How To Use Nose Sprays Correctly

Nasal sprays are the preferred treatment for allergies based on guidelines, but I hear many reasons why people don’t use them. Some simply think they don’t work well. Others have gotten nosebleeds. Some simply don’t like the bad taste they get from using them. If used incorrectly you’ll taste medicine or feel a drip down the back of your throat. Nose sprays won’t work as well if used incorrectly and they might even traumatize the nose, leading to nosebleeds – and that traumatizes some kids and many of their parents. Using them correctly can help alleviate symptoms of allergies and allow kids to enjoy the great outdoors!

Start by using the right nose spray – or sprays

There are many nose sprays out there, and you need to be sure you’re using the correct product for your needs.

First you’ll need to know that allergy symptoms are caused by histamines. In a person who is sensitive to pollen, dust mites, or animal dander, histamine is released in response to exposure. The histamine can cause swelling of the nose or eyes, watery eyes, runny nose, and itch. Allergy treatments either focus on limiting allergen exposure, preventing the histamine release, or blocking the histamine response.

All of the nose sprays used for allergy management (except saline) are listed on the American Academy of Allergy Asthma & Immunology ALLERGY & ASTHMA MEDICATION GUIDE.

Saline

Saline is great for the nose. I actually prefer saline washes over saline sprays, but the sprays are good too. See the 2nd video below for why I love saline washes.

Saline helps to remove the pollen from the nose to limit the exposure time. It also helps to shrink swollen nasal tissues, which makes it easier to breathe, and loosens mucus to help get it out.

Saline is just salt water, so if you want something natural, this is it!

Many parents ask how often to use saline sprays, and it really can be used whenever it’s needed. For prevention of allergies, use it after going outside and before bed during pollen seasons. If you’re using it because of a stuffy nose, you can use it several times a day.

Saline can be used even in babies. If you use saline spray or saline drops they can be followed with blowing the nose (or using an aspirator).

I love to use saline first followed by a good blow (or suction) to clear out the nose. After the nose is cleared, if that’s not sufficient to last the whole day, the other sprays are more effective. Saline doesn’t have medicine to last several hours, but can be used before medicated sprays to help them be more effective.

Mast Cell Inhibitor

Cromolyn sodium is a mast cell inhibitor that can be used for allergies. It prevents the release of histamine, which causes allergic symptoms.

Cromolyn sodium must be started 1-2 weeks before pollen season and continued daily to prevent seasonal allergy symptoms. It doesn’t work as well as corticosteroid nasal sprays, so I generally don’t recommend cromolyn.

These sprays can be used in children as young as 2 years of age.

The biggest drawback is that it is recommended every 4 hours, up to 4 times a day. This is really hard to keep up every day during allergy season.

Antihistamine

If you don’t want the dry mouth or sleepiness associated with an oral antihistamine, you can try a nose spray antihistamine. Both oral and nasal antihistamines block the histamine from causing the typical allergy symptoms.

Antihistamine nasal sprays are approved for use down to 5 years of age.

Corticosteroid sprays tend to work better in the long run, but antihistamines are effective more quickly, so are good for rapid relief.

Antihistamine nose sprays are only needed once or twice a day, but since most kids like oral medicines better than nose sprays and you shouldn’t duplicate with both, I generally recommend that antihistamines be given orally.

Decongestant

Decongestant sprays are popular because they work quickly, but I rarely recommend them. The most common time I use them is to help get things stuck in the nose out.

Oxymetazoline hydrochloride (Afrin, Dristan, Sinex) and phenylephrine hydrochloride (Neo-Synephrine) are some examples of nasal spray decongestants. They are available over the counter.

Decongestant sprays shrink swollen blood vessels and tissues in your nose that cause congestion.

They can be used temporarily in kids over 6 years old, but if you use them longer than 3 days they actually cause more congestion.

Steroid

Corticosteroid nasal sprays can be used in kids over 2 years of age and are the preferred treatment in allergy guidelines because they work well.

These can be used once or twice a day year-round or just as needed for allergy relief. It’s best to start them 2-3 weeks before allergy season starts because it does take time for them to be most effective. If you forget to use them until symptoms start, it may take several days to feel benefit.

Corticosteroid nasal sprays are available over the counter. There are many brands, including less expensive store brands. They have various steroid active ingredients, but all work pretty well.

I generally recommend the non-fluticasone brands for kids. This is not because of the effectiveness of fluticasone. It works. But it smells flowery and many kids will resist it due to the smell.

Nasal steroids are approved for use to help allergies, but they also decrease the amount of mucus from other causes, such as the common cold.

If you’re worried about the side effects of steroids, know that the risk is very low with nasal corticosteroids. The dose is extremely small and nasal corticosteroids are considered to be safe for prolonged use, even in kids.

Because they work so effectively and are well tolerated, nasal steroids are my preferred allergy medicine. They can be used with antihistamines if needed.

Anticholinergic

Ipratropium is the ingredient in anticholinergic nasal sprays. It helps to decrease a runny nose by stopping the production of mucus. One downside to ipratropium is that it doesn’t help congestion or sneezing very well.

Ipratropium nasal spray can be used over 5 years of age for up to 3 weeks at a time for runny noses from allergies and colds.

It is available by prescription only and I’ve never personally prescribed it. I personally think it has too many limitations and few benefits.

Allergen blocker

I have to admit that I’ve never even heard of this before, but I saw it on the American Academy of Allergy and Immunology site referenced above.

Alzair produces a protective gel-like barrier that evenly coats the nasal membranes and acts to block inhaled allergens within the nasal cavity. It’s available by prescription and looks like it’s approved for kids 8 and over.

One downside is that it needs to be used every time you blow your nose, so I don’t see it useful for school aged kids who have to go to the nurse for all treatments.

If anyone has used it, I’d love to hear your comments below about how it works!

Using nose sprays – it’s all about technique

Most people use nose sprays incorrectly, even if they pick the right one.

It’s not intuitive how to use them correctly. We tend to aim towards the center of the nose (which leads to nosebleeds) and inhale too much (which leads to icky drip down the throat).

Getting ready

Blow your nose. Or even better, rinse it with saline!

Take off the cap. You’d be surprised how many people skip this step.

Shake the bottle before each use. Think of Italian salad dressing. If you don’t shake it, you won’t get the good stuff.

You will need to be sure the tube inside the bottle has the liquid in it if it’s a new bottle or hasn’t been used in awhile. Much like when you get a new pump soap, you need to pump a few times to get results. Once you see the mist come out, you know the medicine’s ready to spray out.

Positioning

Be sure to keep the bottle fairly upright during the spraying. See the 1st video below for why this is important.

Many people tilt their head back when using nose sprays. Don’t. You’ll get more drip down your throat and less effective spray onto the nasal tissues.

Look slightly down.

Put the tip of the spray bottle into the nose and aim toward the back of the eye on the same side of the head. Don’t ever aim toward the center of the nose. This causes nosebleeds. Use the right hand to spray the left nostril and the left hand to spray the right nostril to help get the proper positioning.

Spraying

When the tip of the spray bottle is in your nose properly, squeeze the bottle.

Take the bottle out of your nose before releasing the squeeze. If it’s still in your nose, it will suck up whatever’s in there… including germs that can grow in the bottle.

Don’t feel like you need to inhale the stuff to your brain. The medicine works in the nose. Sniffing too much will make the medicine bypass your nasal tissue and go to the back of your throat. This misses the opportunity for the medicine to work where it’s supposed to work and it’s an icky feeling in the throat.

Sniff only enough after the spray to keep it from dripping out.

Finishing up

Wipe the top of the bottle clean before putting the lid back on.

Store the bottle out of reach of children and keep it out of the direct sunlight.

For more

I’ve always said that one day I’d make videos of how to use nose sprays and nose wash systems correctly. I know this post is about nose sprays, but if your nose is plugged with mucus, the sprays just won’t work.

Nasopure has a number of videos on how to use nose washes that I frequently recommend. I don’t get paid at all from Nasopure — I just love the bottle and their website resources. And they’re even made in Kansas City!

Until now I haven’t found a great video on how to use nose sprays. Thanks to Dr. Mark Helm, I’ve finally found a great video for how to use nasal sprays.

I’m off the hook for making videos!

I like this video from AbrahamThePharmacist. He gives great information with a fun style.

I’ve shared the video below many times because it shows just how well a good nose wash can work. I warn parents that most kids don’t love it as much as this girl does. It usually involves a lot of crying and fighting in my experience, but it is so worth it! I don’t know where she got the tip for the syringe, but I’d recommend the Nasopure bottle as shown above.

And finally, for those who think their child is too young to do a nose wash, check out this cutie! She’s in several of the Nasopure videos but she shows perfect technique here!

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!

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!

 

Remembering Medications

Compliance taking a daily medication (or vitamin) can be troublesome for many.  I find myself counseling parents and kids how to remember medicines often.

Here are my favorite tips:

Use a pill box for pills

Pill boxes come in various sizes and either single daily dosing or am/pm dosing, depending on your needs.

Pill boxes allow you to:

  • be sure you have enough for the upcoming week
  • remember if they were taken today
  • keep several types of pills for each day together if taking more than one pill

Liquid medicines

Wash the syringe after each use.

Put it where you’ll see it. Remember the medicine needs to be out of reach from kids… not necessarily the syringe!

Empty the dish drain of all contents daily so you find the syringe and remember to use it.

Or put a clean syringe in visible sight where you often look. Tape it to the milk jug. Put it in a glass next to the kitchen sink or in a glass near your coffee pot.

Grab a pen/marker and draw a “calendar” (Mon am/pm, Tues am/pm, …) on the bottle with space to check off when you’ve given the medicine each day.

Refrigerated medicines

Put the medicine on a shelf that is eye-level, right in front. Don’t let it get pushed to the back.

Return the bottle to the fridge before giving the medicine to lessen the chance you leave it on the counter.

Remind older children who can access the refrigerator that the bottle is off limits!

Keep it where you’ll see it – but out of hands of kids

Keep medicine next to something you do daily (coffee, toothbrush) only if your kids are old enough to respect that it’s medicine. Use associations if you can’t put the medicine itself there.

Make associations with other objects

Use a specific glass that is unique that goes from table to dishwasher to table and never is put away.

Every time you empty the dishwasher, put water in the glass and set it on the table for medicine.

Refill the medicine 1 week before you run out

This allows you flexibility in case you forget to pick it up.

It also allows recognition that there are no refills if that was missed, giving one week to see your doctor.

You can have enough for vacations if you routinely do this, since you can only fill one week earlier than the last fill… plan ahead if traveling!

Keep tabs on number of refills left

The pharmacist should let you know with each refill how many are left. If there are none, call right then to set your next appointment if you haven’t already.

Regular prescription medications goes hand in hand with regular follow up with your doctor to manage the medication dosing. This is important for many reasons, so I try to give as many refills that will be needed until the next visit.
Ask your doctor how they handle refills before the medicine runs out so there are no delays in treatment.

Travel

If you travel often, it helps to keep an empty pill box in your toiletry bag, so when packing it you see the empty box that needs to be filled.

Or you could put a sticky note in the toiletry bag reminding you to pack them.

Use technology

Set your phone or watch to alarm at the times the medicine is due.  Change the tone to one that is unique to remind you.

There’s an app for that! You knew there was, right? There’s an app for everything. Search your app store for a medication reminder.

Put a reminder on your calendar to call for refills and/or schedule appointments before the last minute.

Leave sticky notes around the house or in your bathroom and kitchen if you’re more old school!

If forgetting’s a problem…

Keep some medication in your purse (or at the school nurse) to take if forgotten in the morning if this might still be a problem.

Remember to not leave your purse in the car or other places the medicine will get too hot or cold or in a place your children have access to it. We don’t want them sneaking into your purse for mints and getting a medicine instead.

If the school nurse will keep some, be sure to ask for a nurse’s note when getting the prescription.

Remember to schedule your next visit!

 If able, schedule the next visit before you leave the doctor’s office.  Bring your calendar to each visit!

Call as soon as you can to schedule if you don’t have your calendar available at the doctor’s office or you were unable to schedule for any reason.

If you notice no more refills on the bottle when picking up your medicine, call that day to schedule an appointment. The later you wait, the fewer appointment times will be available. Early morning and later in the day fill first!

If you always forget to call when your doctor’s office is open, look for options for them to call you. Leave a message on their office voicemail and be sure to leave the best time frame and number to call when they return your call. Utilize online appointment requests if available.

More reminders

  • Once habits form, it is easier to remember, but until then be sure to set reminders– especially if the medication must be taken at a certain time each day or if missed doses can be dangerous.
  • Learn what to do if you forget a dose by talking with your doctor or pharmacist. Some medicines are fine to skip a dose, others are not so forgiving and must be taken as soon as remembered.


Final Thoughts on ADHD Medicines

My last post was how to start and titrate ADHD medicines. Today I’d like to discuss more of the fine-tuning issues, such as what happens if medicine isn’t taken every day, how to remember it, what to do if parents disagree about medicine, and even how to plan for travel.

Time Off ADHD Medicines

starting ADHD medicinesOnce a good dose is found, parents often ask if medicines need to be taken every day. 

Stimulants work when they work, but they don’t build up in the body or require consistent use. (This is not true for the non-stimulants, which are often not safe to suddenly start and stop.)

Some kids fail to gain weight adequately due to appetite suppression on stimulants, so parents will take drug holidays to allow better eating.

Days off the medicine also seems help to slow down the need for repeated increases in dosing for people who are rapid metabolizers.

Drug holidays off stimulants were once universally recommended to help kids eat better and grow on days off school. Studies ultimately did not show a benefit to this, so it is not necessary. Some kids suffer if they are not on medications. Behavior issues, including safety issues while playing (or driving for older kids) can be a significant problem when not medicated. Self esteem can also suffer when kids are not medicated. 

Despite the fact that some kids need daily medicine, others don’t. When kids can manage their safety and behavior adequately, it isn’t wrong to take days off. Many kids want to gain better weight, and taking a drug holiday can help with appetite.

Talk to your child’s doctor if you plan on not giving your child the medicine daily to be sure that is the right choice for your child.

Remembering the medicine

It’s difficult to get into the habit of giving medicine to a child every day.  Tomorrow’s post will be about how to remember medicines

My favorite tip is to put the pills in a weekly pill sorter at the beginning of each week. This allows you to see if you’re running low before you run out and allows you to see if it was given today or not. These medicines should not be kept where kids who are too young to understand the responsibility of taking the medicine have access.

Controlled substances

Controlled substances, such as stimulants, cannot be called in or faxed to a pharmacy. Many physicians now have the ability to e-prescribe these.

Controlled substance prescriptions cannot have refills, but a prescriber can write for either three 30 day prescriptions or one 90 day prescription when they feel a patient is stable on a dose.

Stimulants are not controlled substances because of increased risks and side effects. Some of the more significant side effects of ADHD medicines are seen in non-stimulant medicines. 

They are controlled substances because they have a street value. Teens often buy them from other teens as study drugs. This can be very dangerous since it isn’t supervised by a physician and the dose might not be safe for the purchaser. It is of course illegal to sell these medicines.

The DEA does monitor these prescriptions more closely than others. If the prescription is over 90 days old, many pharmacists cannot fill it (this will vary by state), so do not attempt to hold prescriptions to use at a later time.


Acids and Stimulants

It has been recommended that you shouldn’t take ascorbic acid or vitamin C (such as with a glass of orange juice) an hour before and after you take medication.

The theory is that ADHD stimulants are strongly alkaline and cannot be absorbed into the bloodstream if these organic acids are present at the same time.

High doses of vitamin C (1000 mg) in pill or juice form, can also accelerate the excretion of amphetamine in the urine and act like an “off” switch on the med.

In reality  have never seen this to be an issue.

If anyone has noticed a difference in onset of action or effectiveness of their medicine if they take it with ascorbic acid or vitamin C, please post your comment below.

When Mom and Dad disagree

It is not uncommon that one parent wants to start a medication for their child, but the other parent does not.

It’s important to agree on a plan, whatever the plan is.

Have a time frame for each step of the plan before a scheduled re-evaluation.

If the plan isn’t working, then change directions.

Be cautious of how you talk about this with your child. If kids know it is a disagreement, they might fear the medicine or think that needing it makes them inferior or bad.

Do not talk about the diagnosis as if it’s something the child can control. They can’t.

Don’t make the child feel guilty for having this disorder. It isn’t fair to the child and it only makes the situation worse.

Having the medicine when you need it

Refills 

There is nothing more frustrating for a parent and child than to realize that there’s a big test tomorrow and you have no medicine left and you’re out of refills.

Technically none of the stimulant medicines can have refills, but a prescription covering 90 days at a time can be given. This can be done with a 90 day prescription or three 30 day prescriptions.

The technicality of this is sometimes difficult. You cannot call your pharmacy to request a refill. You must ask to have the next prescription filled if your physician provided 3 prescriptions for 3 months.

Be sure to know the procedure for refills at your doctor’s office.

Travel

It’s very important to plan ahead prior to travel if your travel involves the timeframe of needing new medication.

You must plan ahead so that if a refill will be needed during the trip you will either be able to fill a prescription you have on vacation or you will need to fill the prescription in advance.

Most people can get a prescription 7 days prior to the 30 day supply running out but not sooner, so you might need to fill a couple prescriptions a few days earlier in the month each to have enough on hand to make it through your vacation. It takes planning!

Sometimes you can work with your physician and pharmacist to get medicines early prior to travel. Talk to your pharmacist to see if they can help arrange this.

If you are out of town and you realize you forgot your child’s non-stimulant, call your doctor to see if they can e-prescribe it. Many of the non-stimulants are not safe to suddenly stop, so they are likely to send in a prescription. Insurance is not likely to pay for these extra pills if it was recently filled.

International travel will require that you find the laws in the other country to find out if you can bring controlled substances into the country. If you will need additional medicine while you are in that country, you will need to find a way to get the medicine.

 

Mail order

Some insurance companies will allow mail order 90 day prescriptions.

There are insurance companies that not only allow, but require them on daily medicines.

Others do not allow it.

In general I advise against a 90 day prescription if the dose is not established or if there are any concerns that it might not be the perfect dose. If there is any concern that it might need to be changed, a 30 day prescription is a better option.

If you will need to do a mail order, be sure you schedule your appointment to get the prescription early enough to account for the lost time mailing.

Looking for more?

Many parents benefit from support groups to learn from others who have gone through or are currently going through similar situations, fears, failures, and successes. Find one in your area that might help you go through the process with others who share your concerns. If you know of a support group that deserves mention, please share!

ADHD

CHADD is the nationwide support group that offers a lot online and has many local chapters, such as ADHDKC. I am a volunteer board member of ADHDKC and have been impressed with the impact they have made in our community in the short time they have existed (established in 2012). I encourage parents to attend their free informational meetings. The speakers have all been fantastic and there are many more great topics coming up!

Anxiety

Many parents are surprised to learn how much anxiety can affect behavior and learning. To look for local support groups, check out the tool on Psychology Today.

Autism

The Autism Society has an extensive list of resources.

Dyslexia 

Dyslexia Help is designed to help dyslexics, parents, and professionals find the resources they need, from scholarly articles and reviewed books to online forums and support groups.

Learning Disabilities 

Learning Disabilities Association of America offers support groups as well as information to help understand learning disabilities, negotiating the special education process, and helping your child and yourself.

Tourette’s Syndrome and Tic Disorders 

Tourette’s Syndrome Association is a great resource for people with tic disorders.

General Support Group List 

For a list of many support groups in Kansas: Support Groups in Kansas .

School information

Choosing schools for kids with ADHD and learning differences isn’t always possible, but look to the linked articles on ways to decide what might work best for your child. When choosing colleges, look specifically for programs they offer for students who learn differently and plan ahead to get your teen ready for this challenge.

Midwest ADHD Conference – April 2018

Check out the Midwest ADHD Conference coming to the KC area in April, 2018. I’m involved in the planning stages and it will be a FANTASTIC conference for parents, adults with ADHD, and educators/teachers.

Midwest ADHD Conference
The Midwest ADHD Conference will be held in April 2018, in Overland Park, Kansas.


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ADHD Medications: Starting out and titrating

I have spent many days covering a lot about learning and behavioral problems. Topics covered include why and how to get these issues diagnosed, who is involved in the diagnostic process, and treatment options with diet, supplements, and alternative treatments. Yesterday I covered what prescription medications are typically used and side effects they may cause. Today I’ll discuss common ways to choose a medicine, how to titrate it to a proper dose, and when to change to something else.

Tomorrow will discuss final thoughts on how to remember medicines, if it’s okay to take days off, and what to do if parents disagree about the treatment plan.

Getting Started


starting ADHD medicinesThe first step in treating ADHD is getting a proper diagnosis. This should be done with input from parents and teachers since symptoms should be present in at least two settings. ADHD symptoms overlap with many other conditions, and if the diagnosis is not correct, medications are more likely to cause side effects without benefit.

Do not jump into medication until the symptoms have been fully evaluated and a proper diagnosis is made according to DSM criteria.

Stimulant medicines

Stimulant medicines are considered first line treatment for ADHD in kids over 5 years of age.

There are short acting and long acting formulations available for each type of stimulant. There are advantages and disadvantages to each.

Short acting medications tend to last about 4 hours, so can be given at breakfast, lunch, and after school, allowing for hunger to return as each wears off to help kids maintain weight. Short acting stimulants are often used later in the day after a long acting stimulant wears off for teens who need longer coverage.

Long acting medicines tend to last between 6 and 12 hours, depending on the medicine and the person’s metabolism. The benefit is that people don’t need a mid-day dosing, which for school kids means avoiding a daily trip to the school nurse. This can be socially unacceptable for older children. It is also easier to remember once/day medication versus multiple times/day dosing. The downside is that some children don’t eat well midday with long acting medicines.

Which stimulant medicine to choose?

Methylphenidate vs Amphetamine

While some children respond better to methylphenidates, others to amphetamines, some do equally well on either, and some cannot tolerate either.

It is not possible to predict which children will do best on any type, but if there is a family history of someone responding well (or not) to a medicine, that should be taken into consideration of which to start first.

Swallowing Pills

Another thing to consider is whether or not a child can swallow a pill.

Some of the medicines must be swallowed whole.

If you aren’t sure if your child can swallow a pill, have them try swallowing a tic tac. Use a cup with a straw, since the throat is narrowed when you tilt your head back to drink from an open cup.

Another option is to put it in a spoonful of yogurt or applesauce and have your child swallow without chewing.

If your child cannot swallow a tic tac, you can choose a medicine that doesn’t need to be swallowed.

Some come in liquid or chewable formulations. Some capsules can be opened and sprinkled onto food, such as applesauce or yogurt. There is a patch (placed on the skin) available for the methylphenidate group.

Genetic testing

I’ve met many parents who request “the lab to say which medicine will work best.”

There is no lab that does this.

Many companies promote that their genetic test can predict which medicine will be best tolerated, but in truth they do not predict which will work best to maximize treatment and minimize side effects.

There are pharmacogenetic tests that will help to identify if a person has an issue with metabolism that would require a higher or lower than typical dose, but it does not tell which medicine will work best. It also doesn’t verify the diagnosis, so if the diagnosis is incorrect, no medicine is the right one.

Pharmacogenetic testing for ADHD (and other conditions) is still relatively new. It has the potential to significantly change the medication treatment process, a term called Personalized Medicine. Personalized medicine needs to be further validated and its precision improved before it becomes mainstream.

Insurance

I would love to say that cost shouldn’t matter, that we pick the medicine based purely on medical benefit, but cost does matter. Insurance often dictates which medicine we choose. 

Before you go to the doctor to discuss starting medicine look at the formulary from your insurance company. All other things being equal, if one medicine is not covered at all (or is very expensive) and another is covered at a lower tier, it is recommended to try the least expensive option first.

Of course, if the least expensive medicine fails, then a more expensive one might be the right choice. 

Not knowing which will work best in any individual, choosing the least expensive makes sense. Sometimes all approved medications for ADHD are expensive. If that’s the case, see Affording Medications for tips on finding the best price.

Generics historically have been the least expensive, but that isn’t always the case. You must know your insurance formulary to know the cost.

The ADHD Medication Guide is a great resource to look for generics (marked with a “G”), which must be swallowed whole or can be opened or chewed (see the key on page 2).

Age indications

The age indications listed on page 2 of the ADHD Medication Guide are those that have FDA approval at the ages listed, but there are many times that physicians use medicines outside the age range listed.

Some do not even have an age indication listed. These ages are due to testing results, and can be limited because one age group might not have been tested for a specific medicine.

Note that the 17 year and adult medicines are different. Is there really a difference between a 17 and an 18 year old? Not likely.

start low and titrate to best effect

In general it is recommended to pick one of the stimulant medicines and start low and titrate to best effect without significant side effects.

Feedback on how the child is able to focus and stay on task, and reports of other behavioral issues that were symptoms in the first place should be received from teachers and parents, as well as the child if he is able.

There are many things to consider that affect focus and behavior that are not due to the medicine: sleep, hunger, pain, illness, etc. It takes at least a few days to identify if the medicine is working or not or if other issues are contributing to the focus and behaviors.

The younger the child is the longer I usually advise staying on a dose so a parent has a chance to hear from the teacher how things are going. I usually don’t increase faster than once/week in younger kids.

I rely more on the student’s report in middle and high school, since those students can be more insightful and they have so many teachers throughout the day that most teachers are not as helpful. Older students who are in tune with their problems and how they are responding to the medicine might be able to increase every few days, as long as there are no confounding factors that could influence symptoms, such as change in sleep pattern, big test or other stressor, or illness.

Finding the right dose

It is recommended to start with one of the two main classes of stimulants with a low dose, and slowly increase to find the best dose.

Continue to increase until either symptoms are well controlled without significant side effects or side effects won’t allow another increase.

If that stimulant doesn’t work well or has side effects that are not tolerated, then change to the other class of stimulant.

If that one does not work, you can try a different medicine from the class of stimulant that worked best.

If the third medicine doesn’t work, then a non-stimulant can be tried.

I recommend re-evaluating the original diagnosis if the third medicine doesn’t work, since ADHD might not be the cause of the issues and finding the right cause can lead to a better treatment.

Titrating the medicine goes something like this:
  • If symptoms are well controlled and there are no significant side effects, the medicine should be continued at the current dose.
  • If symptoms are not well controlled and there are no side effects that prohibit increasing, the dose should be increased as tolerated.
  • If symptoms are not well controlled (i.e. room for improvement) but there are side effects that prohibit increasing the medicine, consider a longer period of watching on this dose versus changing to a new medicine.

 

Before your visit:

Before you meet with your physician to discuss a new ADHD diagnosis or a possible change in treatment plan, be sure to get the following information and have it available at the visit or the visit will not be as productive as you desire:

  • Insurance formulary
  • Standardized testing from teachers, parents, and other significant adults
  • Verify if your child can swallow a tic tac or pill
  • Any contributing family history (family member responses to medications, family history of heart issues, etc)
Tomorrow there will be more on fine tuning ADHD medications.

Looking for more?

Many parents benefit from support groups to learn from others who have gone through or are currently going through similar situations, fears, failures, and successes. Find one in your area that might help you go through the process with others who share your concerns. If you know of a support group that deserves mention, please share!

ADHD

CHADD is the nationwide support group that offers a lot online and has many local chapters, such as ADHDKC. I am a volunteer board member of ADHDKC and have been impressed with the impact they have made in our community in the short time they have existed (established in 2012). I encourage parents to attend their free informational meetings. The speakers have all been fantastic and there are many more great topics coming up!

Anxiety

Many parents are surprised to learn how much anxiety can affect behavior and learning. To look for local support groups, check out the tool on Psychology Today.

Autism

The Autism Society has an extensive list of resources.

Dyslexia 

Dyslexia Help is designed to help dyslexics, parents, and professionals find the resources they need, from scholarly articles and reviewed books to online forums and support groups.

Learning Disabilities 

Learning Disabilities Association of America offers support groups as well as information to help understand learning disabilities, negotiating the special education process, and helping your child and yourself.

Tourette’s Syndrome and Tic Disorders 

Tourette’s Syndrome Association is a great resource for people with tic disorders.

General Support Group List 

For a list of many support groups in Kansas: Support Groups in Kansas .

School information

Choosing schools for kids with ADHD and learning differences isn’t always possible, but look to the linked articles on ways to decide what might work best for your child. When choosing colleges, look specifically for programs they offer for students who learn differently and plan ahead to get your teen ready for this challenge.

Midwest ADHD Conference – April 2018

Check out the Midwest ADHD Conference coming to the KC area in April, 2018. I’m involved in the planning stages and it will be a FANTASTIC conference for parents, adults with ADHD, and educators/teachers.

Midwest ADHD Conference
The Midwest ADHD Conference will be held in April 2018, in Overland Park, Kansas.


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ADHD Medications: Types and side effects

I have spent several days on the diagnosis of learning and behavioral problems and non-medical, dietary and supplemental treatments that can be used for these issues. Today I will focus on the types of prescription medications used primarily for ADHD as well as their side effects. Tomorrow will cover how to get started on a medication for ADHD.

Approved vs not approved medicines

There are many treatments out there that are not approved for the purpose they are used. This sounds scary, but if done properly might be a good consideration.

Physicians sometimes use treatments that have not been approved for the purpose or an age group because they know from general experience that it works or they are at a loss from approved treatments failing and they need to try something else.

One example is using a shorter acting form of guanfacine (Tenex) that has not been approved to treat ADHD, but it has some advantages over the longer acting form (Intuniv) that is approved for ADHD. The short acting form can be broken, allowing slower titration of dose changes. The long acting form cannot be broken.

Another common example is the use of albuterol, a medicine that helps breathing with conditions that cause wheezing. It is not approved for use under 2 years of age, but it is commonly used for younger children with difficulty breathing — and it helps them breathe, which might keep them out of the hospital and off of supplemental oxygen.

I do not think that all non-approved medicines are good or bad. It is a very individual decision of what medicines to use. Discuss with your doctor if a treatment is approved or if they are using something that is not. Although this is relatively common among people who treat children because many drugs have not been tested in children and have been “grandfathered” into use through experiences that show benefit, be sure the provider is not picking something that has no basis or supporting evidence, especially if he or she profits from the treatment.

Be very wary of anyone who promises a cure – if one really existed everyone would use it.

Medications approved to treat ADHD


When a medication is needed to control symptoms of ADHD, the first line medications are the stimulants unless there are contraindications. Non-stimulant medications are not found to be as effective as stimulants in the majority of children, but they do have a place in the treatment plan for some children. They are sometimes used in addition to stimulants for optimal results.

For information on these medicines, see A Guide to ADHD Medications. It reviews how stimulants act on dopamine and norepinephrine and various time release patterns of different medicines.

ADHD medication guide
ADHD Medication Guide

I love the ADHD Medication Guide (different from the similarly named post above) because it lists the medicines approved to treat ADHD in a colorful chart that groups the medicines in an easy-to-read format.

Categories of Medicines used for ADHD:

Stimulants
  • Methylphenidates (Aptensio©. Ritalin©, Focalin©, Concerta©, Daytrana©, Metadate©, Quillivant©)
  • Amphetamines (Adderall©, Vyvanse©, dexedrine)
Non-stimulants
  • Atomoxetine (Strattera©)
  • Guanfacine (Intuniv©)
  • Clonidine (Kapvay©)
  • Others are used off-label (no FDA approval for the purpose of ADHD treatment): Tenex, Catapres patch, antidepressants, and antipsychotics

Side Effects

Parents usually worry about medication side effects. This is a very legitimate concern, but must be balanced with the risks of not treating. Overall the medicines listed above are very well tolerated.

If a child has side effects to one stimulant, they can usually do well on a different class (methylphenidate vs amphetamine). When neither type is tolerated, a trial of a non-stimulant is indicated. If this isn’t tolerated, reconsider the ADHD diagnosis.

I often hear concerns that parents don’t want their kids changing their personalities or becoming “zombies”. If the right medicine is used at the appropriate dose, this is usually not a problem.

Finding that right medicine and right dose might take some trial and error. Work with your prescriber to get to the right one for your child.

Most commonly observed side effects of stimulants:

Decreased appetite

Appetite is often low in the middle of the day and more normal by supper time if kids take a long acting stimulant.

Good nutrition is a priority. Encourage kids to eat the healthy “main course” first and leave the dessert out of the lunchbox. They should have healthy snacks (think of mini-meals) after school when they get hungry.

Short acting meds improve mid day appetite since they wear off around lunch time. The downside is the child needs to take a dose around lunch time at school.

Kids are often very hungry in the evenings when medicines wear off, so encourage healthy foods at that time.

I have seen some kids who have a really hard time off medicine sitting down to eat. These kids actually gain weight better on medicine because they can finish the meal.

Some kids can improve their appetite with an appetite stimulant. I often use cyproheptadine if weight drops too much in a child. It works best if it is not used every day. I will have kids skip their cyproheptadine at least a couple days each week.

Insomnia

Trouble sleeping is common with ADHD — with or without medicines.

If it is due to the stimulant medicine still being active, trouble sleeping may be relieved by taking it earlier in the day.

If the child’s brain is too active in the evenings because the medicine wears off, learning relaxation exercises can help. Check out the Winding Down section of Sleep Tips for more details.

Increased irritability

Moodiness is especially common as the medication wears off in the afternoon or evening and in younger children.

It makes sense if you consider that all day they are able to focus and think before acting and speaking, but then suddenly their brain can’t focus and they act impulsively.

Typically kids learn to adjust to the medicine wearing off as they mature.

Sometimes just giving kids 30 minutes to themselves and offering a healthy snack can help.

Cognitive behavioral therapy can help.

Anxiety

Anxiety does occur with ADHD and might be under-appreciated before the ADHD symptoms are treated.

Symptoms of anxiety are often missed. They can include avoidance, irritability, moodiness, somatic complaints (headache, stomach ache), and more. HeySigmund has a great list of subtle anxiety symptoms.

When kids can focus better, they might focus more on things that bother them, increasing anxiety and making it more apparent.

It is also possible that anxiety is misdiagnosed as ADHD, which is one reason for stimulant medication failure.

If you notice signs of anxiety, talk to your child’s doctor and/or therapist.

Mild stomach aches or headaches

Stomach aches and headaches are occasionally noted with stimulant medications. It is my experience that they are most common with a new medication or a change in dose.

Because these have many causes, it can be hard to determine if they are really from the medicine or another cause.

If they persist with the medicine, changing to another medication might help.

Tics

Tics are related to treated and untreated ADHD.

People with ADHD are more likely to have tics than the general population.

It was once thought that tics were caused by the stimulant medicines, but it is now thought that they happen independent of the medicine, and medicines might even help treat the tics.

Growth

Weight gain can be difficult for some kids on stimulant medications due to the appetite suppression on the medicine.

Studies have shown a decreased final adult height of about 1-2 cm (1/2 – 1 inch). For most people this small height difference is not significant compared to the benefits in self esteem, academics and behavior children gain on stimulants.

 

Rare side effects of stimulants

Hallucinations

I have only seen two children who could not tolerate stimulants due to hallucinations, but it is very scary for the family when it happens.

Unless there is a significant family history of them, I don’t know a way to predict which child is at risk.

These are a contraindication for continuing that medication, but another type of stimulant or medication can be considered.

Heart issues

Cardiac (heart) problems are overall a rare complication of stimulants and often times are not a contraindication to continuing the stimulant medicine.

There is a small increase in blood pressure and heart rate, both of which should be monitored regularly while on treatment and if the treatment is stopped.

A cardiologist should be considered to further evaluate a patient prior to starting a stimulant if there is any of the following:

  • Shortness of breath with exercise not due to a known non-cardiac cause, such as asthma
  • Poor exercise tolerance compared to children of the same age and conditioning
  • Excessively rapid heart rate, dizziness, or fainting with exercise
  • Family history of sudden cardiac death or unexplained death (such as SIDS)
  • Family or personal history of prolonged QT syndrome, heart arrythmias, cardiomyopathy, pulmonary hypertension, implantable defibrillator or pacemaker

side effects for the non-stimulants:

Atomoxetine

Atomoxetine can cause initial gastroesophageal complaints (abdominal pain, decreased appetite), especially if the dose is started too high or if it is increased too rapidly.

It can also cause tiredness and fatigue when it is first started or if the dose is increased too quickly.

It can increase the blood pressure and heart rate, both of which should be monitored regularly during treatment with atomoxetine.

There is an increased incidence in suicidal thoughts, though uncommon, so children should be monitored for mood issues on this medication.

A rare complication of atomoxetine is hepatitis (inflammation of the liver with yellow jaundice and abnormal liver function labs). The hepatitis resolves with stopping the atomoxetine.

Guanfacine and clonidine

Guanfacine and clonidine both cause fatigue and tiredness, especially when first starting the medication or with increases in dose.

Both of these medications can lower the blood pressure and heart rate, and these should be monitored closely while on guanfacine or clonidine, especially when first starting and increasing dose.

Handouts for medicines

I absolutely love the handouts that Dr. Nerissa Bauer has made for ADHD medications. Click on the image’s caption to go to her website’s page for that handout. The two stimulant classes are first, followed by the non-stimulants.

amphetamine adderall vyvanse
Amphetamines

Amphetamines (Adderall, Adderall XR, Vyvanse, amphetamine mixed salts, Dexidrine, Zenzedi)

 

 

 

ritalin concerta apetnsio metadate
Methylphenidate

Methylphenidate (ritalin, Aptensio XR, Concerta, Metadate CD or ER, Focalin, Daytrana)

 

 

 

strattera, atomoxetine
Atomoxetine

Atomoxetine (Strattera)

 

 

 

clonidine
Clonidine

Clonidine (Catapres, Kapvay)

 

 

 

guanfacine intuniv tenex
Guanfacine

Guanfacine (Intuniv, tenex)

 

 

 

Next up:

Tomorrow’s blog will be about how to choose a medicine to start and how to titrate it to find the best dose.

Looking for more?

Many parents benefit from support groups to learn from others who have gone through or are currently going through similar situations, fears, failures, and successes. Find one in your area that might help you go through the process with others who share your concerns. If you know of a support group that deserves mention, please share!

ADHD

CHADD is the nationwide support group that offers a lot online and has many local chapters, such as ADHDKC. I am a volunteer board member of ADHDKC and have been impressed with the impact they have made in our community in the short time they have existed (established in 2012). I encourage parents to attend their free informational meetings. The speakers have all been fantastic and there are many more great topics coming up!

Anxiety

Many parents are surprised to learn how much anxiety can affect behavior and learning. To look for local support groups, check out the tool on Psychology Today.

Autism

The Autism Society has an extensive list of resources.

Dyslexia 

Dyslexia Help is designed to help dyslexics, parents, and professionals find the resources they need, from scholarly articles and reviewed books to online forums and support groups.

Learning Disabilities 

Learning Disabilities Association of America offers support groups as well as information to help understand learning disabilities, negotiating the special education process, and helping your child and yourself.

Tourette’s Syndrome and Tic Disorders 

Tourette’s Syndrome Association is a great resource for people with tic disorders.

General Support Group List 

For a list of many support groups in Kansas: Support Groups in Kansas .

School information

Choosing schools for kids with ADHD and learning differences isn’t always possible, but look to the linked articles on ways to decide what might work best for your child. When choosing colleges, look specifically for programs they offer for students who learn differently and plan ahead to get your teen ready for this challenge.

Midwest ADHD Conference – April 2018

Check out the Midwest ADHD Conference coming to the KC area in April, 2018. I’m involved in the planning stages and it will be a FANTASTIC conference for parents, adults with ADHD, and educators/teachers.

Midwest ADHD Conference
The Midwest ADHD Conference will be held in April 2018, in Overland Park, Kansas.


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Pill Swallowing Tips

One of the biggest challenges for some people (not just kids) is swallowing pills. At some point transitioning to pills is important. Some medicines don’t come in liquid or chewable form – and if they do, they might taste awful. Some kids simply get so big that the volume of liquid they need to choke down becomes difficult.

Kids often don’t like the taste of medicine.

pill swallowing, medicinesWhen my son was a preschooler, I realized that he swallowed some things whole ~ usually things he didn’t like, like a piece of meat. He sometimes needed oral steroids for wheezing. Steroids in liquid form are notoriously nasty. He would vomit it back up most of the time. The tablets are really small, so I decided to have him try those once. Easy as pie for him! I don’t think we even had to practice. I just told him to not chew because it would taste bad and he knew what to do. I think he was so young, he didn’t know that he should be scared of choking.

If only most people could teach themselves …

Despite it being difficult to learn, most people can learn to safely swallow pills. Once the technique is learned, the size and the shape of the pill isn’t usually an issue.

Don’t wait until they have an illness to start because no one wants to learn anything new when sick. Once they get the technique, be sure to do it often enough that they don’t forget until they need to use it.

There are many tricks people use to swallow pills.
http://www.letstalkkidshealth.org/2018/02/25/learning-to-swallow-a-pill-tips-for-your-child-to-become-a-pro/
Dr. Nerissa Bauer made this easy-to-read handout to help learn to swallow pills.

What works for one doesn’t work for another.

If your child isn’t willing to give it a try, it’s really not worth it. Since this is a mind over matter thing, it will be impossible if they’re not on board. If they’re not ready, every once in a while you can mention how big of a bite of food they just ate and comment that they swallowed it easily. Remind them to let you know when they want to try to swallow a small piece of candy. (For many the temptation of extra candy is an automatic selling point.)

When I had to teach my daughter to swallow pills, I bought a container of Tic Tacs and told her that when she could swallow 3 in a row without choking, she could have the rest and eat them without permission unless she already brushed her teeth at night. She loved that idea and took to the challenge excitedly! She swallowed the first three without a problem. Again, it’s not always that easy.

Teach medication safety and proper use along the way.

Never practice with real medicine, even if it’s over the counter stuff. Kids should know that they’re practicing without real medicine.

At the same time as teaching them to swallow pills you can talk about medication safety: only take it when an adult says it’s okay, keep it away from other children, never share medicine with others, take it as the doctor prescribed if it is a prescription, and how and when to use over the counter medicines.

When you’re giving medicine, talk about what it is and what it’s for. I’m often surprised at college aged teens not knowing what common medicines are used for if they have aches and pains or illness. They need to know!

Start small and work up.
pill swallowing
Practice with cake decorating pieces or small candies.

For kids who are very hesitant, it’s possible to start very small and work up to a standard pill size.

Start with cake decorating beads, balls or sprinkles. Avoid the ones that are very lightweight because they might float and not go down as easily. Most kids agree that something very small will be easy to swallow. Have them show you they can. Build confidence by starting really small so they have a good first try.

If you don’t want to add all that sugar and food coloring, use bread. Break off a very small piece and roll it into a small ball. Slowly increase the size of the bread balls as your child is successful swallowing.

Keep working your way up to a size that resembles most medicines, such as a tic tac.

If a child fails a size, go back down to the smaller size to gain confidence.

Don’t spend more than 10-15 minutes each session. If the child tires or the stomach fills with too much water, it will be non-productive.

Remember to praise any successes.

Always end on a positive note by having the child swallow whatever size he can. So if it’s unsuccessful to move to a larger size, have him go down a size, swallow successfully, then don’t go up again at that session.

You can always try again another day.

Straw Method.

Different people like different positions for swallowing pills.

Some do best with their head back, as is typical with drinking from a cup, so the pill has a straight shot down.

Others do best with the head turned to one side or another.

Some even change their preference over time.

For those who prefer to have the head neutral or a bit forward, using a straw avoids having to tilt back to drink.

Have your child put the candy on the front half of the tongue, then drink out of a straw with the straw at the front of the tongue so the liquid comes out in front of the pill. Some people say to put the tablet as far back as possible, but I think that can trigger the choking reaction, which is not helpful at all.

Tell them to focus on the drink, not the tablet.

Most of the time the pill will naturally go down with the liquid without even thinking about it.

If you like to be green and don’t want to fill a landfill with plastic straws, check out these fantastic glass straws. (I don’t typically endorse products, but this is an entirely unpaid endorsement. We’ve had these straws for years. They go in the dishwasher daily. We’ve dropped them from table height. They still look brand new. We love them for many reasons, and since we use straws all the time, I don’t feel guilty about our environment.)

Hidden pills.

Some people feel more comfortable swallowing food than pills, so putting a pill in a soft food helps. Common foods are yogurt and applesauce. I’ve even heard of parents putting the pill at the top of a yogurt tube, and having the child suck down the yogurt.

The biggest issue with this method is that if a child takes too long to take it, the tablet or capsule might start to break down, and then the child can notice the taste (which is often bitter).

Remind the child to not chew the food first because most medicines meant to be swallowed should not be chewed. Best case scenario, is just the bitter taste, but it could disrupt the absorption and benefit of the medicine if it’s chewed.

Research proven techniques

For more help on learning to swallow pills, check out these videos that show how to swallow pills in different positions. Kids might like to see the techniques themselves before they practice.

 

 

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Affording Medications

Another family called this week to ask if I could change their daughter’s asthma prescription to something cheaper. After looking into their insurance plan’s formulary, there really wasn’t anything cheaper. Every inhaled corticosteroid (which is the first-line medicine recommended to prevent asthma attacks) was expensive – even the generics. This family has to either find a less expensive way to purchase the prescription, choose to leave their child undermedicated, or pay over $300 per month for an asthma preventative medicine. Of course if they don’t give this medicine they risk ending up in the ER in the middle of the night. ER’s are expensive and if it’s a needed trip, it means their child is suffering.

Insurance companies make it hard.

On one hand insurance companies want patients to take the medicine appropriately to decrease long term costs of disease management. They even remind doctors to consider certain medicines if a patient has certain diagnoses and prescriptions haven’t been filled or if follow up appointments haven’t occurred.

On the other hand, they’re pricing many medicines out of reach for many families.

Transparency is a goal for healthcare, but it isn’t there, as Dr. Melissa Welby explains.

What can you do?

Check your formulary

When shopping for new insurance look at the formulary if anyone in your family is on a chronic medication. You will have to talk to an insurance company representative since formularies aren’t publicly displayed anywhere and they’re specific to your plan. This isn’t foolproof because formularies change on a regular basis, but at least learn what they currently have and what your costs would be.

Before doctor visits where you know you’ll be getting refills, check your formulary to see if it has any changes. You can usually log into your insurance company’s website to see your plan’s information.

See if you qualify for Patient Assistance Programs.

These are programs run by drug companies and other organizations that give free medicine to people who can’t afford to pay for them.

You can learn more about these on NeedyMeds, Partnership for Prescription Assistance and RxAssist.

You can also do an online search for “patient assistance program” along with the medicine name.

Shop around.

Look at GoodRx and WeRx to search local pharmacy cash pricing with their coupons. This doesn’t give the cost that your insurance will allow, but you can see how much it would cost with cash and compare to insurance cost. Sometimes it’s cheaper to not use insurance but see if the coupon will work with your insurance and compare costs.

Look at your insurance plan to see which pharmacy they prefer. I’ve had issues with this myself and I’m not sure if this is always helpful.

Get a Drug Discount Card or Coupon.

These can be used by anyone regardless of income or insurance plan. See MoneyCrashers for a nice summary on how discount cards work and when to use them.

You often can’t use insurance when you use the discount card, so you have to look at your deductible and calculate if it’s better to pay more until you meet your deductible and then get things inexpensively/free or if saving the money but not contributing to your deductible is better.

These cards can be used to help buy over the counter medicines (with a prescription) as well as prescription medicines. I think you can even get cards for your pet prescriptions.

To find drug discount cards, look at NeedyMeds, RxAssist, GoodRx, WeRx or the drug company’s website. I find it easiest to search the drug name and coupon together when looking for discounts.

I have a love-hate relationship with discount cards.

If people can’t otherwise afford a prescription (name brand or generic) then a coupon might help them purchase a needed medicine, but we all pay in the end.

Coupons are offered by manufacturers because they increase the sales of brand-name drugs by 60% or more by reducing generic sales. These programs increase drug spending by $30 million to $120 million per drug (and this study is several years old- coupons are increasingly being used so this might underestimate current spending).

Coupons can help people afford medicines, at least temporarily, but they increase insurance costs overall. If you use your insurance plan with the coupon, your insurance company pays more than they would if you purchased a generic, and they pass that cost on to consumers.

The money you spend doesn’t apply to your deductible if you don’t use insurance. Then insurance companies get off without having to pay for your medicines despite the fact that you pay them monthly to help cover your healthcare. I guess the good news is that if you don’t use insurance it doesn’t increase next year’s premium. But they might see you as “high risk” if you don’t fill recommended prescriptions, so that still might affect costs in the end.

Talk to your doctor.

Of course, it all starts with the prescription itself.

When your doctor is writing the prescription, openly discuss cost concerns. Ask about brand vs generic substitutions in the same class of medications that might be available.

We cannot know your specific formulary, but we can try to help you find the cheapest option. Electronic Health Records sometimes link to insurance formulary information to give an idea of which tier a medication is on. I find this works some of the time. Sometimes it isn’t accurate. People still get to the pharmacy and suffer from sticker shock when they’re told the cost. This is why I think it’s so very helpful if you find your formulary before even going to your appointment. It can save a lot of back and forth at the pharmacy if we have the costs at the appointment.

If you get to the pharmacy and cannot afford the medicine, be sure to let your doctor know! We want to help but we can’t if we don’t know the issues.

Affording medications can be difficult, but there are things to do that can help.
Affording medications can be difficult, but there are things to do that can help.