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.

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.



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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New Allergy Guidelines for People Over 12 Years Old

If you or your kids suffer from allergies, I’m sure you want to know how to best manage them. In addition to limiting exposure, medications can be a big benefit. Treatment of allergies can be directed by new guidelines. These guidelines cover the initial medical treatment of seasonal allergies in people 12 years and older.

The American Academy of Allergy, Asthma, and Immunology and the American College of Allergy, Asthma, and Immunology (AAAAI and ACAAI) have published new guidelines in the Annals of Internal Medicine for the initial medical treatment of seasonal allergies in people 12 years and older.

The guidelines for treatment of allergies essentially state:
  • Use steroid nasal sprays first without an oral or nasal antihistamine. Many intranasal steroids are available over the counter without a prescription. A great list is included on the AAAAI website. (Be careful to not to confuse them with the nasal antihistamines, which are in the same chart but identified in the column titled “Class”.)
  • In those over 15 years, the nasal steroid is preferred over a leukotriene receptor antagonist (ie Singulair or montelukast). For those with asthma, the leukotriene receptor antagonist might offer an additional benefit for asthma, but it is not the preferred treatment in either allergies or asthma. (I think the age change is simply due to the ages studied but it was not specified.)
  • In moderate to severe allergic conditions, a combination of nasal steroid and nasal antihistamine can be considered.

These recommendations are based on a review of many studies to show what treatments worked and what didn’t.

They also took into consideration the fact that oral antihistamines can cause sedation and the nasal antihistamines do not.

In general the nasal steroids worked better than other treatments. They did note that for people who do not tolerate nasal sprays, alternates would be oral antihistamines or leukotriene receptor agonists.

UPDATE 3.27.18

I have a new blog on the general identification and treatment of allergies. Check out Spring is Here!

 

Traveling with Kids

Many families travel when school’s out of session, which over the winter holiday season and spring break means traveling when illness is abound. I get a lot of questions this time of year about how to safely travel with kids. Traveling with kids can increase the level of difficulty, but it can be done safely and still be enjoyable!

Sleep disturbances

Sleep deprivation can make everyone miserable, especially kids (and their parents). Make sure your kids are well rested prior to travel and try to keep them on a healthy sleep schedule during your trip.
  • Bring favorite comfort items, such as a stuffed animal or blankie, to help kids relax for sleep. If possible, travel with your own pillows.
  • If you’re staying at a hotel, ask for a quiet room, such as one away from the pool and the elevator.
  • Be sure to verify that there will be safe sleeping areas for every child, especially infants, before you travel.
  • Try to keep kids on their regular sleep schedule. It’s tempting to stay up late to enjoy the most of the vacation, but in reality that will only serve to make little monsters of your children if they’re sleep deprived.
  • If your kids nap well in the car, plan on doing long stretches on the road during nap time. If kids don’t sleep well in the car, be sure to plan to be at your hotel (or wherever you’re staying) at sleep times so they can stay in their usual routine.
  • Some families leave on long trips at the child’s bedtime to let them sleep through the drive. Just be sure the driver is well rested to make it a safe trip!
  • If you’re changing time zones significantly, plan ahead. Jet lag can be worse when traveling east than when going west. Jet lag is more than just being tired from a change in sleep routine, it also involves changes to the eating schedule. Kids will often wake when they’re used to eating because the body is hungry at that time. Try to feed everyone right before they go to sleep to try to prevent this. Breastfed infants might have a harder time adjusting because mother’s milk production is also off schedule.
  • Tired, sick, and hungry all make for bad moods, so try to stay on track on all accounts. Sunlight helps regulate our circadian rhythm, so try to get everyone up and outside in the morning to help reset their inner clocks. Keep everyone active during the day so they are tired at the new night-time.

Keeping track of littles

  • Toddlers and young kids love to run and roam. Be sure that they are always within sight. Use strollers if they’ll stay in them.
  • Consider toddler leashes. I know they seem awful at first thought, but they work and kids often love them! I never needed one for my first – he was attached to parents at the hip and never wandered. My second was fast. And fearless. She would run between people in crowds and it was impossible to keep up with her without pushing people out of the way. She hated holding hands. She always figured out ways to climb out of strollers – and once had a nasty bruise on her forehead when she fell face down climbing out as I pushed the stroller. She loved the leash. It had a cute monkey backpack. She loved the freedom of being able to wander around and I loved that she couldn’t get too far.
  • Parents have a number of ways to put phone numbers on their kids in case they get separated. Some simply put in on a piece of paper and trust that it will stay in a pocket until it’s needed. Others write it in sharpie inside a piece of clothing or even on a child’s arm. You can have jewelry engraved with name and phone number, much like a medical alert bracelet. Just look at Etsy or Pinterest and you’ll come up with ideas!
  • It’s a great idea to take pictures of everyone each morning in case someone gets separated from the group. Not only will you have a current picture for authorities to see what they look like, but you will also know what they were wearing at the time they were lost.
  • If you want more, I wrote a whole blog on keeping kids from wandering.

Airplane issues

  • The great news is that air travel is much safer from an infection standpoint than it used to be. Newer airplanes have HEPA filters that make a complete air change approximately 15 to 30 times per hour, or once every 2-4 minutes. The filters are said to remove 99.9% of bacteria, fungi and larger viruses. These germs can live on surfaces though, so I still recommend using common sense and bringing along a small hand sanitizer bottle and disinfectant wipes to use as needed. Wipe down arm rests, tray tables, seat pockets, windows, and other surfaces your kids will touch. After they touch unclean items sanitize their hands. Interestingly, sitting in an aisle seat is considered more dangerous, since people touch those seats during boarding and when going to the restroom, so if you’re seated in the aisle pay attention to when surfaces need to be re-sanitized. Sitting next to a sick person increases your risk, so if there is an option to move if the person seated next to you is ill appearing, ask to be moved.
  • Most adults who have flown have experienced ear pain due to pressure changes when flying. Anyone with a cold, ear infection or congestion from allergies is more at risk of ear pain, so pre-medicating with a pain reliever (such as acetaminophen) might help. If you have allergies be sure to get control of them before air travel. The best allergy treatment is usually a nasal corticosteroid.
  • It has often been recommended to offer infants something to suck on (bottle, breast or a pacifier) during take off and landing to help with ear pressure. Start early in the landing – the higher you are, the more the pressure will change. Older toddlers and kids can be offered a drink since swallowing can help. Ask them to hold their nose closed and try to blow air out through the closed nostrils followed by a big yawn. If your kids can safely chew gum (usually only recommended for those over 4 years of age) you can allow them to chew during take off and landing.
  • Airplane cabin noise levels can range anywhere from 60 – 100 dB and tend to be louder during takeoff. (I’ve written about Hearing Loss from noise previously to help you understand what that means.) Use cotton balls or small earplugs to help decrease the exposure, especially if your kids are sensitive to loud noises.
  • The Car Seat Lady has a great page on knowing your rights when flying with kids.

Cruise ship issues

  • Learn about cruise-specific opportunities for kids of various ages. Many will offer age-specific child care, “clubs” or areas to allow safe opportunities for everyone to hang out with people of their own age group. Cruises offer the opportunity for adventurous kids to be independent and separate from parents at times, allowing each to have a separate-yet-together vacation. Travel with another family with kids the same ages as yours so your child knows a friendly face, especially if siblings are in a different age group for the cruises “clubs”.
  • Talk to kids about safety issues on the ship and make sure they follow your rules. They should always stay where they are supposed to be and not wander around. There’s safety in numbers, so have them use a buddy system and stick with their buddy. Find out how you can get a hold of them and they can get a hold of you during the cruise.
  • Of course sunscreen is a must. Reapply often!
  • Be sure kids are properly supervised near water. That means an adult who is responsible for watching the kids should not be under the influence of alcohol, shouldn’t read a book, or have other distractions.

Car seats (for planes, trains and automobiles)

  • I know it’s tempting to save money and not get a seat for your child under 2 years of age on a plane, but it is recommended that all children are seated in a proper child safety restraint system (CRS). It must be approved for flight, but then you can then use the seat for land travel.
  • I always recommend age and size appropriate car seats or boosters when traveling, even if you’re in a country that does not require them. Allowing kids to ride without a proper seat will probably lead to problems getting them back in their safe seat when they get back home. Besides, we use car seats and booster seats to protect our kids, not just to satisfy the law.
  • So… my section header was meant to be cute. Trains don’t have seatbelts, so car seats won’t work. But they are a safe way to travel. Car Seat for the Littles has a great explanation on Travel by Train.

Motion sickness

When should pregnant women and new babies avoid travel by air?

  • A surprising number of families either must travel (due to a job transfer, death in the family, out of state adoption, or other important occasion) or choose to travel during pregnancy or with young infants.
  • Newborns need constant attention, which can be difficult if the seatbelt sign is on and needed items are in the overhead bin. New parents are already sleep deprived and sleeping on planes isn’t easy. New moms might still have swollen feet and need to keep their feet up, which is difficult in flight. Newborns are at high risk of infection and the close contact with other travelers can be a concern. And traveling is hard on everyone. But the good news is that overall young infants tend to travel well.
  • It is advisable to not travel after 36 weeks of pregnancy because of concerns of preterm labor. Pregnant women should talk with their OB about travel plans.
  • Some airlines allow term babies as young as 48 hours of age to fly, but others require infants to be two weeks – so check with your airline if you’ll be traveling in the first days of your newborn’s life. There is no standard guideline, but my preference would be to wait until term babies are over 2 weeks of age due to heart circulation changes that occur the first two weeks. Waiting until after 6 weeks allows for newborns to get the first set of vaccines (other than the Hepatitis B vaccine) prior to flight would be even better. Infants ideally have their own seat so they can be placed in a car seat that is FAA approved.
  • Babies born before 36 weeks and those with special health issues should get clearance from their physicians before traveling.
  • Overall traveling with an infant is not as difficult as many parents fear. Toddlers are another story… they don’t like to sit still for any amount of time and flights make that difficult. They also touch everything and put fingers in their mouth, so they are more likely to get exposed to germs.

Illness prevention

Who wants to be sick on vacation? No one. It’s easy to get exposed anywhere during the cold and flu season, so protect yourself and your family.
  • Teach kids (and remind yourself) to not touch faces – your own or others. Our eyes, nose, and mouth are the portals of entry and exit for germs.
  • Wash hands before and after eating, after blowing your nose, before and after touching eyes/nose/mouth, before and after putting in contacts, after toileting or changing a diaper, and when they’re obviously soiled.
  • Cover sneezes and coughs with your elbow unless you’re cradling an infant in your arms. Infants have their head and face in your elbow, so you should use your hands to cover, then wash your hands well.

 

Make sure all family members are up to date on vaccines.

 

Keep records

Take pictures of your passport, vaccine record, medicines, insurance cards, and other important items to use if the originals are lost. Store the images so you have access to them from any computer in addition to your phone in case your phone is lost.

Have everyone, including young children, carry a form of identification that includes emergency contact information.

Create a medical history form that includes the following information for every member of your family that is travelling. Save a copy so you can easily find it on any computer in case of emergency.

  • your name, address, and phone number
  • emergency contact name(s) and phone number(s)
  • immunization record
  • your doctor’s name, address, and office and emergency phone numbers
  • the name, address, and phone number of your health insurance carrier, including your policy number
  • a list of any known health problems or recent illnesses
  • a list of current medications and supplements you are taking and pharmacy name and phone number
  • a list of allergies to medications, food, insects, and animals
  • a prescription for glasses or contact lenses

Enjoy!

Last, but not least: Enjoy your vacation!
Be flexible.

Don’t overschedule. Your kids will remember the experience, so make moments count – don’t worry if you don’t accomplish all there is to do!

Take a look at some of the Holiday Health Hazards that come up at vacation times from Dr Christina at PMPediatrics so you can prevent accidents along the way.

Take pictures, but don’t make the vacation about the pictures. Try to stay off your phone and enjoy the moments!

Itchy, sneezy, puffy… what can you do about allergies?

It’s allergy season! Prevention and treatment is important if you have seasonal allergies so you can enjoy the great outdoors. This is an update to a previous blog I wrote on the subject, since there are many more medicines now available over the counter.

Symptoms of Allergies: 

allergies

Allergies are more than just sneezing.

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

Some kids get a crease across their nose from wiping.

Others get purple circles under their eyes called allergic shiners.

These symptoms last longer than the typical cold, which usually resolves after 1-3 weeks. Fever is a sign of infection, not allergies. Other than fever, it is very difficult sometimes to decide if it is a virus or allergies until a seasonal pattern really develops. Even then it is possible to get colds during allergy season some years!

Treatments: 

It is best to treat before the symptoms get bad. It is easy to monitor pollen counts online to know what’s out there and start treatment before symptoms make you (or your child) miserable. Treatments include medicines and limiting exposure.

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.

In general I prefer the 24 hour antihistamines simply because it is impossible to cover the full day with a medicine that only lasts 4-6 hours. 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 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 by me. Once control of the mucus is achieved, a decongestant isn’t needed.

If you need a decongestant initially, you can use one with your usual antihistamine. Most decongestants on the market 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. Decongestants can cause dizziness, heart flutters, dry mouth, and sleep problems, so use them sparingly and only in children over 4 years of age.

Nasal Spray steroid and antihistamine

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.

Eye drops

Eye drops can help alleviate eye symptoms. They are available both as over the counter allergy drops and 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.

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

Montelukast (commonly known as Singulair) 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. It is available only by prescription, so make an appointment to discuss this if your child might benefit.

Steroids

Steroids decrease allergic inflammation well. These can 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). These require a prescription, so a visit to your provider is recommended to discuss proper use.

Limiting Exposure:  

The longer your airway is exposed to the allergen (pollen, grass, mold, etc) the more inflammation you will have.

Wash off pollen

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

I have found the information and videos on Nasopure.com very helpful to teach kids as young as 2 years to wash their noses.

keep pollen out of the house

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

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 this pdf from the Environmental Protection Agency: Aircleaners.

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!

Think about pets

Keep pets out of bedrooms. 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 is allergic to, consider allergy shots against this type of animal.

Contact lens wearers

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.

Smoke is an added irritant

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.

What if all of the above isn’t helping?

Maybe it’s really not allergies.

Allergies to things other than foods are rare before 2 years of age.

Viruses can cause very similar symptoms to allergies.

Allergy testing is possible by blood or skin prick testing, but can be costly. In most cases I don’t find it very helpful for environmental allergens because you can’t avoid them entirely and you can always limit exposures as above. I think that 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. Note also animal exposures and household conditions. 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. Allergies tend to worsen as kids get older. Switching types of medication or adding another type of medicine might help. If you need help deciding which medicine(s) are best for your child, an office visit for an exam and discussion of symptoms is advised.

Some kids outgrow a dose and simply need a higher dose of medicine as they grow.

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.