Downsides of outside urgent cares

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

Why Wait to See Your Regular Doctor?

Why should you wait to see your regular doctor? The benefits of using your regular doctor’s office to see your PCP or another provider with access to your child’s medical record are many. I previously wrote several tips about how to use an urgent care wisely, but I wanted to spend more time on the benefits of going to your own doctor rather than an independent walk in clinic in more detail, so removed that portion of the post.

Almost as promised, here it is. The almost is that I promised to post this the next week, but a few other topics interrupted the posting schedule. Better late than never!

There is more to this than could be covered in one post, so this is Part 2. It covers the benefits of seeing someone in your regular doctor’s office. Part 3 will cover some of the problems with seeing someone in an independent urgent care.

Your primary care office knows you

Humans benefit from relationships in many ways. When you see the same people over and over, familiarity brings comfort. This can be the same face at the reception desk, the same nurses, or the same physician. Even if the faces change from time to time, the overall clinic’s familiarity can bring comfort in a time of significant illness or disease. When you have something difficult to talk about, it’s easier with someone you’ve built a trusting relationship.

Consider teens…

Think of tweens and teens who need an adult to ask for advice.

If they do not have a medical home where they feel welcome, they are less likely to talk about their problems.

As much as we’d all like to think that our kids will talk to us, they aren’t always comfortable with that. I’ve had kids ask parents to leave to talk about so many issues. Some of their “confidential questions” may seem silly to not talk about with a parent, such as how to use deodorant or how to shave, but it happens. Some are really troubling things, such as suicidal thoughts or abusive relationships.

These need to be discussed with a responsible adult, not another tween or teen, so I’m happy when they are comfortable talking to me.

If they’ve come to the same place year after year for illnesses, injuries, and yearly well visits, they will feel more comfortable.

Even different faces in the same practice offers some consistency

Even if you see different physicians, NPs, or PAs from time to time or go to a satellite office, there is still continuity within that practice.

The medical record has your child’s immunization history, previous drug reactions, any underlying illnesses or frequency of illnesses, as well as any other pertinent information. As long as you use that clinic for most medical care. The more often you use outside clinics, the less comprehensive the medical record becomes.

Primary Care Providers (PCPs) and their staff also know your family and that alone can help!

Business of medicine

Talking about the business of medicine might seem self-serving, and it is, but think about keeping your favorite physician in business. The reality is many private clinics are selling out (or just joining) larger health systems. This raises healthcare costs, increases administrative burdens, and diminishes the personal touch of healthcare.

I hate thinking about business and insurance issues, but as a business owner, I must.

I have two big regrets from my student days.

The first is that I wish I studied abroad because once work and family life start, it’s too hard to take long trips.

The second is that I wish I took business classes to prepare myself for a career in medicine. Most medical students are so eager to learn the massive information about medicine, they forget that one day they might be a business owner.

Unfortunately the number of physicians who own their own practice is falling. I suspect that has a lot to do with physician burnout and the increasing suicide rate of physicians, but that’s another topic!

I’ve learned a lot of business along the way, in large part to SOAPM. Unfortunately not all physicians have learned about business. Life is busy and it’s hard to balance everything. We tend to already work long hours, so it’s hard to fit one more thing in at the end of the day. I think medicine is in the state it’s in now because healthcare has been led by non-clinical business people who might understand business, but have no idea how it impacts the health of people.

Care outside your primary office (Medical Home)

Now that many routine visits are going to outside providers, family physicians and pediatricians are struggling to stay in business.

We still see our patients for illnesses, but they tend to be more chronic issues.

Daily headaches for the past 6 months takes a lot more time in the office than an earache that started this morning. We can’t see as many chronic issues as acute illnesses, so the amount of money we bring into the office is down due to less volume.

The costs of rent, insurance, staff salaries, and more doesn’t go down, so covering those costs becomes difficult.

Urgent care from a business perspective

Routine sick visits are quick and easy.

They’re the bread and butter of primary care offices.

That’s why urgent care centers are popping up in pharmacies and on every other corner. They are short visits, but insurance companies pay well for them. Because they’re short, many can be done in a standard shift. This brings in easy money to a clinic.

Chronic issues, mental and behavioral health, and other issues not typically seen in urgent cares take more time.

If a patient with symptoms more than what can be handled in an urgent care shows up, they are quickly assessed, offered a token treatment and told to follow up with their doctor. Or they’re simply told to go to the ER. Urgent cares don’t waste time on big issues.

The impact urgent care use has on a PCP schedule

You wouldn’t think at first of all the trickle down effects that going elsewhere for care has on your primary doctor’s life.

Remember that if we’re not seeing patients, we aren’t brining money into the practice. The money doesn’t directly line our pockets – it’s needed to pay essential bills. We have to fill our day with patients one way or another.

Well visits and short vs long sick visits

Many doctor’s offices differentiate sick and well slots in their appointment schedule. This allows us to see a balance of well visits for routine care as well as to save time for sick kids and those with chronic issues. Many of us have short and long visit slots to account for the amount of time typically needed for each visit concern.

The more patients go to urgent cares for quick visits, the fewer same day short sick visit slots are needed in PCP schedules. This means we must adjust our schedules to have more well visit and longer chronic issue slots so we’re not sitting around doing nothing.

Schedules of today look and feel different

Since we have less need for short acute visits, we fill those with longer chronic issue visits and well visits. Both of these tend to fill in advance, unlike short acute visits that tend to be needed on the same day.

Some days that means my patients who want to see me are told I have no availability. They can still be seen in my office’s walk in clinic, but they can’t schedule with me.  I’d like to be able to see my patients when they want to be seen, but supply and demand ring true.

Unfortunately, these longer visits are relative money losers and they can be more emotionally draining for the physician due to the chronic nature of the conditions seen. Some days I wish to be able to see a straight forward earache or sore throat….

How much is a visit worth?

We use a billing system that identifies an office visit by complexity and time. This is set by regulations, not your doctor’s office -unless they’re a concierge cash based practice.

A typical sick visit that lasts about 10- 15 minutes is considered a 99213, which is valued at about $74. So two sick visits is therefore worth about $148.

If a visit is over 25 minutes or complex, it is considered a 99214, which is valued at $109. We therefore lose nearly $40 for every prolonged visit because we spend more time. If we saw two different patients in that same time, we’d bring more money into the practice.

Once in awhile this isn’t a big deal, but as more people go to urgent cares for routine illnesses, PCPs are left with mostly complex visits. This hurts the bottom line and is emotionally more draining for the physician. It’s hard to deal with serious issues all day long.

This isn’t about being greedy.

If I was in it for the money, I wouldn’t have picked pediatrics after medical school.

Pediatricians are consistently some of the lowest paid physicians.

I chose pediatrics because I love it. But I still have to pay the bills at the end of the day. We have to pay office rent (or mortgage), malpractice insurance, insurance on our vaccine supply and other inventory, salaries for all staff, health insurance for staff, IT equipment and management, ect.

Just like any business, it takes money coming in to stay in business.

Changes to the value of a visit?

There’s a proposal to change the way office visits are paid by insurance companies.

This is a proposal to have insurance companies set the relative value for each visit at the same payment rate. This means if you’re seen for 5 minutes the doctor gets paid the same as if they spend 45 minutes with you.

I see this being very detrimental for pediatric care because it will encourage many quick visits instead of a comprehensive visit. But if we spend too long with a patient, we can’t earn enough money to pay the bills at the end of the month, so it will be necessary to make visits short to be able to see enough patients at the end of the day to cover costs.

I worry that people will gloss over issues that need more time. Abdominal pain is commonly constipation, but can be many things. We just won’t have time to talk it all through in one short visit.

This is a proposal that will benefit the independent walk in clinics that tend to see many earaches, coughs, rashes, and other quick issues. It will not be good for those of us who manage a lot of mental and behavioral health.

Or our patients.

Free advice is bad for business

It gets worse. Pediatricians give away advice for free all the time.

People call us to ask how to manage symptoms and conditions throughout the day and night. Most of these calls are done for free, yet we pay for staff to take them.

Often parents call and we give advice on how to manage symptoms before following up in the office during business hours. It isn’t uncommon to learn that parents took their child to a late night urgent care instead of waiting.

Parents often call asking if the care given elsewhere is appropriate or if we can we write a school excuse or refill medications when we never even saw the child for the issue.

We can’t manage what we didn’t see.

If you bring your business elsewhere, only go where you trust that the provider has experience with children and can handle your child’s symptoms. When you have questions about their treatment plan, ask them. If you need a school or work excuse, ask them for it.

You’d never buy a Kia and then ask Toyota for parts or free repairs. You return to the original dealer, right? (I chose these brands because they’re the two in my garage now. I have nothing against either, but they’re different.)

Urgent cares don’t give away anything for free.

Stand alone urgent cares don’t cover questions 24/7.

Primary care offices are required to offer 24/7 phone availability. Either they staff it themselves or they pay someone else to do it.

This is just one more way that urgent cares have the business advantage. They don’t have this monetary cost or quality of life issue.

All these calls hurt a medical home’s bottom line because we’re paying our staff to talk to families – often back and forth calls. It’s a considerable amount of time. Time for a service that brings in no money, but we still must pay staff to do it.

Physician burnout

You might wonder what physician burnout has to do with a person choosing to go to an outside urgent care or their physician’s office.

A lot really.

There’s of course a financial loss when people go elsewhere, but it’s more than that.

As mentioned above, the more urgent cares are utilized, the more a PCP must handle more difficult chronic problems, which tend to be more emotionally draining.

PCPs now have to spend extensive time documenting review of outside provider notes. Insurance companies are setting many rules and protocols to reconcile charts and update the primary care record whenever our patients see other providers. In the paper chart days, I could quickly skim consultant notes, but now it takes a couple of hours per day of unpaid time to review them all.

Seriously. Hours. Every day.

I struggle to keep up. And I’m not alone.

New reports come in every day – even when we’re off.

I’m guilty of logging in even when I’m on vacation. This is not healthy for me mentally. I know that. It’s bad for what should be my personal and family time. It’s just easier to me though to spend this time logging in so I can “do a few charts” to keep me from being overwhelmed when I’m back to work. There’s no time to catch up when I have to see patients all day and continue to get new charts to review each day.

Our physicians try to help others out when we’re on vacation, but many charts really should be seen by the PCP, not the partner.

Every day I go to work before seeing patients and stay a couple hours after I’m finished seeing patients. I review charts as I eat lunch unless I have a meeting so I can get home to my family a little earlier each day.

Charting does not bring satisfaction.

One of the benefits of working in healthcare is the satisfaction of knowing that we help others. All the years in training. The sleepless nights. Missed kids activities. All of this is worth it when we feel like we make a difference in someone’s life.

Reviewing charts does not help me feel like I am taking good care of patients. It does update me on what’s going on with them, but it isn’t fulfilling like when I see a patient and help them.

There are so many clicks to review one chart and update it as expected – reconciling mediation lists, updating hospitalizations or the injury list, and more. It’s difficult to keep up.

If most care is done in the medical home, the chart is updated at the time of the visit and these chart reviews would be less. Sometimes it is not advisable to stay within the medical home. There are true emergencies and times that specialists should get involved. These are unavoidable and necessary.

Most urgent care trips are not really urgent. They break the medical home concept for convenience.

No wonder there’s so much physician burnout these days.

Not only do we need to see more difficult or chronically sick patients because the quick acute care illnesses go elsewhere, but we also must review their notes and incorporate them into the patient chart for zero reimbursement.

That’s asking for burnout!

Use the Medical Home

What can you do to help your physician avoid burnout and stay in business?

Be seen by them whenever possible. Let them see the volume of patients they need to see to cover costs. Use them for quick sick visits as well as routine physicals and following up of chronic issues. Avoid going elsewhere unless it’s really needed.

The reality is that many private practice physicians are selling out to (or simply joining) big corporations because they can’t make ends meet.

I’ve heard their patients complain about the loss of personalized service and added costs.

Please consider the long term effects when you use outside services.

What keeps patients in the medical home?

There are many things that have been tried to allow people to be seen in their medical home. Not all work.

Sometimes people just think another location is more convenient. I know this because I get reports from urgent cares that saw a patient of mine when we were open. Instead of calling for an appointment or coming to my office’s walk in, which is available all hours that we’re open, they go elsewhere.

Extended hours

I’ve heard time and time again from patients, other physicians, and medical administration types that extending hours is important to private practice.

Even this can be a problem.

We see patients use outside urgent cares when we have regular business hours. Maybe a 5 minute shorter drive makes a difference?

My office even tried extending hours beyond our already generous regular hours. We were already open longer than standard business hours and our regular hours include walk in for patients all day every weekday and half days on Saturdays, but we stayed open even later for awhile.

Staying open later increased our expenses in staff salaries, but we found that people still went to other urgent care centers. We lost money at that time of day. People had asked for later hours, but then didn’t use them.

Walk in

One of the most complimented aspects of my office is the availability of our walk in clinic. Our patients can be seen in our office by one of our staff any time we’re open by simply walking in.

This has many of the benefits of being seen in the medical home while offering the flexibility of other urgent cares.

It still has the downside of not being able to see your PCP. You will see whoever is staffing the walk in clinic at that time, and of course this person can always consult with your PCP if needed.

It also has lead to the schedule changes noted above, since most people prefer this convenience. We now have relatively few short sick visit slots in the schedule. This can lead to less availability when there are a number of parents who prefer a scheduled appointment on the same day.

Phone calls

As mentioned above, PCPs must be available 24/7 by phone.

A phone call can be used by parents to keep their kids out of urgent cares and ERs. We can offer advice to get through the night (or until the office opens).

Follow the advice, and if your child needs to be seen, try to do it in the medical home. Of course if your child is in uncontrollable pain, is struggling to breathe, is dehydrated, or has other significant issues, he should be seen immediately.

Many offices, my own included, offer a ton of free advice on our websites. This has been debated from a business standpoint since it’s free advice. From a quality of life standpoint, the clinicians in my office like having things easily accessible for parents. When we give advice on the phone or during an office visit, much is forgotten. Having it easily accessible for parents to review is a great resource for them and helps to decrease the number of return calls for clarification. This also helps the physician’s quality of life.

Telehealth

There is a general push toward providing virtual visits through secure video conferencing. Even my insurance company keeps pushing me to register so that I can easily be “seen” when I’m sick. (I haven’t.)

I think this is a very dangerous slippery slope. Many sick people need to be examined to be able to properly diagnose things that require prescription treatments. Yet I know they are happy to call and get a prescription, so if it’s available they will use it.

Again, getting what you want is not always what you need.

I do see great potential for telehealth in the medical home and to improve access to specialists. It can be used to follow up on many issues in an appropriate way.

I worry that people will use it to get poor care for common acute sick issues. When your baby’s fussy or has a fever, you just want help, right? Just because you can doesn’t mean you should use it.

I strongly believe that we need guidelines to use this as a way to bring care to people when they could benefit from it. But telehealth should be restricted to only appropriate uses.

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

From Dr. Mick Connors in Contemporary Pediatrics: What happened to the pediatric medical home?

Top 10 Tips for Going to an Urgent Care

School’s back in session, which means sick season is approaching quickly! The pure volume of sick visits can be overwhelming for any clinic, whether visits are scheduled or walk in, but the nature of walk in clinics makes the volume unpredictable. Sometimes no one in walks in, other times several come at once. Urgent cares and walk in clinics are wonderful for the overall speed at which one can be seen, but how can you help streamline the process? How can you keep your primary care physician in the loop? Here are my top tips for a successful urgent care trip and knowing when to avoid them.

1.  Write down symptoms.

It sounds crazy to write down things since you know your child better than anyone, but if your child is sick you are probably sleep deprived and might forget important details.

Writing things down helps everyone summarize what is going on and get facts straight. The diagnosis often lies in the history, and if the person bringing the child in does not know symptoms well, it’s difficult to make a proper diagnosis.

This also forces you to think about the symptoms, and you might realize that you don’t know everything that’s going on. This is especially true if your child spends time away from you at school, daycare, or with another parent. It’s better to recognize that you need more of the story before you get to the clinic!

2.  Expect to be seen for one acute problem.

Illnesses typically have more than one symptom despite being a single illness. It’s appropriate to bring a child in for multiple symptoms, such as cough, fever, and sore throat.

It is not appropriate to bring them in for those issues as well as a wart and headache of 3 months off and on. If there are unrelated things, expect to deal with the most acute issue and then follow up with your usual physician to discuss the more chronic things at a scheduled appointment.

The nature of walk in clinics is that they move rapidly. The number of patients checking in at any given time can be large, so each visit must be quick. If you need more time to address many issues or one big condition, schedule an appointment.

3.  Don’t attempt to get care for a chronic issue.

Chronic issues are always best managed by your Primary Care Provider (PCP), but exacerbations of chronic issues might need to be seen quickly.

This means that sudden changes to a condition, such as wheezing in an asthmatic, can be addressed at an urgent care, but routine asthma management should be done during a scheduled visit. Your child can go to the walk in for the wheezing, but should follow up with the PCP with a scheduled appointment to discuss any changes needed to the daily medication regimen (Action Plan) to prevent further wheezing.

This is especially important if you went to another urgent care or ER for initial treatment so that your doctor knows about the recent exacerbation of a chronic issue.

4.  Do not add additional children to the visit.

Many parents bring additional kids to the visit and ask if we can “just take a peek” in their ears.

If you want them to be seen, check them in too. Again, walk in clinics move quickly and the “quick” peek often takes longer than you’d think because the child is running around the room or fighting the exam.

The quick peek also does not allow for documentation of findings in the medical record, which might be helpful in the future.

5.  Have your insurance card and co-payment ready at check in.

Streamline checking in by having everything ready.

It’s surprising to me how many people must return to their car for their wallet. For safety reasons, never leave a purse or wallet in your car.

6.  Try to bring only the child who is being seen.

It is difficult to focus on one sick child when another is running around the room, falling off the exam table, or constantly asking questions. This applies to scheduled as well as walk in visits.

I know this becomes a childcare issue, but it can really help focus on the child being seen if you leave additional children at home if at all possible. Think of friends who always offer to have a play date with the healthy child. Or maybe plan to bring one child when the other is at school.

If you must bring multiple kids, set the stage right by avoiding bringing tired and hungry kids. Don’t come at nap time if at all possible. Tired kids are miserable kids. Give them a healthy snack before going to the clinic. Don’t feed your kids at the office – another child could have a food allergy to whatever you’re feeding them, which can put other kids at risk. Bring books or toys that your kids can be entertained with during the visit.

7. Bring medications your child has recently taken.

Often parents have tried treatments at home, but are not sure what was in the bottle.

Bring all medications to help us advise on correct dosage and use of the medications. This includes prescription medicines as well as over the counter supplements, medicines, and natural therapies.

8. Use your regular doctor’s office if available.

I know not all doctor’s offices have walk in hours and most are not open all night long, but most walk in type visits are not emergent and they can wait until the next business day.

Treating symptoms with home remedies is quite acceptable for most illnesses for a couple days. This might even be beneficial to see how the symptoms change over time. Some kids are brought in at the first sign of fever, and look normal on exam, only to develop cough and earache over the next few days. When the symptoms change, so might the exam and treatments!

This is a very important issue and I’ll write more on it next week. Stay tuned! ***Check out Why Wait to See Your Regular Doctor ****

9.  Please don’t use walk in clinics to have health forms filled out.

I know it is tempting to get a quick physical to get a sports form or work physical signed, but doing so breaks the concept of a medical home.

If you get these forms completed outside your PCP’s office, you don’t get a comprehensive visit. The visit with your PCP should include reviewing growth, development, safety, immunization status, and more. It’s more than just filling out forms. You lose the opportunity to share what has happened in the past year and continue to build a trusting relationship.

If the medical home does all the well visits and vaccines, we have up to date records and can update them as needed. Some kids have missed school because vaccines were missed and they can’t return until they get them. Others have gotten extra doses of vaccines because a record of a shot was missing and parents can’t remember where they got the vaccine.

We request a well visit yearly in the medical home after age 3, more often for infants.  If in need of a well visit, please call the office to schedule!

10. Call first if you’re not sure!

If you’re not sure if it’s okay to tough it out at home overnight, call your doctor’s office.

We can often give tips on how to manage symptoms to save the emergency room co pay and germ exposure. Sometimes we do advise going to be seen. If there are concerns about dehydration, difficulty breathing, mental status changes, or other significant issues, waiting overnight is not appropriate.

Most urgent care visits are really not that urgent. They can be handled during normal business hours in your medical home!

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

Why Wait to See Your Regular Doctor When the Urgent Care is Right There?

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!

Meningitis Basics: What you need to know.

Meningitis occurs when a virus or bacteria causes inflammation of our brain or spinal cord. We use several different vaccines to prevent a few types of meningitis, but it’s all very confusing. Recent commercials have raised questions about what these vaccines are and if they’re needed.

Today we’ll go over what meningitis is and what types of germs cause it. Next time I’ll discuss some of the new meningitis vaccines in more detail.

What is meningitis?

Symptoms of MeningitisBoth viruses and bacteria can cause meningitis, but not everyone with these germs gets meningitis. Most people have less severe symptoms when they get these infections.

Not everyone gets all the symptoms listed below when they have meningitis. Some of these symptoms are common to many less serious infections, but if your child has these symptoms and appears more sick than normal, he or she should be evaluated immediately.

Symptoms of meningitis include:
  • fever
  • stiff neck
  • body aches and pains
  • sensitivity to light
  • mental status changes
  • irritability
  • confusion
  • nausea
  • vomiting
  • seizures
  • rash
  • poor feeding

Viral meningitis

Viruses are the most common cause of meningitis. Thankfully viral meningitis tends to be less severe than bacterial meningitis.

Most people recover on their own from viral meningitis. As with many infections, young infants and people who have immune deficiencies are most at risk.

There are many types of viruses that can cause meningitis. It’s likely that you’ve had many of these or have been vaccinated against them.

Non-polio enterovirus

The most common virus to cause meningitis is one from the non-polio enterovirus family.

Fever, runny nose, cough, rash, and blisters in the mouth are all symptoms that kids can get from this type of virus.

Most kids are infected with this type of virus at some point. Adults are less susceptible, and can even have the virus without symptoms.

There is no routine vaccine given for non-polio virus strains.

MM(R)V

Measles, mumps and chicken pox viruses can cause meningitis.

We vaccinate against these typically at 12-15 months of age, so it is uncommon to see these diseases. The MMR and varicella vaccines can be given separately or as MMRV. (Rubella is the “R” and can lead to brain damage in a fetus, but does not cause meningitis.)

Influenza

Influenza can cause meningitis, which is one of the reasons we recommend vaccinating yearly against flu starting at 6 months of age.

Herpesviruses

Herpesviruses can cause meningitis. Despite the name, most of these are not sexually transmitted.

This family of viruses includes Epstein-Barr virus,which leads to mono most commonly. Cold sores from herpes simplex viruses are also in this group. Chicken pox (or varicella-zoster virus) is another of these blistering viruses.

Bacterial meningitis

Bacteria that lead to meningitis can quickly kill, so prompt treatment is important. If you’ve been exposed to bacterial meningitis, you may be treated as well, but remember that most people who get these bacteria do not get meningitis.

Most people who get bacterial meningitis recover, but some have lasting damage. Hearing loss, brain damage, learning disabilities, and loss of limbs can result from various types of meningitis.

Causes of bacterial meningitis vary by age group:

Newborns

Newborns can be infected during pregnancy and delivery as well as after birth. They tend to get really sick very quickly, so this is one age group we take any increased risk of infection very seriously.

Bacteria that tend to infect newborns include Group B Streptococcus, Streptococcus pneumoniae, Listeria monocytogenes, and Escherichia coli.

Mothers are routinely screened for Group B Strep during the last trimester of pregnancy. They are not treated until delivery because this bacteria does not cause the mother any problems and is so common that it could recur before delivery if it’s treated earlier. This could expose the baby at the time of delivery. If a mother does not get adequately treated with antibiotics before the baby is born, the baby may have tests run to look for signs of infection or might be monitored in the hospital a bit more closely.

Once the mother’s water breaks, we time how long it has been because this opens the womb up for germs to infect the baby. If the baby isn’t born during the safe timeframe, your delivering physician or midwife might suggest antibiotics. After delivery your baby might have tests done to look for signs of infection or might be monitored more closely in the nursery.

It is very important that sick people stay away from newborns as much as possible. Everyone should wash their hands well before handling a newborn.

Babies and children

As children leave the newborn period, their risks change. Streptococcus pneumoniae, Neisseria meningitidis and Haemophilus influenzae type b (Hib) are the bacteria that cause disease in this age group.

Thankfully we have vaccines against many of these bacteria. Infants should be vaccinated against S. pneumoniae and H. influenzae starting at 2 months of age. (Note: H. influenzae is not related at all to the influenza virus.)

Vaccines against N. meningitidis are available, but are not routinely given to infants at this time. High risk children should receive the vaccine starting at 2 months of age, but it is generally given at 11 years of age in the US.

Teens and young adults

Neisseria meningitidis and Streptococcus pneumoniae are the risks in this age group.

Thankfully most teens in the US have gotten the S. pneumoniae vaccine as infants so that risk is lower than in years past.

Tweens and are routinely given a vaccine against A, C, W, and Y strains of N. meningitis. A vaccine against meningitis B is recommended for high risk people and can be given to lower risk teens. This will be discussed further in my next blog.

Older adults

Streptococcus pneumoniae, Neisseria meningitidis, Haemophilus influenzae type b (Hib), group B Streptococcus and Listeria monocytogenes affect the elderly

Talk to your parents to be sure they’re vaccinated and follow the vaccine recommendations for yourself too. Vaccines are not just for kids!

‘NI, Leptomeningitis purulenta cerebralis. Alfred Kast’ . Credit: Wellcome Collection. CC BY

 

Swimmer’s Ear

Not all ear infections are created equally. Swimmer’s ear differs from a middle ear infection. It is an inflammation of the skin lining the ear canal and is most common in older children and teens. Middle ear infections (otitis media) are caused by pus behind the eardrum and are most common in infants and younger children.

What is swimmer’s ear?

Swimmer’s ear (AKA otitis externa) gets its name because it is commonly caused by water in the ear canal making a good environment for bacteria to grow, causing an infection of the skin.

Water can come from many sources, including lakes, pools, bath tubs, and even sweat, so not only swimmers get swimmer’s ear.

Increasing the risk of swimmer’s ear:

Anything that damages the skin lining the ear canal can predispose to a secondary infection, much like having a scraped knee can lead to an infection of the skin on your knee. Avoid putting anything in your ears, since it can scratch the skin of the ear canal. This includes anything solid to clean wax out of the ear.

Excess earwax can trap water, so cleaning with a safe method can help prevent infection. A little wax is good though — it actually helps prevent bacterial growth. For more on earwax, please see Ear Wax: Good and Bad.

Yes, it sometimes hurts!

Swimmer’s ear can cause intense pain. Sometimes it starts as a mild irritation or itch, but pain worsens if untreated. It typically hurts more if the ear is pulled back or if the little bump at the front of the ear canal is pushed down toward the canal.

Ear buds (for a music player) or hearing aides can be very uncomfortable (and increase the risk of getting swimmer’s ear due to canal irritation).

Other symptoms:

Sometimes there is drainage of clear fluid or pus from the canal.

If the canal swells significantly or if pus fills the canal, hearing will be affected.

More severe cases can cause redness extending to the outer ear, fever, and swollen lymph nodes (glands) in the neck.

Swimmer’s ear can lead to dizziness or ringing in the ear.

Prevention of swimmer’s ear:

Controlling wax

If your child has excessive wax buildup, talk with his doctor about how often to clean the wax. Wax does help keep your ears clean, so you don’t want to clear it too much!

Keep out!

Never put anything solid into the ear canal.

Drying ears

Dry the ear canals when water gets in.

  • Tilt the head so the ear is down and hold a towel at the edge of the canal.
  • Use a hair dryer on a cool setting several inches away from the ear to dry it.
  • If kids get frequent ear infections or are in untreated water (such as a lake), use over the counter ear drops made to help clean the canal. You can buy them at a pharmacy or make them yourself with white vinegar and rubbing alcohol in a 1 to 1 ratio. Put 3-4 drops in each ear after swimming. The acid of the vinegar and the antibacterial properties of the alcohol help to clear bacteria, and the alcohol evaporates to help dry the canal.
  • DO NOT use these drops if there are tubes or a hole in the eardrum, if pus is draining, or if the ear itches or hurts.
Avoiding swimming when needed

If your child has a scratch in the ear or a current swimmer’s ear infection, avoid swimming for 3-5 days to allow the skin to heal.

Avoid bubble baths and other irritating liquids that might get into ear canals.

If there’s tubes…

If your child has tubes placed for recurrent middle ear infections, talk with your ENT about ear protection during swimming.

The use of ear plugs for swimming with tubes has been controversial, but are generally not needed. Dr. Burton discusses this in 5 Fantastical Ear Tube Myths .

Treating swimmer’s ear:

Pain control

If you think your child has swimmer’s ear, start with pain control at home with acetaminophen or ibuprofen per package directions.

Heating pads to the outer ear often help, but do not put any heated liquids into the ear.

Visit your doctor

Most often swimmer’s ear is not an emergency, but symptoms can worsen if not treated with prescription ear drops within a few days.

Bring your child to the office for an exam, diagnosis, and treatment as indicated. Most can go to their usual physician during during normal business hours if you can get adequate pain control at home.

When to be seen immediately

If the pain is severe, redness extends onto the face or behind the ear, the ear protrudes from the head, or there are other concerning symptoms, your child should be seen immediately at their primary care office or another urgent/emergent care setting.

Ear wicks

Occasionally we will remove debris from the canal or insert a wick to help the drops get past the inflamed/swollen canal.

Never attempt this at home unless you’ve been instructed on how to do it safely!

Prescription ear drops and oral medicine

The prescription ear drops may include an antibiotic (to kill the bacteria), a steroid (to decrease inflammation and pain), an acid (to kill bacteria), an antiseptic (to kill the bacteria), or a combination of these.  They are generally used 2-3 times/day.

Have your child lie on his or her side to put the drops in the ear. He or she should remain on that side for several minutes before getting up or changing sides to allow the medicine to stay in the ear. They can use a cotton ball or tissue to collect and dripping when they get up.

Symptoms generally improve after 24 hours and the infection clears within a week.

Oral antibiotics are usually not required unless the infection extends beyond the ear canal.

If an infection causes more itch than pain or does not clear with initial treatment, we might consider a fungal infection. This requires an anti-fungal medication.

No swimming until the infection clears.

Swimming just adds insult to injury. Let the skin heal before getting it soaked in the pool again!

Special circumstances

Kids (and adults) with diabetes or other immune deficiencies are more likely to get severely sick with any infection.

Visit your doctor early if you suspect a problem.

Summer Penile Syndrome

Did you know there’s a name for the super swollen male parts from bug bites? Actually two names: Summer Penile Syndrome and Lion Mane’s Penis. Doctors might even call it seasonal acute hypersensitivity reaction. If you’ve ever seen it, you know it can be quite impressive.

What is summer penile syndrome?

Summer penile syndrome is a fairly common concern during the summer months. It’s usually due to a chigger bite on the sensitive skin of the penis or scrotum. You can often find a small bug bite near the center of the swelling.

They can itch like crazy, but usually don’t interfere with urinating.

Despite the significant swelling, there isn’t usually much pain, only itching. Unless there’s a secondary infection, there won’t be any fever.

What is a chigger?

Chiggers are a type of mite, which is an arachnid in the same family as spiders and ticks. They are also called harvest mites, harvest bugs, harvest lice, mower’s mites, or red bugs. Chiggers are so small they often go unnoticed until several hours after they attach to our skin. They can attach even under clothing, and the most common places that we notice chigger bites are in the areas of our pants.

Chiggers live in moist, grassy and wooded areas. They are commonly found in the warm summer months.

Adult chiggers don’t bite. It’s the larvae that cause itchy problems. The larvae are red, orange, yellow, or straw-colored, and no more than 0.3 millimeters long.

File-Chigger bite
Chigger. Source: https://commons.wikimedia.org/wiki/File:File-Chigger_bite.svg 
After crawling onto the skin, the larvae inject digestive enzymes into the skin that break down skin cells. They do not actually bite the host even though the bumps are called chigger bites. They form a hole in the skin called a stylostome. Their saliva goes into deep skin layers, which results in severe irritation and swelling.

People usually start to itch within a few hours and often scratch the feeding chiggers away. A hot shower with plenty of soap will kill chiggers and prevent them from finishing their meal, so showering after being in grassy or wooded areas can help prevent deeper reactions.

The good news is that in the US, chiggers are not known to carry diseases.

Prevention

Even though they don’t cause disease, chigger bites are something to avoid because they can cause significant itching for weeks.

Bug sprays with DEET will deter the chiggers. DEET is approved for use in children over 2 months of age.

Clothing can be treated with permethrin to avoid ticks and chiggers. Permethrin can be purchased at sporting goods stores to pre-treat your clothing. It should not be used directly on skin. Once dried into the clothing, permethrin will last for about six washings. You can also treat your shoes, which makes a lot of sense since chiggers are usually found in the grass and crawl up onto your skin.

Even untreated clothing can help a little if you don’t have time to pre-treat with permethrin. Wear long sleeves and long pants. Be sure to tuck the pant legs into your socks so they can’t enter from the bottom leg hole.

For more on bug sprays, including citronella, picaridin, oil of lemon eucalyptus and more, see the EPAs information on registered and unregistered products. You can even use this handy tool to find the right product for your needs.

How do you treat chigger bites?

Much like any bug bite, control of the itch is important. If kids scratch any itch, it can become secondarily infected from the break in the skin allowing germs in.

Antihistamines

Antihistamines are used for allergic reactions. We commonly use them for seasonal allergies, but they can help most allergy reactions.

Bug bites itch when our bodies react to the saliva injected into our skin with histamine. Histamine is our body’s allergic response and it itches. If you aren’t allergic to the bite, you won’t itch from it. This is the way we react to allergies, which is why we get itchy eyes and noses with allergies to pollen.

Diphenhydramine (Benadryl) is a short acting antihistamine that can help control allergic reactions, but tends to make kids tired or wired. It also only lasts a few hours, which can require frequent dosing.

I don’t like topical antihistamines, which are often sold to treat bug bites. I worry that kids will get too much of the medicine when it is applied to each bite. It’s a low risk, but still a risk. Just because they aren’t taking it by mouth doesn’t mean it isn’t absorbed. Children using a topical antihistamine for an extended time over large areas of the skin (especially areas with broken skin) may be at higher risk, especially if they also are using other diphenhydramine products taken by mouth or applied to the skin.

I am a fan of using an oral long-acting antihistamine, such as cetirizine or loratadine, to treat bug bites. Most kids with one bug bite have many. One dose of an oral antihistamine helps to control the overall histamine reaction, making each bite itch less.

Antibiotics

Despite the significant swelling, these usually do not require prescription antibiotics.

If your child has open areas from scratching the skin, you should keep the area clean and consider using a topical antibiotic ointment to help prevent infection.

Steroids

Over the counter topical hydrocortisone is a very low dose steroid. It can be used on insect bites to help stop the itch.

Stronger steroids that require prescriptions are occasionally used, but you will need to see your physician to discuss the risks and benefits of prescription steroids.

Oatmeal baths

Soaking in an oatmeal bath might help the itching. It works very well for dry skin conditions and sunburn relief as well.

You can buy commercially made oatmeal bath products or you can grind regular plain oats to make it fine enough that it dissolves in bath water. Test a small amount in a cup of water to see if it’s finely ground enough before putting 1 cup of oats into the bath water.

Some people have even made a paste of oats and applied it directly to the itchy skin for relief.

Baking soda

Another kitchen remedy for bug bite itch relief is baking soda. Mix a pinch of baking soda with a few drops of water to make a paste. Put this paste on the bites. Reapply as needed.

Ice or cool cloth

One more kitchen treatment is ice. Many kids won’t tolerate this one, but if they can’t tolerate an ice pack placed over clothing, you can try applying a cool wet washcloth directly to the skin.

When should you see your doctor?

If your child has any of the following symptoms, talk with your doctor.

  • Trouble urinating.
  • Pain or itch not controlled with the above measures.
  • Fever.
Fear has big eyes
By Robbie Grubbs from Houston (What????) [CC BY-SA 2.0 (https://creativecommons.org/licenses/by-sa/2.0)], via Wikimedia Commons

Suddenly my child’s peeing all the time… what’s up?

When children suddenly start peeing all the time, we need to consider the many potential causes. There are many reasons kids have frequent urination. Sometimes it’s as simple as they like to flush the toilet or splash in the sink. This is common in newly potty trained kids. But peeing all the time can also signify a medical problem that needs to be addressed. Learn the potential risks of why children run to the restroom frequently or start to have accidents. This can help parents decide if they need to rush to the ER.

Associated symptoms to identify

Frequent urination can be associated with other things that give us a clue as to what is going on. Sometimes they do not seem connected to the urine, so you might not associate the symptoms. Discuss the issues that apply to your child with your child’s physician.

Behavioral changes

Behavioral changes can be a clue. For instance, look for signs of anxiety. Remember that anxiety does not always look like fear. The frequent urination might be due to worrying about not making it to the bathroom in time and having an accident.

Pain

Pain while urinating might signify an infection. Infections often have other symptoms as well.

Pain might also be from skin irritation due to improper wiping in girls. In uncircumcised boys, pain can develop from improper cleaning under the foreskin. Staying in wet swimsuits too long also can lead to skin irritation and painful urination.

Pain in the abdomen, back or side can indicate problems with the kidneys or an infection. Sometimes this is due to constipation. It will require a physical exam and possibly testing to determine the cause. Schedule an appointment with your child’s primary care physician. If the pain is so severe that he or she cannot sleep, walk, or move easily, go to the ER.

Change in urine odor and color

A change in urine smell and color is important to note. Red, brown, cloudy or smelly urine can be signs of kidney damage, infection, bleeding problems, dehydration, and other serious conditions.

Some foods, such as asparagus and coffee, can change the smell of urine. Color changes can also happen as a result of foods, such as beets or berries turning urine red, or rhubarb or fava beans turning urine brown.

Many medications and vitamin supplements can change the color and odor of urine. It will be important to discuss your child’s recent foods, medicines, and supplements with his or her physician.

Other signs of illness

Other signs of illness can offer clues. Think about fevers, cough and cold symptoms, swelling of the eyes or legs, joint pains, and more.

One example to consider would be Rhinovirus. Rhinovirus typically causes upper respiratory tract infections with cough, runny nose, and pink eye. It can also sometimes cause vomiting and diarrhea or urinary tract infection symptoms.

Causes of frequent urination

Diabetes

Frequent urination can be a sign of diabetes. This is a potentially life threatening issue and needs to be addressed immediately.

Symptoms of diabetes will include being very thirsty and frequent urination. Kids might appear dehydrated despite the high urine volume. They can have weight loss, dry mouth, and low energy. Kids with untreated diabetes usually appear sick and tired.

When sugars reach a critical level, diabetics develop fruity breath. This is associated with a pattern of breathing called Kussmaul breathing. This is a medical emergency. Diabetes can be a rapidly developing problem. If you notice this breathing pattern, get to an ER immediately.

Testing for diabetes initially uses a sample of urine. Urine is tested for sugar. If there is sugar in the urine, blood will also be checked.

Children with newly diagnosed diabetes are referred to an endocrinologist. Endocrinologists are specialists in diabetes and other hormone issues. Newly diagnosed diabetics often spend a few days in the hospital for stabilization of medical issues and teaching of how to manage at home.

Urinary tract infection

Urinary tract infections (UTIs) commonly cause frequent urination. Other symptoms, such as fever, pain with urination, and urinary accidents, often occur. Bacteria and viruses can cause UTIs.

UTIs are more common in girls and in boys who are not circumcised.

A urine test can help to determine if there is a UTI. A quick urinalysis can suggest an infection, but a culture is needed for actual diagnosis. A urine culture takes up to 2 days to grow bacteria. Bacterial UTIs are treated with antibiotics. Viral UTIs self resolve after a few days.

Constipation

Many parents are surprised at all the things pediatricians blame on constipation. I can’t say how many parents deny that their child is constipated when they are. An x-ray often shows the abdomen is full of poop even when kids poop every day.

Note: I don’t always get an x-ray to diagnose constipation. Studies are only needed to help with diagnosis if the exam findings are not clear. Usually it’s obvious from the description of the stooling pattern and the look of the poop. Kids often cannot describe their poop accurately, so I use a Bristol Scale. You can use this at home to talk to your kids about their bowel movements.

Many children with constipation don’t initially seem to be constipated so a trial of Miralax is often recommended. This treats the constipation if it exists and is part of the diagnostic evaluation. Diet changes and changes to toileting habits are also important. These take longer to make a difference so I still recommend Miralax.

If treating the constipation helps, continue to treat until it is no longer needed.

Pollakiuria = increased frequency of childhood

Increased frequency of urination, also called pollakiuria, is common and not harmful. Other terms that have been used to describe this condition include extraordinary daytime urinary frequency and increased frequency of childhood.

The cause of this is unknown but often is triggered by a stressful event. Kids with this have a normal physical exam and urinalysis.

Pollakiuria involves frequent urination during the day. Kids will feel the need to urinate frequently, even though there’s really no physical reason.

Most children do not change their nighttime urinary pattern. If they previously wet the bed, they still will. If they previously stayed dry all night, they will continue to stay dry at night.

Pollakiuria is seen more often in boys, but also occurs in girls. It’s most common between 4 and 10 years.

Despite the frustrating symptoms, it’s not a serious illness and it self resolves. It generally lasts 1-6 months and can be quite problematic due to the frequent bathroom trips needed. Some kids pee as often as every 30-90 minutes.

To diagnose this, a child should be seen to discuss the symptoms and to do a physical exam. Often constipation aggravates this issue, so close attention to stool patterns and the abdominal exam are important. A urinalysis should be done to rule out diabetes or urinary tract infection. Pollakiuria is a diagnosis of exclusion. This means there is no test for it, but we rule out other potential causes of frequent urination.

This problem typically starts suddenly and ends suddenly. It can last for months.

What can you do to help if there’s no treatable cause?

If there is a treatable medical condition, treating that condition will usually help the frequent urination. While it seems like there’s nothing to do to help if there’s no cause found, don’t get discouraged! There are things to do that can help.

Contrary to what many intuitively think, drinking plenty of water is beneficial. Don’t limit water!

Don’t punish kids for needing to use the restroom or for having accidents. It may not be under their control at all. If it is a behavioral issue, the child needs support, not punishment. Punishment or belittlement will only make them feel bad. This worsens the situation. It can be hard to not get frustrated, but take a big breath and try to remain calm. Use words that are neutral and not judgmental.

Be sure the teacher knows what’s going on. If your child needs to go to the bathroom frequently, he needs to be allowed.

Remind your child that he or she is healthy. This can help to reduce the anxiety and stress in their minds. Stress can make this condition worse, so reassurance is very important!

Show your child that it’s possible to wait for a longer period of time to urinate. Explain that there will be no urine leakage because that fear increases anxiety about not going to the bathroom. The more confidence they develop, the better their bladder control. Practice waiting a little longer before going to the bathroom and celebrate small improvements.

Foods to avoid if your child has frequent urination:

The foods and drinks listed below may or may not increase frequent urination.

Avoid these for at least for 2 weeks. Slowly re-introduce one at a time to see if they lead to increased urination.

  • Highly acidic foods such as salsa, sodas, teas, coffee, cranberry juice and orange juice.
  • Caffeine acts as a diuretic and increases urine. It’s found in coffee, tea, chocolate, sometimes ice cream or other treats.
  • Spicy foods such as chili peppers, jalapeño peppers, horse radish, curry and salsa.
  • Artificial colors.
  • Carbonated beverages.

Most importantly…

The most important thing to remember is to first rule out medical causes that need to be treated.

Once those are ruled out, this is a lesson in patience. Don’t belittle your child or use harsh words when they need to use the bathroom again. And again. This will pass.

Work on having your child hold their urine for a few minutes longer with encouragement. Frequent urination usually stops as suddenly as it started.

New back to school recommendations for strep throat!

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

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

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

What is Strep throat?

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

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

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

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

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

Does strep throat need to be treated?

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

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

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

Use antibiotics wisely

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

One major reason is to help delay antibiotic resistance.

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

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

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

But antibiotics make us feel better faster, right?

Antibiotics tend to shorten the symptoms by about 16 hours.

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

Look at risk/benefit ratio for all treatments

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

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

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

Are there risks to not treating?

Untreated Strep infections can lead to complications.

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

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

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

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

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

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

About the testing available:

The test commonly used to identify strep is most accurate after symptoms have been there for awhile. The rapid Strep test for the presence of the strep bacteria about 97% of the time. A culture done at the same time may grow the strep bacteria in a few days, but antibiotics are not recommended until either the rapid test or culture is positive, so you’re not getting a head start on antibiotics if the initial rapid test is negative.

Because the rapid strep test looks at the presence of strep , strep testing just tells you the germ is there. The clinical symptoms of strep disease is why you need treatment.  Up to 30% of school age children have strep in their throat. The strep is not necessarily causing disease without symptoms of strep. These symptoms include rapid onset of sore throat, headache, tummy ache and fever, without cough and runny nose.  This is the tricky part and the reason you need your pediatrician to determine if testing is needed.
Do not use telehealth to get your sore throat treated.

In children it is not recommended to diagnose strep throat without a throat swab test. This should be done in a medical clinic to avoid inaccurate testing.

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

When should you not test or treat?

Kids under 3 years old

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

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

Viral symptoms

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

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

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

Recent strep

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

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

contacts of someone with strep

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

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

Pets?

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

Why not just test every sore throat?

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

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

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

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

My back to school recommendations for strep throat:

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

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

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

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

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

Thank you!

Thanks to Dr. Kathy Cain of Topeka Pediatrics for some helpful editing tips!

 

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!