them in the morning and symptoms changed. Many symptoms are worse overnight, which makes it difficult to assess during the day. Of course if symptoms are urgent at night, go to a 24 hour facility that can adequately evaluate the situation.

If you are able to wait until regular business hours, you must describe it so we can understand it.

If you feel uncomfortable with the treatment plan, talk to the provider. List your concerns and let them address them. That’s not the same thing as demanding a prescription or further testing. It means asking for more information about why they feel the current plan is the correct one.

3. Surveys

Many hospitals, clinics and insurance companies are surveying patients to see if “good care” was provided. These surveys are used to place providers on insurance contracts and decide payment and salaries.

People are happier and think care is better if something was done. A lab, x-ray, or prescription (whether needed or not) is “something” people can identify.

People do not feel that information about viral illnesses and what treatments can be done at home is as worthwhile as a tangible treatment, even if it’s the correct treatment. They see the prescription as making the cost and time taken for the office visit “worth it” even if it is bad care. Leaving empty handed (but with proper treatment) doesn’t satisfy.

And the surveys reflect that.

Sadly, the pressure felt by physicians and other medical providers to perform well on surveys has been shown to have many negative side effects. Healthcare costs rise from unnecessary tests and treatments. Side effects of unnecessary treatments occur. Hospitalization rates and death are even higher with high patient satisfaction scores.

Don’t look for a quick fix. Look for the right fix.

Antibiotics certainly have their place. They are very beneficial when used properly. For a fun read about being responsible with antibiotics, visit RESPECT ANTIBIOTICS: USE THEM JUDICIOUSLY TO ENSURE WE CAN STILL WAGE THE WAR AGAINST BACTERIA from Dr. Michelle Ramírez.

If we use antibiotics inappropriately, they cause more problems.



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Measles Outbreaks: What can you do to protect your family?

Any area can be affected by measles. My county is in the middle of an measles outbreak right now. This is despite relatively high MMR vaccine rates above 95% for at least 1 MMR by 3 years of age. There are a lot of questions about measles outbreaks, so I thought I’d tackle a few. Like most pediatricians, I’ve never seen measles and I hope to not miss it if I do. We all need to be aware of its symptoms so we can recognize it when we see it!

What is measles?

Measles is a viral illness that includes fever, cough, fatigue, red eyes, and a characteristic rash. The rash spreads from head to trunk to lower extremities.

Measles rash PHIL 4497 lores
Source: https://commons.wikimedia.org/wiki/File%3AMeasles_rash_PHIL_4497_lores.jpg

RougeoleDP
Source: https://commons.wikimedia.org/wiki/File%3ARougeoleDP.jpg
Measles is usually a mild or moderately severe illness. It can lead to pneumonia, encephalitis, and even death (risk of 2-3 per 1000).

One rare complication of measles infection that occurs many years after the illness appears to resolve is subacute sclerosing panencephalitis (SSPE). It is a fatal disease of the central nervous system that usually develops 7–10 years after infection.

 

 

 

Koplik spots, measles 6111 lores
Source: https://commons.wikimedia.org/wiki/File%3AKoplik_spots%2C_measles_6111_lores.jpg
Koplik spots are a specific rash seen in the inner cheek. Koplik spots are visible from 1 – 2 days before the measles rash and disappears to 1 – 2 days later. They look like white spots with a blue center on the bright red background of the cheek. They can easily be missed because they are not present for long, but if seen are classic for measles.

What is the timeline of symptoms after exposure?

Measles is highly infectious. It is primarily transmitted by large respiratory droplets in the air, so handwashing doesn’t help prevent exposure.

An area remains at risk for up to 2 hours after a person with measles was there. This is why it is IMPERATIVE that you should not leave your house if you suspect you have measles until you have spoken with the health department or your physician. DO NOT go to a walk in clinic or your doctor’s office unannounced. You will need to make arrangements to meet someone outside and wear a mask into the building. You will be put in a special negative pressure room, which is not available in most clinics.

More than 90% of susceptible people develop measles when they’re exposed.

The average incubation period for measles is 11–12 days. It takes 7–21 days for the rash to show. It is due to this long time for the characteristic rash that susceptible people who were exposed are put in isolation for up to 21 days.

Most people are contagious from about 4 days before they show the rash until 4 days after the rash develops. If a person has measles and the rash resolves, they can leave isolation when cleared by their physician and/or the health department.

What is a measles outbreak?

Measles outbreaks are defined as 3 or more measles cases linked in time and space.

How do outbreaks start?

I know the big question on everyone’s mind during an outbreak is, “Where did it start?”

Often an unimmunized traveler brings the measles virus into the US. Countries in Europe, Africa, Asia, and the Pacific continue to have outbreaks. Travelers who visit those countries can return to the US and share the virus for a few days before symptoms are recognized. Anyone who was in the same area as an infected person for up to 2 hours after that person left the area could be exposed.

In case you’ve heard that vaccines can lead to outbreaks: that’s not the case. Measles shedding from the MMR does not cause disease.

What happens during an outbreak?

Measles Outbreaks: What can you do to protect your family?During an identified outbreak of any reportable infectious disease, the health department directs what to do. They attempt to identify and notify all people who are at risk.

Our current outbreak involves several infants from the same unnamed daycare in addition to people not associated with the daycare. I know many families are worried that their child was at that daycare. Families at that daycare will have been notified by the health department already. The health department will track all known contacts of those families.

Local health departments also will notify the public of known locations of potential contact with the virus. The above linked article lists the known locations that infected people visited during their contagious period.

Why are infants at risk?

Infants are at particular risk because they are not typically vaccinated against measles until 1 year of age.

When the virus is in a setting with infants, such as a daycare, it can easily spread.

Infants under 2 years of age who are infected also tend to have more complications from the disease than older children and adults. This is one of the biggest reasons to not wait until 2 years to start immunizations, as some anti-vaccine groups suggest.

If you think you were exposed to or have symptoms of measles

It is IMPERATIVE that you should not leave your house if you suspect you have measles until you have spoken with the health department or your physician.

DO NOT go to a walk in clinic or your doctor’s office unannounced.

You will need to make arrangements to meet someone outside and wear a mask into the building. You will be put in a special negative pressure room, which is not available in most clinics.

Do not go to the pharmacy to pick up medications. Don’t go to the grocery store for food.

Do not leave your home unless it is to a medical facility that knows you’re coming and is prepared.

(Yes, I know I repeated myself for much of this section, but it’s that important!)

The MMR vaccine can help stop the spread

The MMR vaccine is recommended routinely at 12-15 months and again at 4-6 years of age. Vaccines not only help the vaccinated, but provide herd immunity to those too young to be immunized and to those who are immunocompromised.

Please be sure your family is up to date on all their vaccines. All children over 1 year of age should have at least 1 MMR vaccine. All school aged children and adults should have 2 MMRs. By vaccinating your family, you not only protect them, but also those around you!

Why is a second dose given?

The second dose is used to provide immunity to the approximately 5% of people who did not develop immunity with the first dose. It is not a booster because it doesn’t boost the effect of the first dose.

The second MMR helps some people develop immunity if the first vaccine did not work effectively.

This second dose can be given as early as 28 days after the first.

Why don’t we start the vaccine series earlier?

Many parents worry that we don’t give live virus vaccines to infants because they’re less safe, but that’s not why at all.

Maternal antibodies (fighter cells from mom that got into baby during pregnancy) can inhibit the body from being able to build its own antibodies well against a vaccine.

Maternal antibodies are good because as long as they’re in the baby’s body, they fight off germs and protect the infant! They tend to hang around for the first 6-12 months of life.

If a disease has a low incidence, it is acceptable to let the maternal antibodies do their job for the first year.

By the first birthday most maternal antibodies have left the infant, so a vaccine can be used to build the baby’s immunity.

Sometimes we do vaccinate earlier

If there is a high risk of exposure it is recommended to give the vaccine as early as 6 months in case the maternal antibodies are already too low for infant protection.

Many parts of the world have high measles rates so fit into this recommendation. When infants between 6 and 12 months travel internationally, they should receive one dose of MMR vaccine prior to travel.

Sometimes during US outbreaks it is recommended to vaccinate infants 6-12 months. The local health department helps to determine which infants should be immunized in this situation.

If the maternal antibody levels are still high in the infant, the vaccine won’t work. In this situation the baby should still be protected against the disease from mom’s antibodies. That is why this early vaccine does not “count” toward the two needed after the first birthday.

At some point the maternal antibodies go away, we just don’t know when exactly, so the baby who gets the MMR early needs another dose after his first birthday to be sure he’s making his own antibodies once mom’s go away. This dose after the birthday is the first that “counts” toward the two MMRs that are needed.

The next dose of MMR can be anytime at least 28 days after the first counted dose, but we traditionally give it between 4-6 years with the kindergarten shots.

What if someone who hasn’t been vaccinated is exposed?

measles outbreaks, what can you do to protect your family
Source: http://www.immunize.org/photos/measles-photos.asp

The MMR vaccine may be effective if given within the first 3 days (72 hours) after exposure to measles. This is why the local health department is so aggressive in identifying cases during an outbreak.

Immune globulin (IGIM, a type of immunity that doesn’t require a person to make their own immunity) may be effective for as long as 6 days after exposure. IGIM should be given to all infants younger than 6-12 months who have been exposed to measles. The MMR vaccine can be given instead of IGIM to infants age 6 through 11 months, if it can be given within 72 hours of exposure.

Are boosters of the MMR needed?

are mmr boosters needed
From my practice Facebook page. Note: In this reply I was going off of my experience many years ago. At that time the advice was only 1 additional MMR, but my research for this blog shows otherwise!

Those of us who work in healthcare must have titers checked to verify immunity to many of the vaccine preventable diseases.

Healthcare workers come into contact with sick patients and patients with weak immune systems, so this is one way to help control disease spread.

From Immunize.org:
Adults with no evidence of immunity (defined as documented receipt of 1 dose [2 doses 4 weeks apart if high risk] of live measles virus-containing vaccine, laboratory evidence of immunity or laboratory confirmation of disease, or birth before 1957) should get 1 dose of MMR unless the adult is in a high-risk group. High-risk people need 2 doses and include healthcare personnel, international travelers, students at post-high school educational institutions, people exposed to measles in an outbreak setting, and those previously vaccinated with killed measles vaccine or with an unknown type of measles vaccine during 1963 through 1967.

Most people don’t know their immune status, and it’s not recommended at this time to check it for the general population.

During an outbreak exposed people might be asked to be tested to help identify risk factors and track disease patterns.

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Dark Under Eye Circles

I see a lot of kids with circles under their eyes. There’s a lot of confusion as to what causes them. Dark circles under the eyes may simply be hereditary – a trait that runs in families, but they also can signify chronic disease.

I’ll cover some causes that are feared but not likely and common causes that can be treated to help decrease the dark appearance of the circles.

Not likely causes

Anemia

allergic shiners, circles under eyesMany parents worry that anemia, or a low red blood cell count, is causing their child’s under eye circles. I’m not sure why this thought is so prevalent, but it’s not the first thing I think about when I see dark circles under the eyes of a child.

Iron deficiency is linked to anemia because iron is a building block of a red blood cell. Iron deficiency is relatively common in kids due to poor diet, so if your kids don’t eat foods rich in iron, you should talk to their doctor.

Anemia can happen in kids, but if under eye circles is the only symptom, it’s not likely. If there are other symptoms then blood work might be indicated.

Symptoms of anemia may include:

  • Pale skin, including the inner eyelids
  • Irritability
  • Feeling tired or having low energy
  • Poor focus and attention
  • Weakness
  • Craving of ice or eating non-food items (pica)
  • Rarely (with more severe anemia)
    • Yellow jaundice (yellow eyes and skin)
    • Rapid heart rate
    • Fast breathing
    • Swelling of hands, feet, or puffy eyelids

Poor sleep

Yes, we often think of circles under the eyes from poor sleep. Poor sleep is not usually the cause of under eye circles in a child, especially when they otherwise appear well rested.

Kids who have chronically poor sleep can appear tired and sluggish, but they also have other symptoms, such as irritability, hyperactivity, poor school performance, and increased injuries.

If you’re worried about your child’s sleep, talk to your pediatrician.

Vitamin deficiency

There are many products containing various vitamins that are sold to help decrease under eye circles, but evidence is lacking that vitamin deficiencies are common causes of under eye circles in children.

Unless there are other significant problems, it is not recommended to check vitamin levels to evaluate under eye circles.

If your child is a picky eater and has a limited intake of nutrients, talk to your pediatrician.

What does cause dark under eye circles?

The skin under the eyes is very thin, so when blood passes through the thin skin it can produce a dark color, much like the blue color of your veins. If the blood circulation slows, the blue color can be more noticeable.

Congestion in your sinuses can lead to congestion in the small veins under your eyes. The blood collects in the skin under your eyes and these swollen veins dilate and darken. This creates the effect of dark circles and puffiness.

Dark circles are of course more noticeable in fair skinned people.

The most common cause of under eye circles is chronic congestion, but chronic congestion can be from various causes.

Allergic shiners

Allergies are probably the most common cause of dark circles under the eyes, so the circles are also called “allergic shiners.” They get this name due to the purplish hue of the skin, resembling a black eye, AKA “shiner.”

If allergies are the cause, you will usually see other symptoms of allergy, such as

  • Runny nose
  • Itchy, watery eyes
  • Sneezing
  • Itchy throat
  • Itchy roof of mouth
  • Sinus pressure or fullness

Treating the allergies can often make the allergic shiners disappear.

Upper respiratory tract infections

Viruses that cause nasal congestion can also lead to dark circles under the eyes. These can be brief if the cold clears quickly, or seem to come and go with recurrent infections, as often happens during the cold and flu season.

Sinus infections can cause chronic congestion, leading to dark under eye circles.

Though there’s no quick fix to most upper respiratory tract infections because they’re caused by viruses, you can use saline nasal rinses to help clear some of the congestion.

Smoke exposure

Smokers and their children often have chronic congestion.

Studies show that second hand smoke leads to more frequent upper respiratory tract infections and ear infections in kids. It’s not surprising that these kids also develop chronic circles under their eyes.

Mouth breathing

Mouth breathing can itself be from many causes.

Commonly nasal congestion from allergies and upper respiratory tract infections leads to mouth breathing.

Large adenoids can also contribute to mouth breathing and under eye circles, as explained by Ear, Nose, and Throat specialist, Dr. Deborah Burton in GET THE TRUTH ABOUT THE CONSEQUENCES OF MOUTH BREATHING.

Dehydration

Dehydration can make dark circles look more prominent due to sluggish blood flow.

The eyes also appear to sink into the sockets when we’re dehydrated, which can accentuate the dark circle appearance.

Treating and preventing under eye circles

The best ways to prevent dark circles include many things that help us stay healthy anyway.

  • Control allergies
  • Teach kids to wash their hands and keep hands away from their face to help prevent infections
  • Drink plenty of water
  • Use sunscreen (sun damages skin over time)
  • Give a healthy balance of foods and talk to your pediatrician if your child isn’t eating a good variety of nutrients
  • Ensure plenty of sleep for age
  • Use nasal saline rinses (see below)
  • If chronically congested or mouth breathing, talk to your child’s doctor to find and address a cause
  • Avoid smoke and secondhand smoke, which lead to chronic congestion
  • Use moisturizers if skin is dry
  • Avoid pollution as much as possible, since it can contribute to chronic congestion

Saline rinses

I often refer to Nasopure’s website because it has great instructions on how to rinse the nose for kids as young as 2 years of age. It also has videos to help kids get comfortable with the idea. I refer to the site simply because I like it, and I receive no compensation for the recommendation.

I do participate in the Amazon Affiliate program, and if you use one of these links to purchase a nasal wash kit, I do make a small profit. As always, I only link to products that I endorse regardless of where you purchase it.


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All About Ear Infections – Prevention

Ear infections are all too common and cause a lot of distress for kids and their families. What can we do to help prevent them from happening?

This is part 3 of a three-part series.

  1. All About Ear Infections – What they are and why they happen
  2. All About Ear Infections – Treatments
  3. All About Ear Infections – Prevention

What can be done to prevent ear infections?

Avoid all smoke exposure.

Tobacco smoke is known to predispose children to ear infections, upper respiratory infections and wheezing.

Do not bottle prop.

Keeping a baby’s head elevated a bit while bottle feeding can help prevent ear infections.

Breastfeed.

Breast milk is protective against many types of infection, including ear infections.

General infection prevention.

Avoid taking your infant to places where there are a lot of people during sick season.

Wash hands often. Teach kids to really wash their hands. Because they don’t do a great job much of the time.

Attempt to limit sharing of toys that young children mouth, and wash them between children.

If your child attends daycare, try to find one where there are fewer children per room.

Vaccinate.

One of the biggest causes of bacterial ear infections is pneumococcus. Your child will be vaccinated against this as part of the standard vaccine schedule.

Saline.

If you know me, you know I often recommend saline to the nose.

Saline drops for babies followed by suctioning.

Nasal saline rinses for kids over 2 years of age. (Nasopure has a great library to teach proper use and even videos to get kids used to the idea.)

Saline is a great way to clear the mucus from our nose, which can help prevent cough, sinus infections, and ear infections.

Keep the pacifier in the crib.

When kids play, they often drop their pacifier, which can encourage germs to accumulate on it before they put it back in their mouth.

Xylitol.

There are several studies that suggest chewing gum with xylitol as its sweetener helps prevent ear infections in children who can chew gum. For younger infants, there are nose sprays with xylitol. Xylitol is a naturally occurring substance that is used as a sweetener is many products, many of which are reviewed here. I do not endorse any of these, but do find this a helpful resource.

Treat acid reflux.

This can include dietary changes, positional changes, or medications. Talk to your doctor to see which is right for your child.

Treat allergies.

Treating allergies can help decrease mucus production and improve drainage.

For More Information:

Middle Ear Infections: Summary of the AAP ear infection guidelines
Xylitol sugar supplement for preventing middle ear infection in children up to 12 years of age

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