Those of you who follow my blog or are my patients know that I’ve never been a fan of Tamiflu. I’ve written To Tamiflu or Not To Tamiflu and I’ve posted Tamiflu from guest blogger, Dr. Mark Helm. Despite the CDC’s recommendation to use Tamiflu frequently, I rarely prescribe it. And when I do, I often find that the whole course isn’t completed because the kids don’t tolerate it well – usually vomiting, but occasionally they’ve had scary hallucinations. I haven’t seen very much benefit, especially given the cost (and often the difficulty of finding it during peak flu season).
As I’ve said before, Tamiflu doesn’t seem to work as well as needed and it has significant side effects. Not all studies done on Tamiflu were published. Only studies showing a little benefit and minimal side effects were considered in making the recommendations to use it. If many studies show no benefit but aren’t published, it makes it seem better than it is. Most studies are done in adults, but studies in children for prevention of flu and treatment of flu also fail to show much benefit.
A 2013 review of all the studies done in adults found only a 20.7 hour reduction in symptoms (yes, less than one day). In the elderly and those with chronic diseases (among the highest risk adults) no reduction was found. They also found no evidence of decreasing the risks of pneumonia, hospital admission, or complications requiring an antibiotic. This same review also showed more side effects than commonly reported. Nausea, vomiting, and psychiatric side effects are common.
Will the CDC join in?
I hope that the CDC reviews its recommendations for antiviral use before the influenza season hits this year. Until then, plan on getting your family protected with the flu vaccine. It isn’t perfect, but it does help keep us from getting sick and it can help save lives!
It’s allergy season! Prevention and treatment is important if you have seasonal allergies so you can enjoy the great outdoors. This is an update to a previous blog I wrote on the subject, since there are many more medicines now available over the counter.
These symptoms last longer than the typical cold, which usually resolves after 1-3 weeks. Fever is a sign of infection, not allergies. Other than fever, it is very difficult sometimes to decide if it is a virus or allergies until a seasonal pattern really develops. Even then it is possible to get colds during allergy season some years!
It is best to treat before the symptoms get bad. It is easy to monitor pollen counts online to know what’s out there and start treatment before symptoms make you (or your child) miserable. Treatments include medicines and limiting exposure.
I don’t want kids with outdoor allergies to be afraid to go outside, so taking medicines to keep the symptoms at bay while out can help.
Antihistamines work to block histamine in the body. Histamine causes the symptoms of allergies, so an antihistamine can help stop the symptoms. Some people respond well to one antihistamine but not others.
In general I prefer the 24 hour antihistamines simply because it is impossible to cover the full day with a medicine that only lasts 4-6 hours. Different antihistamines work better for some than others. Personally loratadine does nothing for me, fexofenadine is okay, but cetirizine is best. I have seen many patients with opposite benefits.
You will have to do a trial period of a medicine to see which works best. If they make your child sleepy, giving at bedtime instead of the morning might help.
Prescription antihistamines are available, but usually an over the counter type works just as well and is less expensive. Insurance companies rarely cover the cost of antihistamines these days.
Antihistamine and decongestant combinations
Antihistamine and decongestant combinations are available but are not usually recommended by me. Once control of the mucus is achieved, a decongestant isn’t needed.
If you need a decongestant initially, you can use one with your usual antihistamine. Most decongestants on the market are ineffective. If you ask the pharmacist for pseudoephedrine, it is available behind the counter. It was replaced by phenylephrine years ago due to concerns of methamphetamine production, but works a little better than phenylephrine.
Decongestants do NOT fix a cold, they only dry up some of the mucus. Decongestants can cause dizziness, heart flutters, dry mouth, and sleep problems, so use them sparingly and only in children over 4 years of age.
Nasal steroids are often the preferred treatment based on effectiveness and tolerability.
Eye drops can help alleviate eye symptoms. They are available both as over the counter allergy drops and prescription allergy eye drops. If over the counter drops fail, make an appointment to discuss if a prescription might help better.
Most insurance companies don’t cover prescription allergy eye drops well, so you might want to check your formulary before asking for a prescription. This is usually available on your insurance website after you log in.
Tips to administer eye drops include washing hands before using eye drops, put the drop on the corner of the closed eye (nose side) and then have the child open his eyes to allow the drop to enter the eye.
Montelukast (commonly known as Singulair) works to stop histamine from being released into the body. It helps control both allergies and asthma and is best taken in the evening. Once a person has been on montelukast for a couple of weeks, they usually don’t need an antihistamine any longer. It is available only by prescription, so make an appointment to discuss this if your child might benefit.
Steroids decrease allergic inflammation well. These can include both oral steroids for severe reactions (such as poison ivy on the face or an asthma attack) and inhaled corticosteroids for the nose (or lungs in asthma). These require a prescription, so a visit to your provider is recommended to discuss proper use.
The longer your airway is exposed to the allergen (pollen, grass, mold, etc) the more inflammation you will have.
Wash off pollen
Wash hair, eyelashes, and nose after exposures — especially before sleep. They all trap allergens and increase the time your body reacts to them.
I have found the information and videos on Nasopure.com very helpful to teach kids as young as 2 years to wash their noses.
keep pollen out of the house
Remove clothing and shoes that have pollen on them when entering the house to keep pollen off the couch, beds, and carpet.
Wash towels and sheets weekly in hot water.
Vacuum and dust weekly. Consider cleaning home vents. Consider hard flooring in bedrooms instead of carpeting.
Wash stuffed animals and other toys regularly and discourage allergic children from sleeping with them.
There are many types of air filters that have varying benefits and costs. For information on air filters see this pdf from the Environmental Protection Agency: Aircleaners.
Keep the windows closed. Sorry to those who love the “fresh air” in the house. For those who suffer from allergies, this is just too much exposure!
Think about pets
Keep pets out of bedrooms. If you know a family member is allergic to an animal, don’t get a new pet of this type! If you already have a loved pet someone in the home is allergic to, consider allergy shots against this type of animal.
Contact lens wearers
If itchy eyes are a problem for contact lens wearers, a break from the contacts may help. Talk with your eye doctor if eye symptoms cause problems with your contacts.
Smoke is an added irritant
Keep smoke away. Smoke is an airway irritant and can exacerbate allergy symptoms. Remember that the smoke dust remaining on hair, clothing, upholstery, and other surfaces can cause problems too, so kids can be affected even if you don’t smoke near them.
What if all of the above isn’t helping?
Maybe it’s really not allergies.
Allergies to things other than foods are rare before 2 years of age.
Viruses can cause very similar symptoms to allergies.
Allergy testing is possible by blood or skin prick testing, but can be costly. In most cases I don’t find it very helpful for environmental allergens because you can’t avoid them entirely and you can always limit exposures as above. I think that tracking seasonal patterns over a few years can identify many of the allergens. You can still treat as needed during this time. Reports of pollen and mold counts are found on Pollen.com. Note also animal exposures and household conditions. Write symptoms and exposures weekly (or daily). It often doesn’t take long to see patterns. Testing is important if allergy shots are being considered.
Need help tracking allergy symptoms?
There’s an app for that! Here’s one review I found of allergy apps. I don’t have any personal experience of any, so please put your favorite in the comments below to help others!
Wrong medicine or wrong dose.
Some people have more severe allergies and need more than one treatment. Allergies tend to worsen as kids get older. Switching types of medication or adding another type of medicine might help. If you need help deciding which medicine(s) are best for your child, an office visit for an exam and discussion of symptoms is advised.
Some kids outgrow a dose and simply need a higher dose of medicine as they grow.
Is Nothing working?
Consider allergy shots (immunotherapy) to desensitize against allergens if symptoms persist despite your best efforts as above. Schedule an appointment with your pediatrician to discuss if this is an option for your allergy sufferer.
Spring Break is around the corner, which means many of my patients will be traveling to various areas of the world for vacation or mission trips. Many of these areas require vaccines prior to travel, so plan ahead and schedule a travel appointment with your doctor (if they do them) or at a travel clinic. Many insurance companies do not cover the cost of travel medicine visits, medications, or vaccines, but they are important and are a small cost in comparison to getting sick when on your trip.
Vaccinate when you can!
Immunization records will need to be reviewed, so if you are going to a travel clinic outside your medical home (doctor’s office) be sure to bring the records with you.
Vaccines work best when they are given in advance, so do not schedule the pre-travel visit the week you leave! Some vaccines that are recommended are easily available at your primary medical office but others are not commonly given so might require a trip to a local health department, large medical center, or travel clinic.
Check with your insurance company to see if the cost of the vaccine will be covered or not so you can include your cost in your travel budget if needed.
Watch the food and drinks
Many diseases are spread through eating and drinking contaminated foods. If in doubt: do not eat! Cooked foods are generally safer. Any fresh fruits or vegetables should be washed in clean water before eating. Be sure all dairy products are pasteurized. Avoid street vendors, undercooked foods (especially eggs, meats, and fish), salads and salsas made from fresh ingredients, unpeeled fruits, and wild game. Drink bottled water or water that has been boiled, filtered or treated in a way that is known to be reliable. Use the same water to brush teeth. Do not use ice unless you know it is from safe water because freezing does not kill the germs that cause illness.
As always, wash hands often, use sanitizer as needed when washing is not available, and avoid touching the “T” zone of your face (eyes, nose, and mouth). Do not share utensils or foods. Avoid people who are obviously ill.
Medicines for travelers Diarrhea
Many companies that schedule international travel recommend bringing antibiotics for prevention or treatment of diarrhea.
This is not recommended by many experts due to the rise of “superbugs” with the use of unnecessary antibiotics.
In general, the use of antibiotic prophylaxis is recommended only for high-risk travelers, and then only for short periods.
The average duration of illness when untreated will be 4 to 5 days, with the worst of the symptoms usually lasting less than a day.
Antibiotics should be reserved for the treatment of more serious illnesses that include fever and significant associated symptoms such as severe abdominal pain, bloody stools, cramping, and vomiting.
Bismuth subsalicylate is available over the counter for adults and can reduce traveler’s diarrhea rates by approximately 65% if taken four times daily. Risks of bismuth products are that it can turn the tongue and stool black and they contain salicylate. Salicylate carries a theoretical risk of Reye syndrome in children, so should be avoided in children.
Probiotics and prebiotics have been shown to help prevent and treat diarrheal illnesses safely in most people with intact immune systems.
Many diseases are spread by mosquitos. Contact with mosquitoes can be reduced by using mosquito netting and screens (preferably insecticide-treated nets), using an effective insecticide spray in living and sleeping areas during evening and nighttime hours, and wearing clothes that cover most of the body. Everyone at risk for mosquito bites should apply mosquito repellant. See below for prevention medication options.
Vehicle safety risks vary around the world. Know local travel options and risks. Only use authorized forms of public transportation. For general information, see this International Road Safety page.
Learn local laws prior to travelling.
Be sure to talk with your teens about drug and alcohol safety prior to travel. Many countries have laws that vary significantly from the United States, and some teens will be tempted to take advantage of the legal nature of a drug or alcohol.
Remind everyone to stay in groups and to not venture out alone.
Dress appropriately for the area. Some clothing common in the United States is inappropriate in other parts of the world. Americans are also at risk of getting robbed, so do not wear things that will make others presume you are a good target.
Wear sunscreen! It doesn’t matter if you’re on the beach or on the slopes, you need to wear sunscreen every time you’re outside. Don’t ruin a vacation with a sunburn.
It is a great idea to take pictures of everyone each morning in case someone gets separated from the group. Not only will you have a current picture for authorities to see what they look like, but you will also know what they were wearing at the time they were lost.
Take pictures of your passport, vaccine record, medicines, and other important items to use if the originals are lost. Store the images so you have access to them from any computer in addition to your phone in case your phone is lost.
Have everyone, including young children, carry a form of identification that includes emergency contact information.
Create a medical history form that includes the following information for every member of your family that is travelling. Save a copy so you can easily find it on any computer in case of emergency.
your name, address, and phone number
emergency contact name(s) and phone number(s)
your doctor’s name, address, and office and emergency phone numbers
the name, address, and phone number of your health insurance carrier, including your policy number
a list of any known health problems or recent illnesses
a list of current medications and supplements you are taking and pharmacy name and phone number
a list of allergies to medications, food, insects, and animals
a prescription for glasses or contact lenses
Specific Diseases to Prevent
Risks of illness vary depending on where you will be travelling and what time of year it will be. I refer to the CDC’s travel pages and the Yellow Book for information on recommendations. Some of the most common issues to address are discussed below in alphabetical order.
Dengue is a mosquito-borne viral illness. It is seen in parts of the Caribbean, Central and South America, Western Pacific Islands, Australia, Southeast Asia, and Africa. There is no vaccine or specific treatment. Mosquito bite prevention measures are important.
Infants should begin vaccinations against Hepatitis B starting at birth and against Hepatitis A starting at a year of age. Be sure these vaccines are up to date. Hepatitis A is spread through food and water, so be sure to follow the above precautions even if vaccinated.
Malaria transmission occurs in large areas of Africa, Latin America, parts of the Caribbean, Asia (including South Asia, Southeast Asia, and the Middle East), Eastern Europe, and the South Pacific. Depending on the level of risk (location, time of year, availability of air conditioning, etc) no specific interventions, mosquito avoidance measures only, or mosquito avoidance measures plus prescription medication for prophylaxis might be recommended.
Atovaquone-proguanil should begin 1–2 days before travel, daily during travel, and 7 days after leaving the areas. Atovaquone-proguanil is well tolerated, and side effects are rare but include abdominal pain, nausea, vomiting, and headache. Atovaquone-proguanil is not recommended for prophylaxis in children weighing <5 kg (11 lb).
Mefloquine prophylaxis should begin at least 2 weeks before travel. It should be continued once a week, on the same day of the week, during travel and for 4 weeks upon return. Mefloquine has been associated with rare but serious adverse reactions (such as psychoses or seizures) at prophylactic doses but are more frequent with the higher doses used for treatment. It should be used with caution in people with psychiatric disturbances or a history of depression.
Primaquine should be taken 1–2 days before travel, daily during travel, and daily for 7 days after leaving the areas. The most common side effect is gastrointestinal upset if primaquine is taken on an empty stomach. This problem is minimized if primaquine is taken with food. In G6PD-deficient people, primaquine can cause hemolysis that can be fatal. Before primaquine is used, G6PD deficiency MUST be ruled out by laboratory testing.
Doxycycline prophylaxis should begin 1–2 days before travel to malarious areas. It should be continued once a day, at the same time each day, during travel in malarious areas and daily for 4 weeks after the traveler leaves such areas. Doxycycline can cause photosensitivity so sun protection is required. It also is associated with an increased frequency of vaginal yeast infections. Gastrointestinal side effects (nausea or vomiting) may be minimized by taking the drug with a meal and it should be swallowed with a large amount of fluid and should not be taken before bed. Doxycycline is not used in children under 8 years. Vaccination with the oral typhoid vaccine should be delayed for 24 hours after taking a dose of doxycycline.
Chloroquine phosphate or hydroxychloroquine sulfate can be used for prevention of malaria only in destinations where chloroquine resistance is not present. Prophylaxis should begin 1–2 weeks before travel to malarious areas. It should be continued by taking the drug once a week during travel and for 4 weeks after a traveler leaves these areas. Side effects include gastrointestinal disturbance, headache, dizziness, blurred vision, insomnia, and itching, but generally these effects do not require that the drug be discontinued.
We routinely give the first vaccine against measles (MMR or MMRV) at 12-15 months of age, but the MMR can be given to infants at least 6 months of age if they are considered high risk due to travel or outbreaks. Under 6 months of age, an infant is considered protected from his mother’s antibodies. These antibodies leave the baby between 6 and 12 months. The antibodies prevent the vaccine from properly working, which is why we generally start the vaccine after the first birthday.
Any vaccine dose given before the first birthday does not count toward the two doses required after the first birthday, but might help protect against exposure if the immunity from the mother is waning. It is safe for a child to get extra doses of the vaccine if needed for travel between 6 and 12 months.
Meningococcal disease can refer to any illness that is caused by the type of bacteria called Neisseria meningitidis. Within this family, there are several serotypes, such as A, B, C, W, X, and Y. This bacteria causes serious illness and often death, even in the United States. In the US there is a vaccine against meningitis types A, C, W, and Y recommended at 11 and 16 years of age but can be given as young as 9 months of age. MenACWY-CRM is newly approved for children 2 months and older.
There is a vaccine for meningitis B prevention recommended for high risks groups in the US but is not specifically recommended for travel.
Meningitis vaccines should be given at least 7-10 days prior to potential exposure.
Travellers to the meningitis belt in Africa or the Hajj pilgrimage in Saudi Arabia are considered high risk and should be vaccinated. Serogroup A predominates in the meningitis belt, although serogroups C, X, and W are also found. There is no vaccine against meningitis X, but if one gets the standard one that protects against ACWY, they will be protected against the majority of exposures. The vaccine is available for children 9 months and older in my office and a newer vaccine is approved for 2 months and up. Boosters for people travelling to these areas are recommended every 5 years.
Tuberculosis (TB) occurs worldwide, but travelers who go to areas of sub-Saharan Africa, Asia, and parts of Central and South America are at greatest risk. Travelers should avoid exposure to TB in crowded and enclosed environments and avoid eating or drinking unpasteurized dairy products. The vaccine against TB (bacillus Calmette-Guérin (BCG) vaccine) is given at birth in most developing countries but has variable effectiveness and is not routinely recommended for use in the United States.
Those who receive BCG vaccination must still follow all recommended TB infection control precautions and participate in post-travel testing for TB exposure.
It is recommended to test for exposure in healthy appearing people after travel. It is possible to have a positive test but no symptoms. This is called latent disease. One can remain in this stage for decades without any symptoms. If TB remains untreated in the body, it may activate at any time. Typically this happens when the body’s immune system is compromised, as with old age or another illness.
Appropriately treating the TB before it causes active disease is beneficial for the long term.
Typhoid fever is caused by a bacteria found in contaminated food and water. It is common in most parts of the world except in industrialized regions (United States, Canada, western Europe, Australia, and Japan) so travelers to the developing world should consider taking precautions. There are two vaccines to prevent typhoid.
Children over 2 years of age can be vaccinated with the injectable form. It must be given at least 2 weeks prior to travel and lasts 2 years.
The oral vaccine for children over 5 years and adults is given in 4 doses over a week’s time and should be completed at least a week prior to travel. The oral vaccine lasts 5 years.
Neither vaccine is 100 % effective so even immunized people must be careful what they eat and drink in areas of risk.
Yellow fever is another mosquito-borne infection that is found in sub-Saharan Africa and tropical South America. There is no treatment for the illness, but there is a vaccine to help prevent infection. Some areas of the world require vaccination against yellow fever prior to admittance. Yellow fever vaccine is recommended for people over 9 months who are traveling to or living in areas with risk for YFV transmission in South America and Africa.
At this time it is advised that pregnant women and women who might become pregnant avoid areas in which the zika virus is found. For up to date travel advisories due to this virus, see the CDC’s Zika page.
While these guidelines are written for physicians and other medical providers, if patients understand the guidelines it can help them know what to do when they (or their children) have a sore throat. Many parents presume Strep with every sore throat, but in reality only 20-30% of sore throats are bacterial in kids. The large majority (70-80%) are from a virus and do not need an antibiotic. In adults the number of sore throats needing antibiotics is even lower – only 5-15%. Nationwide, 70% of people who go to a medical provider with a sore throat get an antibiotic. This means many are treated unnecessarily.
Why do we treat Strep throat with antibiotics?
In most cases Strep throat will be handled by the body’s immune system over a relatively short time. Without treatment most symptoms go away within a few days.
Before antibiotics were available most people with Strep throat got better on their own. Unfortunately the Strep bacteria can affect the heart (rheumatic fever) or kidneys (streptococcal glomerulonephritis) or cause other problems if left untreated. Treating with antibiotics early can prevent some of these complications.
Why do we want to avoid antibiotics if it is a virus?
Antibiotics do not help the body get better or even feel better faster if a virus is causing the symptoms. They simply are ineffective against viruses.
They do carry risks: diarrhea and allergic reactions are two relatively common issues.
Overusing antibiotics leads to bacterial resistance, which means when someone is sick with a bacterial infection, several antibiotics might fail because the bacteria has become a “super bug” and less inappropriate use will cause fewer super bugs.
How can you know when to bring your kids in for evaluation?
Strep throat and viral sore throats have a lot of common symptoms.
Strep throat typically causes a sudden onset of one or more of the following:
If there are “cold” symptoms such as runny nose, cough, hoarse voice, diarrhea, or eye discharge, it is more often from a viral upper respiratory tract infection, not a bacterial infection.
Children under 3 years of age are less likely to get Strep throat, but it is very common in school aged children.
The only way to know if it is Strep throat or not is to get a throat swab and test it. A rapid antigen test is typically available in less than 10 minutes. If it is positive, treatment is indicated. If it is negative, a culture can be done to confirm Strep or no Strep. This takes about 2 days.
To prevent rheumatic fever, treatment should be started within 9 days of symptoms starting. Unfortunately treatment does not affect the kidney disease that rarely is a complication of Strep throat.
It is not an emergency to run in to the ER overnight for possible Strep throat, but do bring kids in if they have symptoms of Strep without viral symptoms.
Also bring them in if their viral symptoms warrant evaluation in their own right (difficulty breathing, extreme pain, dehydration) or if you are unsure what is going on.
My summary of the guidelines:
1. Establish the diagnosis by swabbing the throat and doing a rapid antigen test and/or culture. Do not treat “because it looks like Strep” because it usually isn’t.
2. If the rapid antigen test is negative in children and adolescents, a back up culture is indicated. Adults do not need a back up culture unless Strep is highly suspected.
3. Blood titers are not recommended to check for current Strep throat infection because they reflect past infections. These are used to evaluate more chronic conditions.
4. Testing is not recommended if symptoms suggest a viral infection (cough, runny nose, hoarseness, oral ulcers). Falsely positive Strep tests can happen, and then an unnecessary antibiotic would be given with a virus infection.
5. Children less than 3 years of age do not routinely need to be tested for Strep because they are very low risk of complications of rheumatic fever, but the provider can test them if they have known exposure and symptoms of Strep.
6. Follow up throat cultures after treatment are not routinely recommended but can be considered in certain circumstances (if carrier status is suspected).
7. Testing or treatment of contacts of patients with Strep throat is not recommended if those contacts have no symptoms. (This means if Brother has a positive Strep test, there is no need to test or treat Sister if she has no symptoms. But… if she develops symptoms she should come in for a test.)
8. Patients with Strep throat should be treated with an appropriate antibiotic for an appropriate time. This is typically a penicillin (such as amoxicillin) for 10 days. For those with a penicillin allergy, cephalosporins or clindamycin or clarithromycin for 10 days is recommended. Azithromycin for 5 days at Strep dosing levels is acceptable for patients with allergies to other antibiotics.
9. Use of fever reducer/pain relievers, such as acetaminophen or ibuprofen, should be considered as needed. Aspirin should be avoided in children. Steroids are not recommended.
10. Patients with recurrent Strep throat at close intervals should be evaluated for chronic Strep throat carrier status with repeated viral infections.
11. Strep carriers do not require antibiotics because they are unlikely to spread Strep to close contacts and are not at risk of developing complications of Strep (rheumatic fever).
12. Tonsillectomy is not recommended to reduce the frequency of Strep throat.