Pharmacogenetic Testing: Personalized Medicine

Pharmacogenetic testing involves testing a person’s genetics to find out how a certain drug would work in that person. Learn the pros and cons of this testing.

I’ve recently seen increasing numbers of parents who want testing to decide which medication to use for their child’s condition before trying any medicines. Many admit that they don’t know much about it and want to learn more. Pharmacogenetic testing involves testing a person’s genetics to find out how a certain drug would work in that person. While that sounds like it would be fantastic to know, it has many limitations. We’ll talk about the pros and cons below.

Traditional dosing of medicines

Before they can be approved to be used, drugs are tested in large groups of people.

Dosing schedules are determined based on safety and efficacy of the medicine, but this is in a group. It relies on information gathered from a mass of people, and majority rules. This means that whatever works for most people is what becomes the recommendations.

Although this works for most people, any individual can have a variation that is not seen with the large numbers in a group. We all know people that can’t tolerate certain medicines. In the past we use family patterns to help predict tolerability. If a family member (or especially if multiple family members) report that certain medicines require lower or higher doses to be tolerated and effective, then we use that in our decision making for prescribing medicines. Of course it isn’t a perfect way to do things, but it can help.

What is pharmacogenetic testing?

Pharmacogenomics is the study of how genes affect a person’s response to drugs. It’s a growing field that involves using what we know about the person’s genetic make up and how they will metabolize a medication. This can allow the prescriber to use certain medicines and not others, or begin with overall higher or lower doses than standard recommendations suggest.

It is personalized to a person’s genetic makeup, so it’s often called personalized medicine or precision medicine.

Many medicines work well for most people, but there are people who will metabolize certain things slowly, allowing the medicine to build up to toxic levels when dosed per standard amounts. Other people may require higher doses due to a very rapid metabolism. Some people should avoid certain medications all together. Knowing these dose adjustments and risks before even starting a medicine could be very beneficial!

Certain proteins affect how drugs work. Pharmacogenetic testing looks at differences in genes for these proteins. These proteins include liver enzymes that chemically change drugs. These changes can make the drugs more or less active. Even small differences in the genes for these liver enzymes can have a significant impact on a drug’s safety or effectiveness.

What are some uses in general pediatrics?

I’m limiting this discussion to uses that a general physician would use this type of testing. There are other uses for chronic diseases that are managed by specialists and beyond my scope.

Please realize that these are the commonly requested uses, not recommended uses.

ADHD

The most common time that I’m asked about this type of testing is for kids with ADHD.

Many parents are afraid of side effects of stimulants and have heard of other children who needed many adjustments of medication, both type of drug and dosing.

Starting a new stimulant medication can be frustrating, especially if it takes weeks or months to find what works. Parents would like to avoid that and start with the best.

Unfortunately the tests currently available do not predict which medicine will be most effective. They test how it will be metabolized.

Many people who show best tolerability for a certain drug may find that drug ineffective in managing their symptoms. This is due to many factors, but in the end still leaves us with the need to do a trial of various medicines to find the best one.

Failure to find a beneficial medicine based on these trials may lead to reassessment to be sure the diagnosis is correct. Proper diagnosis is not tested with the pharmocogenetic tests.

Anxiety and depression

Anxiety and depression medications are another type of medicine that has many options, and some respond to one better than another.

The traditional way to start is to look at family history (which is also a study of genetics, although included in the cost of your visit and doesn’t include a lab). Unfortunately, many people do not know of family member’s specific health details, especially what medicines they were on and what their reactions were.

When we pick a medicine, we start with low doses, and increase as tolerated and needed. If the first medication doesn’t work or isn’t tolerated, it is stopped and another is tried. This can prolong the time it takes to feel better, which is significant, and likely the reason people want a quick answer with a lab test.

Unfortunately, much like the ADHD testing mentioned above, the tests don’t predict which medicine will manage symptoms best. They only predict how they will be metabolized.

Should you get tested?

I am excited for the future of personalized medicine.

We may no longer need to try multiple medicines to be able to see which are better tolerated. Starting near the target dose, rather than starting at a low dose and titrating up, which prolongs the time it takes to get to an effective dose, would be welcomed in many people.

Unfortunately, I think psychopharmalogical testing is not yet for prime time.

The FDA agrees. They’ve sent out warnings that these tests should not be used to help choose a medicine.

Just because your body will metabolize a medicine more slowly or rapidly doesn’t predict if it will be effective to treat your symptoms.

It is still very costly and insurance companies resist paying for it. With high deductible plans, many people must pay the cost. With the new FDA warning, it is unlikely that insurance companies will cover the cost of these tests anytime soon.

It is being widely used in cancer and HIV patients and has helped to prevent significant side effects that often lead to hospitalization. From an insurance company standpoint, they’re saving money by covering the test for these purposes. From a patient standpoint, they have added security that they will respond well to the treatment.

For more:

Pharmacogenomics and Personalized Medicine By: Jill U. Adams, Ph.D. (Freelance science writer in Albany, NY) © 2008 Nature Education Citation: Adams, J. (2008) Pharmacogenomics and personalized medicine. Nature Education1(1):194

ADHD Medicines: Starting out and titrating

Can pharmacogenetic testing save time and money when choosing a new medicine? Personalized medicine is exciting, but is it ready for prime time?

Top 10 Quest for Health KC posts of 2018

Have you read all of the most popular 2018 posts from Quest for Health KC?

At the end of the year I like to take a look at which posts were popular to help identify what I should write about in the next year. It also gives me the opportunity to share with readers all the best posts they might have missed along the way.

10. Help! I’m sick and I have a baby at home!

Parenting is a tough job, even when you’re not sick. When you have an infant and you’re sick, not only do you have extra sleep needs, but you have to try to keep your baby healthy despite being around your germs. What can you do when you’re sick with a baby at home?

9. Top 10 reasons a child or teen is tired.

We all know the jokes about that teens sleep past noon, but the truth is they need to catch up on sleep deprivation. Learn the top 10 reasons a child or teen is tired.

8. Summer Penile Syndrome

During the summer months one of the most uncomfortable reasons I see boys is that their penis and/or scrotum is swollen significantly. Learn what Summer Penile Syndrome is and what to do about it.

7. Dark Under Eye Circles

When kids have circles under their eyes, parents worry that something’s wrong. Sometimes there’s a treatable reason, sometimes not. Learn all the most common causes of under eye circles and what to do about them.

6. The flu shot doesn’t work

I’m pro-vaccine, so this title might surprise you. I hear the argument that the flu shot doesn’t work so often that it deserves to be addressed.

5. Flu Season Fears: What should you do?

Every flu season as we start to hear reports of kids dying from influenza the fear surfaces. This was written during one of the worst outbreaks in recent history. Be protected against each flu’s season fear with a flu vaccine and healthy habits!

4. Antibiotic Allergy or Just a Rash?

We see rashes all the time when kids are on antibiotics, but thankfully most do not mean a child is allergic. Learn when to suspect antibiotic allergy versus just a rash.

3. Lip Licker’s Dermatitis

When saliva gets on our skin, it breaks it down. Licking the lips leads to increased cracking and bleeding. Some kids have a wide ring of dry skin around their mouth from lip licker’s dermatitis. Learn what you can do to help them heal their smile.

2. What happens if a vaccine booster is delayed?

There are many reasons that people fall behind on their vaccines. Some are intentional, some due to circumstance. Regardless of the cause, what happens if a vaccine booster is delayed?

1. Bumps, ridges, and soft spots on a baby’s head. When should you worry?

I wrote this because I hear concern about bumps, ridges, and soft spots on baby’s (and older kid’s) heads quite often. Learn when you should worry and when it’s okay.

What was your favorite?

I’m surprised at the popularity of a few of these and sad that some of my personal favorites didn’t make the list.

I wish more people would read what fever is so they worry less about a number. Learning the evolution of illness might also help parents understand why exam findings are different on different days. I hear far too often that an ear infection was missed, but it’s more likely that they developed since the first exam.

I’ve also written a little on insurance and the business of medicine, but it doesn’t surprise me that those are not as popular. Sadly, we all need to understand the intricacies of billing and insurance as well as how the business of medicine works. As more and more private practice physicians sell out to large corporations, we’ll all feel the negative impacts.

Nip it in the bud?

When kids start to get sick, don’t you wish you could nip it in the bud before it gets worse?

If your kids have ever been sick, you know it can go from an annoyance to a fairly scary ordeal pretty quickly. When should you bring your kids to the doctor so we can prevent their symptoms from getting worse? We all want to know when we can nip it in the bud!

Can we prevent progression and spread of illness?

Mom: We’re here because my little one has a cold. It always settles in her ears, so I want to get on top of things and nip it in the bud this time.

Me: Her ears look great today, so keep doing what you’re doing. I’m glad you’ve started giving extra fluids, using saline in her nose, and letting her stay home from preschool to rest.

Mom: But we have family coming into town. They have a new baby, so I don’t want the baby to get sick. Can’t we just have an antibiotic now to help everyone?

Me: There’s no sign of a bacterial infection. She has what’s most likely a cold from a virus. Antibiotics don’t help.

Mom: But can’t we just try? She always gets an ear infection.

Me: It doesn’t work that way. Antibiotics don’t prevent ear infections. They don’t even treat the large majority of ear infections, since they’re viral. 

Mom: But we’ll be around a baby.

Me: An antibiotic would give a false sense of security. Your daughter would still be contagious from the virus. Viruses can be very serious in newborns. Your daughter shouldn’t be around the new baby until she’s well. 

Mom: But …

This circular conversation can continue indefinately.

I hear requests like this all the time. Unfortunately, illness doesn’t work that way. We don’t give antibiotics to prevent ear infections. They don’t stop the spread of most infections because most are from viruses.

If your doctor gave you antibiotics for your last cold “just in case” and you felt better, it’s likely you would have felt better anyway. That’s what happens with colds.

I realize when your baby has had several ear infections it seems tempting to give a treatment to prevent this cold from turning into another ear infection. But it doesn’t work that way. 

But she always gets and ear infection...

Antibiotics don’t:

  • Prevent the spread of viral illnesses. 
  • Keep an illness from changing from a virus to a bacteria.
  • Make all sinus infections go away.
  • Treat all ear infections.
  • Make people feel better immediately.
  • Come without risk.
Antibiotics usually aren't needed for sinus pressure, which is typically from a virus or allergies.

You take risks every time you use an antibiotic.

We need to use antibiotics wisely. Antibiotics are generally safe and most of us tolerate them well. But sometimes they lead to side effects, such as rashes and diarrhea. They can also cause true allergic reactions.

Over time bacteria can learn how to avoid being killed by antibiotics, called developing resistance. This can put us all at risk of deadly bacterial infections that have no cure. 

You take risks every time you take an antibiotic. Use them only when necessary.

But we have to get better fast!

  • Your teen has finals.
  • You must get back to work.
  • The baby being up all night fussing is wearing you down.
  • Your family has a big trip coming up.
  • You’re pregnant and you don’t want a sick family member in the home.

Whatever the circumstance, we can’t make someone not contagious anymore. It takes time for the symptoms of a virus to go away. There’s just no short cut. No way to prevent the natural course and progression

Up next…

Next week we’ll talk about what to do when you or your family is sick and how to prevent illness in the first place. (Prevention is always best!)

Nosebleeds

Nosebleeds can look very scary, but they’re common and usually can be managed at home with a few simple measures. Learn what to do and when to worry.

Many of us remember having a lot of nosebleeds as children, yet they bring fear to parents when their kids have them. Why won’t it stop? Why are they getting so many? Is there a bleeding disorder? Does it need to be cauterized or packed? Most of the time a nosebleed is just that. A nosebleed. I had several myself this past week. I was staying in a hotel and I think the air was dry. Yes, they’re annoying, but not horrible.

What, why, and when?

Unfortunately, nosebleeds are common in kids — especially when they are sick or suffering from allergies (due to swollen nose tissues) or the air is dry.

Nosebleeds often happen at night, when the head is at the level of the heart.

They also start with a forceful blow of the nose, sneezing, or other things that cause sudden pressure in the nose. 

The part of the nose that commonly bleeds is the center part separating the nostrils. If you look carefully up the nose toward the center on both sides, you can often see blood vessels close to the surface. After a bleed you can often see the scab.

Trauma to the nose can cause bleeding higher up, but the most common bleed in kids is very close to the tip of the nose. 

For more causes of nosebleeds, check out Dr. Deborah Burton’s post 12 well-known causes of nasty nosebleeds in children.

Once it bleeds, it is likely to bleed again and again until the skin completely heals. Sometimes it is just a few specks of blood when the nose is blown, other times it is full-on bleeding that seems to keep going and going. 

When the nose is bleeding:

  • Sit or stand. Don’t lay down– that increases the pressure in the head, which increases the bleeding.
  • Don’t tilt the head back — that causes blood to go down the back of the throat. You can tilt it forward slightly.
  • Pinch the nostrils at the highest part the nose is soft (just below the hard part) with a tissue or cloth.
  • HOLD IT FOR 10 MINUTES. Do not peek. Do not check. Do not let go.
  • Seriously, don’t let go for 10 minutes. This is the step kids have a hard time with. One minute seems long. Ten is forever. Hold it for 10 minutes anyway.
  • Some people like to put an ice pack over the nose, but if you do this, still try to hold pressure on the nostrils. Put the ice pack on top of the nose, above your fingers that are holding pressure.
  • AFTER 10 minutes, gently remove the tissue or cloth. If it is still bleeding, hold for ANOTHER 10 minutes. Still don’t peek during this time.
  • If after the two 10 minute holds (20 minutes of pressure total) it is still bleeding, it is time to go to the doctor. If you haven’t tried a real 10 minutes of consistent pressure, that is what they will do first, so save yourself the trip and the money and HOLD IT FOR 10 minutes!

After the bleeding stops:

  • Do not blow the nose for 24 hours if possible to allow the skin to heal under the clot.
  • Add humidity to the air with a humidifier or vaporizer.
  • Do not pick the nose.
  • Add a lubricant to the nostrils. Use a cotton tipped applicator or a tissue. My kids loved the “Vaseline sword” — we put vaseline on the tip of a tissue and pulled it into a sword shape. We put the sword in the nose, plugged it from the outside, and pulled the sword down, coating the inside of the nose with the petrolatum jelly.
  • Treat allergies if needed to decrease the swelling in the nose tissues.

Remember that as long as there is a scab in the nose, it will re-bleed if the scab falls off before the skin completely heals underneath. Keep moisture in the air, the nostrils lubricated, and remind kids to not pick!

Most nosebleeds are simple nosebleeds, despite how scary they look!

Red flags (or things to see a doctor about):

  • Frequent nosebleeds that take 20 minutes of pressure to stop.
  • Bruises that are not explained by injury. (In general, any child with bruises all over the shins is normal. Think of areas that don’t often get bumped or hit — if they are bruising for no reason, that is more of a concern.)
  • Red or purple spots on your skin that don’t blanch with pressure. These are petechia and can be seen when there is a clotting problem.
  • Blood in the stool. While the most common cause of this is constipation, if you have multiple sites of bleeding, you should be evaluated by a doctor.
  • If you think your child stuck something up the nose that might have contributed to the bleed.
  • When trauma to the nose or face leads to the nosebleed, it should be checked out.
  • If your child seems pale, unusually tired or dizzy, or has unexplained weight loss or fevers.
  • Gums bleeding. This is commonly due to poor oral hygiene and gingivitis, but can be due to a clotting problem.
  • If your child takes any medications that thin the blood. (This is unusual in kids, more common in adults, but high doses of fish oil might increase bleeding risks.)

What do doctors do about nosebleeds?

  • Usually all that is needed is home treatment and I simply reassure the parent and child with the above information.
  • If there are frequent bleeds, I will sometimes recommend cauterization of the nose. This sounds scary, but it is a relatively easy procedure. One common method is using silver nitrate. It is applied to the areas where the blood vessels are close to the surface of the nose. In many people a single treatment is all that is needed. Some people require repeat treatments.
  • Treat any underlying allergy to control the nasal swelling.
  • If there is a family history of a bleeding disorder or signs of other bleeding (bruises or petechiae, rectal bleeding, gum bleeding, heavy menstrual bleeding) blood work can be done to see if there is a bleeding disorder.
  • When trauma is the cause of a nosebleed, we make sure there is no hematoma or broken bones.

Sudden Barky Cough? Think Croup

The barky cough of croup is distinctive. It’s not a typical wet or congested cough. It’s like a seal bark. The good news is we can often treat it at home.

Many parents get scared when they hear the barky cough of croup. I’ve even been scared when my own children have it. I know what it is, but their breathing gets so labored that it’s scary.

Sounds of coughing

Parents describe many coughs as “croupy” but most of the time they’re mistaking a wet, mucous-filled cough for croup.

It can be difficult to sort out all the various sounds of coughing, which is why I previously gathered a number of videos into one blog.

The barky cough of croup is distinctive. It’s not a typical wet or congested cough. It’s like a seal bark. The good news is we can often treat it at home.

What is croup?

Croup is a distinctive set of symptoms that occur due to inflammation around a young child’s voicebox in the larynx and trachea.

Many people describe a croupy cough as a seal bark sound. They often make a hoarse or squeaky sound called stridor when they inhale.

Croup often starts suddenly in the middle of the night. 

What causes croup?

Croup is usually caused by viruses and tends to be most common in the Fall. The viruses that cause croup are common and usually cause runny nose or congestion and sometimes cause a fever. 

One child may get full-blown croup, but another will get a simple cold with the same virus. Some kids seem to get croup often, while others may never get it.

Can older kids get croup?

Croup is most common in kids less than 5 years of age, but older kids can occasionally get it. 

Older children and adults tend to get laryngitis with the same viruses that cause croup. Their airways are bigger, so the swelling that occurs near the voicebox isn’t as severe.

Croup is tricky

Croup often looks like a simple upper respiratory tract infection or cold during the day. Nothing to worry about…

In the middle of the night you will hear a sudden barking sound, much like a seal barking. A child with croup looks distressed and very sick at night, but seems much better the next day. 

For many kids, it’s just one night of this scary cough, but it can last several nights in others.

Some kids continue to have what is called stridor or trouble talking during the day. Stridor is a hoarse sound that you can replicate by breathing in while tightening your vocal cords. It sounds like a squeak or wheeze as kids breath in. Stridor is due to the swelling near the vocal cords that’s found in croup.

This is a simple yet very helpful video to hear the sound of croup and for management tips. 

How is croup diagnosed?

Croup is what we call a clinical diagnosis. No lab or x-ray is needed.

A doctor or nurse will ask questions about various symptoms, and if we hear the classic cough or stridor, it supports the diagnosis.

How is croup treated?

If you recognize croup, there are many at home treatments you can try. 

Cool air

Taking kids outside into the cool night air often helps soothe the airway. 

If the weather isn’t appropriate, you can open your freezer door and let them breathe in that air. (This has never been my favorite advice because it means a sick kid will be breathing on the frozen food and then there’s the wasted energy…)

Steam

The airway can also be soothed by taking kids into a bathroom, closing the door, and turning the shower to the hottest setting. Just sit in the bathroom – not in the shower. 

Usually after 10-15 minutes breathing normalizes. 

One thing I learned when my son first had croup: don’t leave the bathroom as soon as breathing calms down. Turn off the shower and just sit there for awhile. We had a rebound croup that was less scary, but unnecessary, when we tried to get him back to bed quickly. Letting the room get closer to the home’s normal air quality before going back into the hall and bedroom is time well spent.

Humidifiers and vaporizers

When we’re sick in the dry weather months, I always recommend adding a vaporizer or humidifier to the bedrooms. This is especially helpful if a child is at risk for croup due to age.

What about medicine?

Fever/pain relievers

If kids are uncomfortable, you can use acetaminophen or ibuprofen as a pain reliever. These do not help the cough, but they can help with comfort.

Steroids

Since steroids decrease inflammation, they are often used when kids get croup. These can only be used with a prescription and your doctor’s instructions. See your doctor if you’re interested in any prescription medicine.

Breathing treatments

Croup is often mistaken for wheezing, but it is not treated with a bronchodilator like asthma.

The swelling near the voicebox is much different than the smaller airway narrowing that occurs with wheezing, and the bronchodilators (albuterol or levalbuterol) work on the smaller airways. 

If kids have asthma, they can wheeze from the same virus that leads to croup, and in that case their asthma medicine helps.

In the hospital or ER setting some kids will get a breathing treatment of epinepherine. This should only be done in a supervised setting so they can be properly monitored.

Antibiotics

Croup is usually caused by a virus, so antibiotics don’t help.

There is also something called spasmotic croup, but that also is not treated with antibiotics. 

When should kids go to the ER or their doctor?

Since croup is worst at night, most of the kids who need to be seen end up in the ER. If your child has stridor during the day, they can be seen at their usual doctor’s office. 

If the above home treatments don’t work after about 15-20 minutes, you should take your child to be seen.

Kids who seem very anxious due to breathing difficulties will also benefit from a proper medical exam and treatment.

Trouble swallowing along with difficulty breathing should be evaluated by a physician.

If you notice that your child seems better leaning slightly forward while sitting, he should be seen.

Any child who is not up to date on vaccines, especially the Hib vaccine, should be seen with labored breathing. Epiglottitis is now rare, thanks to vaccines, but if a child isn’t vaccinated, it is still possible to get this. It can cause stridor, fever, difficulty breathing, and other similar symptoms to croup. Be sure the physician knows your child isn’t vaccinated!

Teal Pumpkin Project

Teal pumpkins have been popping up during the Halloween season in recent years, yet many people don’t know what they really mean. Displaying a teal pumpkin means that your home has non-food items available for the little goblins and superheroes as they come looking for treats.

Why is this important?

Because what child likes to be left out of the fun of Trick or Treating?

When a child has severe food allergies, diabetes, or another condition that limits the types of foods he or she can eat, they are often left out of class parties and trick or treating.

What can you do to support these kids?

Show parents that you are giving kids the option of a safe treat by displaying a teal pumpkin.

There are many non-food treats that kids would love ~ stickers, pencils, glow sticks, bubbles, plastic jewelry, vampire teeth, pencil toppers, hair pieces, magic trick cards, and many more. Be sure you have some that are safe for toddlers.

Why non-food things? Can’t we just avoid nuts?

Non-food items are better than nut-free because kids have allergies to all kinds of things, and it is impossible to know in advance what all those allergies are.

When kids must limit their overall sugar intake, non-food treats rule.

What about the kids who want candy?

Just because you offer non-food items, it doesn’t mean that you can’t also give candy.

Simply let kids know you have both options and ask which they prefer. Keep two containers: one of candy and one of non-food items.

How do you get a teal pumpkin?

We put together some reusable teal pumpkins at my office several years ago. My initial plan was to spray paint some plastic pumpkins, but decided to use Duct tape to cover plastic pumpkins instead. Duct tape has less smell. We didn’t have to wait for them to dry, and if we ever want to use them outside, they will be fairly weather-proof. They’ve held up well over the years.

Pretty cute, huh?

Let people know you’re participating!

Share this idea with your neighbors and friends. Use social media. Put a note in your neighborhood bulletin. Share with your school nurse. Ask stores to display a flyer.

Kids have to know what the pumpkin means. Display signs as well as your pumpkin letting them know you have non-food options as well as candy.

Register as a site that will offer non-food items on FoodAllergy.org.

For more information and a free printable flyer (like the one pictured in our office above), ideas on what to provide, and more information in general, see The Teal Pumpkin Project.

Use a teal pumpkin to show kids with medical conditions that you have non-food items this Halloween!

My child has Neutropenia. Should I worry?

One abnormal lab we see in otherwise healthy kids is a low absolute neutrophil count (ANC). This is also called neutropenia. Know when you should worry.

It is recommended to screen for anemia (low red blood cell or hemoglobin levels) around one year of age. Our office orders a complete blood count (CBC), which checks for red blood cells, white blood cells, and platelets – the main components of our blood. Sometimes we find things that we weren’t looking for. In the winter months, neutropenia is one of those things.

What is neutropenia?

One relatively frequent abnormal lab we see is a low absolute neutrophil count (ANC). A low ANC is also called neutropenia.

What are neutrophils?

Neutrophils are a type of white blood cell that fights bacterial infections. When their numbers get too low, it can increase the risk of serious bacterial infections.

While some people have low ANCs that cause significant immune deficiencies and can lead to infection, the most commonly seen low ANC we see are brief dips after a viral infection. 

Blausen 0676 Neutrophil
By BruceBlaus. Blausen.com staff (2014). “Medical gallery of Blausen Medical 2014”. WikiJournal of Medicine 1 (2). DOI:10.15347/wjm/2014.010. ISSN 2002-4436. [CC BY 3.0 (https://creativecommons.org/licenses/by/3.0)], from Wikimedia Commons

What causes neutropenia?

Most causes of neutropenia are due to infection, drugs, severe malnutrition or immune disorders.

The most common cause of neutropenia we see in otherwise healthy kids is due to a recent infection. In most cases this type of neutropenia quickly resolves without any treatment.

Some viruses, such as hepatitis B, Epstein-Barr, and HIV, are associated with prolonged neutropenias.

The drugs that can cause neutropenia are not commonly used medications.  Routine testing for neutropenia would be done when those medications are used because the risk is known. That’s one reason why people with cancer treatments often have regular blood counts checked.

Vitamin B12, folate, and copper deficiencies are very uncommon in children, but can lead to abnormal blood counts.

Three levels of neutropenia:

The large majority of kids with neutropenia have only mild drops in their ANC and are not at significant risk of illness. In general the more severe the drop, the more significant the infection risk.

  • Mild neutropenia: The ANC ranges between 1000-1500/μL
  • Moderate neutropenia: The ANC ranges between 500-1000/μL
  • Severe neutropenia: The ANC is less than 500/μL

What do you do if there’s neutropenia?

Since most mild cases of neutropenia self-resolve, it is not usually anything for parents to worry about.

I used to recheck all of these, but found that many kids needed several rechecks because they always had a mild viral infection so the levels stayed suppressed (low). Despite the low ANC, they never got significantly sick.

Of course if there is another clinical reason, such as a significant illness or growth problems, following up even a mild lab abnormality is recommended. If kids start getting sick, their blood counts should be rechecked because of the clinical concern.

When kids are otherwise healthy, I find that we end up chasing abnormal levels if we try to recheck, so I’ve stopped rechecking automatically.

  • When a child is overall healthy and growing well, the level is only mildly low (above 1000) I do not recheck the level unless there is a clinical concern. If your doctor wants to recheck it (or if you want it rechecked), that is appropriate to do.
  • When the level is in the mid-range (500-1000) or if the child has had problems with recurrent infections or growth, a confirmation (repeat test) and possible further evaluation is more likely to be recommended.
  • If the level is in the severe range (less than 500), it should be rechecked and the child should be closely monitored due to high risk of severe bacterial infections.
  • Some physicians recommend repeating a blood count with any fever for a year in kids who have had any degree of neutropenia, so you’ll have to talk to your child’s doctor for a plan.

What symptoms might happen if the ANC is low?

Most children with a temporarily and mildly low ANC will have no symptoms and need no treatment.

Children with chronically low ANCs may have more infections that require antibiotics, such as pneumonia, skin infections (abscesses, cellulitis) and lymph node infections. They might also have chronic gum disease, mouth sores, or vaginal or rectal ulcers.

Common colds often contribute to the temporary dip in the ANC, but are not caused by the low ANC. A different type of white blood cell fights off viral infections, so the low neutrophil count is specific to bacterial infection risk. 

Common symptoms seen with neutropenia:

  • Frequent significant infections (not just the chronic runny nose of a daycare kid)
  • Serious respiratory infections, including pneumonia or sinus infections
  • Skin infections (e.g. cellulitis, abscesses)
  • Multiple serious infections (e.g. meningitis, bone infections)
  • Lymph node infections
  • Gum disease
  • Mouth sores/ulcers
  • Vaginal, urethral, or rectal ulcers

When should you worry?

The level of ANC as well as the cause both determine the risk level.

Lower levels of neutrophils increase the risk of an overwhelming infection. An example would be when people are immune suppressed from chemotherapy they are at very high risk of bacterial infections.

On the other hand, an otherwise healthy person with a mildly low ANC is not more likely to get a bacterial infection than another person with a normal ANC.

If the child has any of the symptoms noted above or a very low ANC level, we start to worry more. Each case must be evaluated by the person who ordered the test and who has recently seen your child.

What treatment is done for a low ANC?

Most children do not need any specific treatment. They are monitored for recurrent infections, especially infections that require antibiotics. They are also monitored for growth, since if a body is chronically sick, it often doesn’t grow well.

Each infection that requires antibiotics is treated and blood counts might be checked to see how low they are at the time.

In children who have a chronically low ANC or a significant illness with a low ANC, a hematologist (blood specialist) is often consulted. They help evaluate why the ANC is low and if it requires a special treatment that stimulates the bone marrow to make more neutrophils.

For more information:

Benign familial leukopenia and neutropenia in different ethnic groups.

Pediatric Autoimmune and Chronic Benign Neutropenia

Developing Responsibility and Resiliency in Our Children

Our goal as parents is to have our kids grow up with responsibility and resiliency so they can leave our home. How can we accomplish that?

As the years go by, I have seen very bright kids struggle with life and average intelligence kids thrive. I often think about how parents could help their kids grow into independent adults or hinder that growth by trying to be a good parent. Good intentions aren’t always the best way to do things, and sometimes the best parents sit back and let kids figure it out themselves. In the end, our goal as parents is to have our kids grow up with responsibility and resiliency so they can leave our home. Our desire to keep kids safe can seem to conflict with the need to let them grow up.

Is it safe?

So often parents attempt to keep their kids safe in the moment, but don’t consider what long the term implications are.

Parents want to keep their kids safe under their wings, at home or in a supervised activity. If their child is not directly in sight, they are at least within reach of a cell phone for immediate access.

Cell phone for “safety”

I often hear that parents buy a phone for their kids “for safety” purposes, but studies are showing the opposite. Cell phones lead to many dangerous situations for young kids and tweens. Smartphone use is associated with anxiety, depression, poor sleep, and more.

Bullying has always been a problem, but now it is more widespread. Kids can’t even escape in their own home due to social media.

Screen time takes away from playing outside, which contributes to obesity.

Smartphones also decrease the time spent interacting with people in real life and getting tasks accomplished. When kids spend excessive time communicating with their friends through apps, they miss out on real interactions that can help develop important social skills. Although it’s not a diagnosis yet, screen behaviors seem to be very addictive. Limiting time can become difficult when kids always carry a device.

Screens interfere with sleep. Sleep is critical to a growing brain and body, so sleep deprivation leads to many problems.

Inappropriate material is easily accessible online. Kids learn how to starve themselves and get encouragement for unhealthy behaviors. They share challenges that are very dangerous. Pornography and sex trafficking are huge issues.

Look into the Wait Until 8th movement for reasons to wait until 8th grade to give your child a smartphone. Gain support from other parents when your child says they’re the “only one” without one. Even teens recognize the problem.

Being out and about

If you never let your child visit a friend’s home or play outside, they will learn to be afraid outside their own home.

Many parents are afraid to let their kids walk to school. Realistically it’s a low risk that their child will become abducted, but a very real risk that the loss of exercise will impact their long-term health.

It’s rare in many neighborhoods to see kids outside playing. Some may be inside unable to go out because parents aren’t home. Others prefer to play video games. There are many at structured after school activities, which don’t allow for child-driven play and problem solving. If other kids aren’t out playing, the incentive for your kids isn’t there to go outside. It isn’t as fun to play alone. Talk to your neighbors to find times that their kids will be home and encourage outdoor fun at that time. This helps to build your neighborhood into a community!

Dr. Peter Gray shows how the decline of free play is directly correlated with dramatically increasing rates of anxiety, depression, suicide, and narcissism in children and adolescents. He discusses why free play is essential for children’s healthy social and emotional development. He also offers suggestions of how we can make this happen while keeping our kids safe. Take 15 minutes to watch it.

Playing sports

As Dr. Gray mentions, it’s the free play that seems to be important to help our kids develop resiliency.

Our kids consider sports their “play” time, but sports are directed by adults. Kids don’t learn what they need to learn about creativity, self motivation, problem solving, and all the other skills learned by kid-directed and kid-initiated play.

Overprotected kids

An article that I read years ago still resonates with me. The Overprotected Kid shows how parents try so hard to keep their kids safe that we sometimes prevent them from learning about real life.

The article is based on allowing kids to roam and play with things that haven’t been engineered to keep them safe. In our litigious society, that seems excessively dangerous to some. There are even stories of parents being turned into authorities for allowing their kids unsupervised time outside or even taking public transportation to school.

In my opinion, too many parents worry that kids aren’t safe when unsupervised. They forget what dangers lurk in too much supervision.

Where’s the right balance?

Building Snowmen from Snowflakes

Dr. Tim Elmore is a recognized speaker and author who focuses on building the next generation. Here’s an excerpt from his post, How to Build Snowmen from a Snowflake Generation:

Too often, our young give up due to “learned helplessness.” This happens, however, in both a surprising and sinister fashion. It’s all about control. Studies reveal that when the activities in their day are controlled by adults (and hence, not in their control), both their angst and hopelessness rise. The more we govern and prescribe the agenda, the less they feel hopeful and the more they feel helpless.

Further, learned helplessness promotes irresponsibility. Kids feel little responsibility to work because it’s “not up to them.” I believe most middle class students assume that if they make a mistake, some adult will swoop in and rescue them. While this may feel good, it hinders development. Feeling that outcomes are in their control gives them a greater sense of hope and ownership.

Established generations must slowly encourage and even insist on giving them control of the “agenda.” This is the only way to build ownership, engagement and responsibility. It requires trust and flexibility, since young people may not perform to our standards. We must decide what we want most: perfection or growth.

He goes on to say:
What message do you suppose it sends a student when the adults in his life continue to swoop in and save him whenever something goes wrong? While it may feel good at first, it communicates: “We don’t think you have it in you to solve this problem. You need an adult to help you.” Consequently, these young people don’t feel like adults themselves until somewhere between ages 26-29. They can remain on their parents’ insurance policy until age 26. In one survey, young adults reported they believe adult-life begins with “having their first child.” Today, this doesn’t happen until long after 18 years old. So while we give them the right to vote, they may have no concept of reality. Rights without responsibilities creates virtual adults and often, spoiled brats.
Teaching children responsibility is like teaching them to ride a bike. Offer less support and finally let go.

Growth Mindset

Did you know that success is not determined by intelligence? Our mindset, grit, and resilience are more predictive of success.

The good news is that we can all learn to have a growth mindset, which is a great start to becoming resilient. See my sister blog for more information on How to Get a Growth Mindset.

Success is correlated with a growth mindset more than intelligence. So how do you get it? It's not as difficult as you might think.
How to get a growth mindset.

Downsides of outside urgent cares

Do the downsides of using an outside urgent care outweigh the benefits? Is it worth it to wait for your usual doctor’s office?

I started writing a simple blog about using urgent cares appropriately to get the best care, but I quickly realized that it’s a bigger topic than it first seems. I’ve covered the visit experience itself and the benefits of using your medical home. Now it’s time to talk about the downsides of using an urgent care outside your medical home. Do the downsides of using an outside urgent care outweigh the benefits? Is it worth it to wait for your usual doctor’s office?

Who will you see?

There are many types of independent urgent cares. My community has some that are associated with hospital systems or pharmacies and some that are independent. They are staffed with many different types of providers. Some are even pediatric focused, but others are staffed with people who have little training or experience seeing kids. That means you need to know who you’re seeing and what their background is.

Limited pediatric experience

The provider at the clinic may or may not have adequate training in pediatrics. They often do not have others around who can help if a problem arises that is out of their comfort zone or level of experience and training.

This can lead to over treatment,  under recognition of a serious condition, and over testing with unnecessary labs or x-rays.

Training matters

Simply put, make sure your provider has extensive training in pediatrics.

This is not a “we’re better than you” point.

I do not think that every physician is a good clinician by default. Neither do I think nurse practitioners or physician assistants are not good at what they do. Both physicians as well as NPs and PAs can be great or not so great. We all have our strengths and weaknesses which are built on our interests, training, and experience.

I am getting the following numbers from What Kind of Doctor is Your Doctor? The link includes a nice chart of even more doctor types.

Pediatricians spend at least 3 years during residency learning how to take care of kids. This involves about 2400 hours per year for 3 years taking care of sick kids after medical school. Medical school is about 6000 hours of training. Total clinical training (excluding college years) is a minimum of 13,600 hours. Pediatricians know kids.

Family physicians also spend 3 years in residency after medical school, but that time is not focused on child health. The amount of training caring for children varies based on the program and their experiences.

Physician Assistants spend 2-3 years in a master’s program, with an estimated training time of 2000 hours total. This is not focused on child health at most programs. Much like family physicians, their time is divided between adults and children.

Nurse practitioners spend 1-2 years in a master’s or doctorate program. Clinical training requirements vary from 500-1000 hours. Again, these hours include both adult and pediatric patients. Traditionally most nurse practitioners went into graduate school after many years of nursing experience. That is becoming less common as many are going straight from nursing school into graduate programs, so they do not always have those working years of experience prior to getting their advanced degree.

Years of experience

Of course with all of the training hours, there is also experience after training. You are correct if you say that every person with experience is not better than someone without experience, but in general experience helps.

If a person spends 40+ hours a week for many years taking care of kids, they  continue to learn along the way. Sometimes they pick up bad habits, but I can only hope that with experience comes competence. This is best done when people work in a setting that has more experienced colleagues to offer advice along the way, not when they’re thrown into a clinic alone from day one and made to figure it out on their own.

Remember all those clinical hours medical residents spend learning? They are essentially working under those who are more experienced for several years, learning to manage complex (and minor) issues along the way. So even a brand new physician has more experience than some other providers with several years of work experience that may or may not have been supervised.

The risk of getting what you want vs what you need

Most people use walk in clinics for convenience. When their child is sick or injured, they want help ASAP. That’s understandable.

I’ve written before about why convenience isn’t always best and why sometimes it’s okay to wait. Here’s a very common example of not getting what you need:

If a baby is crying, the eardrum gets red, but isn’t necessarily infected.

Misdiagnosis

A provider without a lot of experience will often err on calling it an ear infection simply because it’s red. That makes parents happy because they think they’re doing something to make their child better.

They’re not if it’s not a bacterial infection. There’s risk to taking unnecessary medicine.

Quick medicine

It’s fastest to write a prescription and move on to the next patient rather than to explain what to do to treat a viral infection.

This is not good care, but it’s common.

Treatments don’t always need a prescription

Don’t feel like you leave empty-handed if you leave the clinic with the information that your child doesn’t need labs or prescription medicine.

Leave with the knowledge of what to do if symptoms change.

Learn how you can help ease symptoms and make them feel better.

You’re not empty-handed – you’re empowered with knowledge!

And then there’s the required surveys…

You have probably been asked to do a survey after shopping. Sometimes you do it for store credit or to help a nice sales person meet their quota.

Sadly, surveys have made their way into healthcare. We can’t offer a discount for your next visit, but many of us are required to collect a certain number of surveys each quarter.

Medical staff are being graded by patients to be sure they’re giving “quality care” ~ and I put that in quotes because I don’t believe that it measures quality at all. I discuss this in more detail in Don’t look for quick fixes for your cold!

Giving a prescription for an antibiotic makes parents happy, regardless if it is necessary. They feel like their trip was worth it because they “got something” to treat the symptoms. This means better satisfaction scores for the clinic because people like to leave with a treatment. It also brings in more money because faster turn around means more patients can be seen. The shorter wait time also drives up satisfaction despite the fact that it’s not good care.

It takes longer to explain how to treat a cold than it does to write a quick script. Parents are generally happy with the visit, but antibiotics are overused and the recommended treatments aren’t adequately discussed. And that’s not okay.

No follow-up

Independent urgent cares do not offer follow-up of issues to see if there is improvement.

Not following up not only prevents assurance that the patient gets appropriate follow-up, but it also keeps the provider from learning how diseases and conditions progress over time. This is one reason why some people with years of experience still tend to over treat or under recognize things.

Phone help

Stand alone urgent cares do not take phone calls to answer medical questions. They don’t even answer follow-up questions about your visit by phone.

If you have questions, you must call your PCP or return to the urgent care. If we haven’t seen the child for the issue, we are unable to give appropriate advice.

Prescription “refills”

I’ve been asked on many occasions to refill a medication from an urgent care because it was spilled or forgotten on a trip.

I can’t refill a prescription I didn’t write.

The parent can’t call the urgent care provider for a refill because they don’t accept calls.

That’s quite a predicament!

Referrals

If you require a referral to see a specialist for any reason, it is usually required for your PCP to do that paperwork. There are insurance plans that do not require referrals, and you may schedule on your own unless the specialist requires a referral.

If we haven’t seen your child for the issue at hand, especially if we have no documentation at all about the referral, we often cannot do it without seeing your child.

Why do we need to see your child first?

It is one of the requirements that we must abide by in some of our insurance contracts. Seeing the physician who knows a patient best can help to avoid unnecessary appointments with specialists.

Required documentation

Sometimes it’s as simple as we can’t refer for something we don’t know about. Many referrals require a copy of an office visit.

If we didn’t see your child for a visit, we have no visit supporting the need for the referral. We need documentation to send for the referral.

Sometimes a specialist is not needed

I have seen many situations where an urgent care physician, NP, or PA recommends follow-up with a specialist of some sort that isn’t needed. They often don’t realize that it is quite within the scope of practice of a primary care provider. They cannot know the skill set of every PCP in town. Call your PCP to see if they can handle the issue. It can save you money in lesser copays if you see your PCP first.

An example of this is a concussion. Every provider in my office is competent following most concussions and clearing for play when indicated. Other examples are rashes (including acne), simple fractures and constipation. I’ve seen patients who waited a very long time and paid a lot of money to see specialists for each of these indications based solely on the urgent care recommendation. Most of the time I’m completely unaware of the whole issue until I see them next and they mention seeing the specialist.

They get the same treatment plan at the specialist as we could provide in my office, but at a much higher cost and decreased convenience.

Incorrect diagnosis

I’ve also seen a number of kids with issues diagnosed at urgent care centers that I disagree with the assessment or plan. This brings us back to all the issues listed above.

One common example of this is a toddler with “recurrent ear infections” who has only had ear infections when seen by an urgent care provider. Every time they see me with the same symptoms, their ears are okay. I often wonder if these kids ever had a real ear infection. Maybe they did and it is simply coincidence, but if they didn’t, they don’t need the risk of anesthesia for tubes. I’d like to have the conversation face to face with the parent after I examine the ears myself.

Continuity of care

There are gaps in care even at urgent cares where there is a pediatrician, nurse practitioner, or physician assistant with extensive pediatric training.

They do not know your child’s full medical background and do not update your child’s health record in the medical home.

Following in one office allows us to see the chronicity or recurrence risk of an issue. If your child goes multiple places for every sore throat, no one recognizes that a tonsillectomy might be beneficial.

Related posts

Don’t look for quick fixes for your cold!

Convenience Care

Help Us Help You! Make the most out of phone calls

Improper Use of Antibiotics: Don’t take the risk

Top 10 Tips for Going to an Urgent Care

Evolution of Illness

Don’t withhold recess!!!

Play is an important part of every child’s day. Recess should never be held for behavior modification. Chris Dendy shares important facts in this post.

I’m amazed at the number of parents who tell me that their child misses recess to finish homework or as a consequence for inappropriate behavior. It seems counterintuitive to restrict play when kids are unfocused or behaving out of line. We now have a lot of research on how kids with ADHD don’t respond to typical behavioral modifications. It’s not really a choice for them to do the behaviors they’re doing, so trying to offer recess as a reward just doesn’t work. With all this accumulated research, it’s surprising that some schools and teachers continue to support restricting recess.

Today’s blog is from Chris Dendy, an expert on ADHD. She is an acclaimed author and speaker. Chris has worked as a classroom teacher, school psychologist and mental health counselor. She’s worked as local and state level mental health administrator, has been a lobbyist and has served as executive director of a statewide mental health advocacy organization and as a national mental health consultant on children’s issues. Her Facebook post below shows the importance of recess.

I have edited her original post to make headlines more visible, but I did not change the content at all. See her original post linked at the bottom of this page.

BOTH AAP & CDC STRESS THE IMPORTANCE OF PLAY

EVERYONE SUFFERS WHEN YOU WITHHOLD RECESS:

When recess is withheld as a punishment for misbehavior or incomplete academic work, both teachers and children suffer. Teachers who know their research never withhold recess and here’s one key reason why:
“misbehavior is higher on days when children with ADHD don’t have recess.”

CHILDREN’S BRAINS WORK BETTER AFTER EXERCISE:

After exercising, students show improved attention, retention of information, working memory, mood and social skills. School officials also report a reduction in school suspensions. Students with better fitness levels earn higher scores on academic achievement tests.

EXERCISE GROWS NEW BRAIN CELLS:

Interestingly, John Ratey, M.D. a well-known psychiatrist, describes exercise as “Miracle-gro” for the brain because it actually builds new neurotransmitters and increases blood flow to the brain. The author of How the Brain Learns, Dr. David Sousa, explains that “down time” is needed to allow the brain to recharge and process new information. Recess provides this much needed recharging time.

IF A STUDENT IS CONSTANTLY MISSING RECESS, LOOK FOR UNIDENTIFIED LEARNING PROBLEMS:

One of the most common reasons for keeping students in during recess is to complete unfinished work. Instead of withholding this important activity, educators must determine the underlying reason for the failure to finish the classwork and implement a preventive strategy: utilize positive interventions instead of punishment!

For example, the culprit may be deficits in executive skills including inattention, difficulty getting started, or slow processing speed. Secondly, many students with ADHD have trouble getting started on their work and must be given an external prompt to start working. Finally, twenty-eight percent of children with ADD inattentive have slow processing speed. Children who struggle with this slow processing should be provided shorter assignments and/or extended time.

Unfortunately, researchers report that many of our children are on doses of medication that are too low for peak academic performance. Even though they are on medication, students with low medication doses will have problems paying attention and working efficiently. Teacher rating scales of classroom performance are available that reflect how well medication is working.

INCREASE MOVEMENT THROUGH “IN-HOUSE FIELD TRIPS:

Veteran teacher Jackie Minniti, suggests giving “in-house field trips” to allow increased movement and subsequent increased blood flow to the brain: for instance, give out supplies, close the door, take a note to the teacher across the hall that simply says, “Hi”, and then the student returns to his class. Doing jumping jacks or dancing to music in the classroom can be very helpful. Minniti’s positive incentives include rewarding timely work completion with five minutes extra recess time or giving stars on a chart toward a class pizza party.

FIND VOICE OF REASON AT SCHOOL OR ASK YOUR DOCTOR OR PSYCHOLOGIST TO WRITE A STATEMENT SAYING RECESS SHOULD NOT BE WITHHELD.

If you have a reasonable teacher, talk with her about trying these positive intervention strategies first instead of punishment. If you think the teacher will not be receptive to your suggestions, then consider getting a note from your physician stating that your child must have recess each day. The next step will be to ask that deficits in executive skills and the need for recess be addressed in an IEP or Section 504 plan. If the teacher fails to comply with these requirements in the IEP, you will have to approach the guidance counselor, special education coordinator, or principal for assistance.

THE CENTER FOR DISEASE CONTROL (CDC) STATES THAT RECESS SHOULD NOT BE WITHHELD AS PUNISHMENT:

Because of growing concerns about obesity and other chronic diseases, Congress passed the “Healthy, Hunger-Free Kids Act” in 2010 that resulted in the Centers for Disease Control in Atlanta developing guidelines in several areas including recess.
Each local school system that has a National School Lunch Program must develop a school wellness policy to address Congressional concerns. The CDC expressly states, “Schools should not use physical activity as punishment or withhold opportunities for physical activity as a form of punishment.” Exclusion from recess for bad behavior in a classroom (including incomplete academic work) “deprives students of physical activity experiences that benefit health and can contribute toward improved behavior in the classroom.”

AMERICAN ACADEMY OF PEDIATRICS (AAP) STATES UNSTRUCTURED FREE PLAY IS CRITICAL:

Here are highlights adapted from their policy statement.

1. Eliminating recess may be counterproductive to academic achievement. Recess promotes not only physical health and social development but also cognitive performance.
2. Creative supporting free play as a fundamental component of a child’s
normal growth and development.
3. Recess is a necessary break in the day for optimizing a child’s social,
emotional, physical, and cognitive development.
4. Recess may help provide the recommended 60 minutes of moderate to vigorous activity per day to fight against obesity.
5. Recess offers the opportunity to build lifelong skills required for communication, negotiation, cooperation, sharing, problem solving.

Updated from Dr. Dendy’s original article published in ADDitude magazine.

For more information:

From the AAP: The Crucial Role of Recess in School