Vaccines Don’t Have to Hurt As Much As Some Fear

Many kids are scared of shots. Some even fight parents and nurses when it’s time to get shots. The more they fight and worry, the worse it gets. But it doesn’t have to be that way.

Increasing the fear

In general there are some things that increase anxiety about shots or just make them seem bad.

Lying

Do not tell kids it won’t hurt. Shots can hurt. Lying doesn’t help. It just minimizes their fear and makes things worse. It might hurt, but how much is variable. Pain is a very individualized feeling. You can describe it as a pinch. Some kids do better with advance warning.

No promises

Never tell kids they won’t get a shot at the doctor’s office. They might be due for one (or more) and if they were specifically told they won’t get one, they are usually more upset.

Threats

Don’t threaten kids with shots if they misbehave. This makes kids see shots as a negative.

Siblings

Siblings can increase anxiety with their teasing. Don’t share the need for shots with siblings and if it’s possible to leave siblings at home when one child will need shots, that might work best.

Your fears

Some kids worry more because parents are worried or presume the child will be worried. When the parent starts talking about shots in a worrisome manner it feeds into the fear. Try to be factual. Don’t start telling them it’s okay and not to worry. That tells them there’s something to worry about.

Building anticipation

Some kids do best if they don’t know shots are coming. If they ask if they’ll get shots at an upcoming visit, you can say you don’t know. If you think your child will lose sleep for days worrying about the shots, this is often the best way to handle it. Then the doctor and nurse at the office can deliver the news and it isn’t your fault.

How to prepare

If you want to prepare your kids before bringing them in for shots or if you just need some help when you’re at the office, follow these tips:

Risks and Benefits

I often ask kids if they’ve ever gotten hurt playing outside. They usually say yes. Then I ask if they still wanted to play outside again. They usually say yes. I might sound surprised that even though they know that they can get hurt, they still want to play, but then I “realize” that it was because the benefit (playing) outweighs the risk (getting hurt). Then we talk about the benefits of the shot are so much more than the quick poke and a little pinch feeling. This works really well for the middle school shots because they’re old enough to get the connection.

Medicine?

Don’t pre-treat with an oral pain reliever. Studies have shown that acetaminophen and ibuprofen decrease the immune response, which might make the vaccines less effective.

Crying’s okay

Don’t tell kids to not cry. It’s okay to be scared and to feel pain. Let them know what is and is not okay. If they cry it’s okay. It is not okay to kick, hit, run, or do anything that can harm others or themselves.

Education

Educate kids about how vaccines help us. There are many resources available. When they understand why the shots are good for them, it helps them to accept them.

Practice

Practice what happens when we get shots.

Have them practice sitting still and making their arms loose.

Wipe the arm with a tissue as you explain the person giving the shot will clean the area with a very cold wet tissue to clean the area. (I avoid the term alcohol swab because the term alcohol confuses younger kids who learn about drug prevention in school.)

Pinch the arm to show them there will be a small pinching feeling.

Put a bandaid on the area if they like or just explain that they can get a bandaid when it’s over. (If your child hates bandaids, tell the person giving shots that they prefer to not have them.)

Let them practice giving you a “shot” too.

Show that the poke will be fast and they can move their arms up and down afterwards to make the sting go away.

Lovies

Bring a comfort item from home, such as a stuffed animal or blankie.

Blowing

There is evidence that blowing out or coughing during the injection helps decrease the pain. We often recommend this for kids old enough to blow or cough.

Sometimes we’ll entice preschoolers with bubbles or pinwheels. It really helps!

Distraction

Other forms of distraction can help too. Telling stories, reading books, or watching a video on a smart phone or tablet are great distractions.

Sit vs Lay Down

Studies have shown that allowing kids to sit (rather than force laying down) during shots is perceived as less painful. The less restraining the child needs, the better. It makes sense that if they need to be held down they will be more scared and it will be perceived as more painful.

I have seen tweens and teens prefer to lay down if they have a history of getting light headed with needles or they’re worried about fainting.

Order of vaccines

Ask the person giving the vaccines to save the most painful vaccine for last, if applicable. (Our nurses do this routinely.)

Pain DISTRACTOR devices

Our office sometimes uses Buzzy when kids are especially afraid of shot pain. As long as the child isn’t overly worked up and they aren’t opposed to the coldness of the ice, Buzzy works fantastically! If kids have worked themselves into a frenzy it isn’t sufficient to distract in this way.

Bribery

I used to think bribery was not a good parenting technique… until I had kids. It can be very effective. If you can promise a reward for being brave, such as stopping for a smoothie or getting a favorite treat, that can work wonders.

Just do it

I like this Dr. Mom’s take on getting shots. Dr. Corriel knows that her son will just need to do it. Fear and all.

Help with anxieties in general

(great for life worries, not just shots!)

Build up bravery

After kids do things that they were afraid of, congratulate them for the attempt. Remind them that even though they were scared they did it. This helps set the pattern that they can be brave when faced with any fear.

Kids can even keep a list of things that they did despite being scared to try. Make a “Bravery Book.”

They can use the list whenever a new fear pops up to see how many things they’ve already done and how brave they really are.

video to future self

I’ve started recommending that parents take a video of kids to show their future self if they can say it didn’t hurt as much as they worried it would.

We all tend to remember the anxious phase of excessive worry, but forget that it wasn’t that bad.

Show the video the next time shots are due. Their own self stating it wasn’t bad can be reassuring!

Meditation

Use a meditation app, such as Stop, Breathe & Think. It’s free and helps with general anxieties as well as mindfulness. Download it and use it at home several times to let them get comfortable using it.

Some great articles:

Share Quest for Health

HPV Vaccine Concerns

The large majority of the parents who bring their children to my office want their children to be vaccinated against any disease we can protect them against. The HPV vaccine is one exception. While most of my patients are given the Gardasil at their 11 or 12 year check up, some parents still “want to do their research” or “have heard things” so they decline to protect their kids at those visits. Sadly they often return year after year and say that they still haven’t done their research, so their child remains unprotected. Sometimes they’ll say that they will let their child decide at 18 years of age. Sadly, by that age many will have already been infected.

I recently had a parent share HPV Vaccine: Panacea or Pandora’s Box? The Costs and Deceptiveness of the New Technology with me. She had concerns based on the information in this article. The first thing I noted was that it is from 2011. This is outdated, since we have learned so much in the six years since it was published, yet like many anti-vax articles, it continues to circulate online.

 The first argument is that it won’t last long enough.

It is therefore possible that the protective effects of the vaccination will wane at the time when women are most susceptible to the oncogenic effects of the virus (those over 30), providing protection to those who do not need it (adolescents) and failing to provide protection to those who do (women over 30).

Studies show protection lasts 10 years and hasn’t dropped by that time. If future studies show a booster is needed, we can add that. That in no way should mean to not give protection for the years it is really needed – adolescence and young adult life. I cannot agree with the statement that providing protection “to those who do not need it (adolescents)” at all. Yes teens need protection. I’ll get more into their risks below. And the fact that women over 30 are more likely to develop the cancer does not mean that is when they come into contact with the virus. It’s kind of like saying that kids don’t need to brush their teeth because they don’t have cavities. If you wait for the cavities to develop, it’s too late!

The second argument is based on old version of the vaccine.

We now use the 9 valent variety, which covers the large majority of cancer causing strains. Again, even if there are other strains, why not protect against what we have?

Natural immunity lasting longer than vaccine immunity?

The argument that natural immunity will last longer than the vaccine immunity is not a valid argument. Natural immunity can wane with some diseases too, and if we can protect against the disease, it is preferable. Boosters for many vaccines are needed when we know immunity wanes. That’s okay. Some parents advocate to not vaccinate and get the real disease. When their kids get whooping cough they’re miserable. Many are hospitalized. Some even die. I’d rather do boosters! (This may be a bad example because I don’t think our booster for whooping cough lasts long enough and there are complications with giving boosters more often, but ongoing surveillance and research will continue and hopefully improve the situation.)

The cost issue is interesting.

If it was not cost effective in the long run, insurance companies wouldn’t pay for it. It’s that simple. They’ve done the math. Australia is a great example. Their cancer rates are down because HPV is a mandatory vaccine.

Debunking Risks

The risks listed have all been shown to not be as risky as once shown.

Abstinence as prevention?

The article also alludes to this being a sexually transmitted disease so we can just teach abstinence until marriage.

There are so many things wrong with this.

First, this virus can spread through non-intercourse activities, which can be part of a normal and healthy teen relationship.

Second, even if your child is a virgin at marriage, their spouse might not be. Or the spouse could die and they remarry.

Or there could be infidelity in marriage.

There may not be signs of this virus during an infection. Testing for HPV is recommended for women over 30 years of age, but is not available for men at any age, so teens and young adults will not know if they have the virus or not.

And we know that abstinence only teaching fails. Some people raised in strict Christian households have sex outside of marriage.

Teaching kids to protect themselves is much more effective to prevent many sexually transmitted infections, but condoms don’t always protect against HPV transmission.

And there’s always rape. One out of four women has been sexually assaulted. One in four! What a horrible thing to be raped. Then to find out you get cancer from that…

What about males?

They argue it hasn’t been tested in males.

It has.

And it cuts cancer rates in men too. They’re not just vectors as stated in the article.

We keep learning

This article is several years old.

It didn’t yet know that the cancer rates in Australia would fall like we now know.

We’ve learned much more information than they knew in 2011 when it was written.

We know the HPV vaccine is safe.

It is best given before the teen years to induce the best immune response and to get kids protected before the risk of catching the virus becomes more likely.

It isn’t a lifestyle choice to get this virus, as it seems the author claims. People have sex. This virus and other infections can spread through sex. But this virus is also spread without intercourse (such as through oral sex or skin to skin contact without sex), which is why 80% of the adult population has had the virus at some point.

If you don’t think the risk is real

Someone You Love is a documentary that follows several women with HPV related cancer. If you still think the vaccine isn’t worth it for your child, watch it. I am not paid in any way to recommend this. It simply is a powerful documentary that shows the devastation of HPV disease and you should see that before saying your child doesn’t need protection.

Do I recommend the vaccine?

I strongly feel this is a safe and effective vaccine. So much so that my own teens received three doses of the original Gardasil and one dose of Gardasil 9 despite no official recommendations for this booster. I want to protect them in any way that I can.

If I had any concerns about its safety I would not have given it to my own children.

I don’t think I can list any study or give any argument stronger than that.

Many people raise concerns about the HPV vaccine, but the studies show it's safe and effective to prevent cancer in both men and women.

Tamiflu status downgraded!

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).

WHO Downgrades Tamiflu

The World Health Organization (WHO) has recently downgraded the status of Tamiflu. The CDC and FDA will have to chime in for the US recommendations, but the WHO is a respected source of medical guidelines and I look forward to a response from the CDC.

Risks vs benefits

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.

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!

 

tamiflu
Tamiflu is an antiviral used against influenza, but there are many questions of safety and efficacy.

It’s Back to School Time, Time to Think Safety!

Walking to school is wonderful for kids because they get exercise, which can help with focus at school and their overall health. It can be also be a time to talk with friends or family and build community bonds. As kids are heading back to school after the summer break, we must think about their safety.

Walking to school can pose dangers, especially if drivers are distracted talking to their own children or texting. Please stop texting and driving. Don’t touch your phone at all while driving. Calls and texts can wait. If they can’t, pull over and check the message while parked.

Really.

Talk to your kids about safety:

walking to school with others

Kids should walk with an adult until they show the maturity to walk safely without direct supervision. The specific age will depend on the area as well as the child’s maturity.

Are there safe sidewalks? Are there busy roads to cross? Are there other kids walking the same route? Are there homes along the way they can go to in case of emergency? How long is the walk?

When kids have mastered the route and are competent to walk the distance alone, find walking partners. Have kids stay in groups or with a walking buddy as much as possible.

See if your school can help arrange walking buses, where kids all walk the same route to school with adult walk leaders.

Find the safest route

Choose sidewalks wherever possible, even if that means the trip will be longer. If there are no sidewalks, walk as far from vehicles as possible, on the side of the street facing traffic.

If possible, avoid areas near high schools, where there are more teen drivers.

Cross streets safely

If there are crossing guards, use those intersections. If there are street lights, wait until the “walk” symbol appears.

Never cross in the middle of a block, use intersections.

Look both ways twice before crossing.

Do not text or play games when in the street.

Remind kids that if they are crossing a street, they should make eye contact with a stopped driver before crossing, even if there’s a “walk” symbol. Drivers turning right might turn on red and not notice small pedestrians.

Know the route

Teach kids to use the same route every day or discuss which route they will take each day if they use different routes.

If they don’t arrive to school or home as planned, you know the route to search.

Walk the routes with them until they know how to safely navigate each.

Avoid distractions

Listening to music (especially with earbuds), playing video games, watching videos, and texting all keep kids from paying attention to their surroundings.

Even talking on the phone is distracting, so don’t assume they are safer if they talk to you all the way home when you’re at work. They are more likely to trip and fall, step into a street without looking first, or not notice that they’re being followed if they’re distracted.

They should be aware of their surroundings at all times.

Getting a ride rules

Remind kids to never accept a ride from anyone unless you pre-plan it. Rain, snow, and cold weather make it tempting to hop in a car, so have kids dress appropriately for the weather and arrange safe rides as needed.

Contact information

Have kids keep important contact information in their backpacks in case of emergency. At least two people should be on this list. People on the list could include a parent, grandparent, or trusted adult friend/neighbor. Names and phone numbers should be included.

Going on wheels

If they are riding a bike, scooter, or skateboard to school, they should follow the rules of the road and proper safety.

Suggestions for adults:

Be alert

Be extra cautious when driving in the before and after school times, especially near schools and in neighborhoods.

Make your sidewalk walkable

Be nice and don’t use your sprinklers in the before and after school times so kids can stay on the sidewalks and not wander into the street to avoid getting wet.

In the winter, clear snow and ice as needed.

Never text and drive

Put your phone on silent and in a place you can’t reach it while driving.

Texts can wait.

Buckle up for safety!

If kids are in your car, make sure they are properly buckled.

Only teens and adults should be in the front seat.

Use an appropriate car seat or booster seat.

Kids shouldn’t wear their backpack in the car, nor should they unbuckle while in a drop off line to get their backpack on before the car is stopped.

Carpools

If your kids will carpool with other families, be sure they are in proper seats at all times.

It’s tempting to not use boosters for short drives, but it’s never safe to have kids improperly restrained. Find boosters that are easy to move between cars.

 

Talk to kids about safety when walking to school.

Dry Drowning – What Parents Need to Know

I thought about calling this one “We’re drowning in dry drowning phone calls” because we are getting many worried calls about dry drowning, but that’s overly dramatic and I hate headlines that make things seem like the sky is falling…

I had never heard of dry drowning until social media picked it up a couple of summers ago. Maybe I did as a resident, but since I’ve never seen it, I’d forgotten the term. Either way, it isn’t very common at all.

Several articles have emerged since the original writing of this post that clearly indicate there is no such thing as dry drowning.

One of the reasons I think so many parents are worried is that it is common for kids to go under water: in the tub and in the pool. Many get water in their mouth or complain that it went up their nose. Few actually get any into their lungs, which is where it can cause problems. How can you know when you need to worry?

Most of us recall a time we coughed briefly after inhaling liquid, and we were fine. So when is it worrisome? It’s when the water that gets into the lungs causes inflammation within the next day or two. This inflammation makes it hard for the lungs to work – the air tubes are swollen, so air can’t get through. Treatment is giving oxygen, sometimes with a ventilator (breathing tube and machine) until the inflammation goes down.

Symptoms you need to recognize and act upon by taking your child to an ER:
  • Cough: If your child has coughing for a minute or more after being in water, he’s at risk. This indicates that the child is trying to clear the airways. If water got down there and they cough most up, some can remain behind and lead to inflammation over time. Watching your child carefully for the next 3-4 days is important. This can be hard to recognize initially, so a complete evaluation is important if any other symptoms develop.
  • Difficulty breathing: Anyone who is struggling to breathe needs further evaluation. Signs can be rapid breathing, sucking in the ribs or the stomach, difficulty talking, or even a look of fear from difficult breathing.
  • Near drowning: If your child had to be pulled out of the water, he should be evaluated in an ER. Even if he seems fine afterwards. The reaction is delayed, so they can seem to be 100% better and then go downhill.
  • Behavior changes or confusion: If a child is confused, lethargic** or has a change in ability to recognize people, he should go to the ER. Serious illnesses can present with a change in mental status, including significant infections, concussion, heat exhaustion, brain tumors, and drowning. The ER doctor will ask what else has been going on to help identify the cause of confusion.  **Many people misuse the term lethargic. Lethargic isn’t the same thing as being tired after a long day. The medical definition is “Relatively mild impairment of consciousness resulting in reduced alertness and awareness; this condition has many causes but is ultimately due to generalized brain dysfunction.”
  • Vomiting: Vomiting after a day at the pool can be due to infection (from swallowing contaminated pool water), food poisoning (from food left in the heat too long) or dry drowning. It’s best to check it out in the ER.
What will happen in the ER?

Many parents don’t want to go to the ER because of high co-pays. We try to keep kids out of the ER as much as possible. But some issues are better taken care of in an ER. Most offices don’t have the equipment or staff to manage these issues well. Dry drowning can be life threatening, and the evaluation and treatment should start in the ER. I cannot say exactly what the doctor will do, since that will depend on your child’s symptoms and exam. There is no specific treatment for this, only supporting your child’s airway and breathing as the swelling goes down.

  • If the doctor thinks your child may have swelling of the airways, he might order a chest x-ray to look for pulmonary edema (lung tissue swelling).
  • An iv might be started to be able to give adequate fluids, since your child might not be up to drinking well.
  • Oxygen levels will be monitored and extra oxygen might be given.
  • Since the swelling worsens before it gets better, if there is a strong suspicion of dry drowning your child will be admitted for further observation.
  • Some kids need help breathing and are put on a ventilator (breathing machine) until the swelling goes down.
Prevention is important!
swimming
Watch your kids when around water!

As with many things, we should do all we can to be sure our kids are safe around water. This includes the bathtub and toilet as well as swimming pools, lakes, and ponds.

  • Childproof your home when you have little ones who might play in a pet water bowl or the toilet.
  • Teach your kids water safety. Swimming lessons can help them learn skills. Tell them to never try to dunk each other. They shouldn’t pretend they’re drowning because it might distract a lifeguard from a true emergency.
  • Learn infant and child CPR.
  • If you have a pool or pond at home, be sure there is a fence limiting access from your house.
  • Watch your kids closely and keep them within reach when they’re in water until they are strong swimmers. When they are strong swimmers you can let them swim outside your reach as long as lifeguards are present.
  • Learn what distress in the water looks like. The movie depiction of drowning with a lot of yelling and thrashing around is not what usually happens. If someone can verbalize that they’re okay, they probably are. Drowning victims can’t ask for help. There is a video linked to this page of what to look for with drowning that shows an actual rescue.
From this site, signs of drowning:
  • Head low in the water, mouth at water level
  • Head tilted back with mouth open
  • Eyes glassy and empty, unable to focus
  • Eyes closed
  • Hair over forehead or eyes
  • Not using legs – Vertical
  • Hyperventilating or gasping
  • Trying to swim in a particular direction but not making headway
  • Trying to roll over on the back

Addendum:

    • I just read a post that gives references regarding drowning definitions. It appears I didn’t forget learning about dry drowning in medical school.

It isn’t really a thing.

The symptoms listed above that I recommend getting evaluated are still concerning symptoms, but they might be from another cause.

Check these out:

On “Dry Drowning”

Drowning in a Sea of Misinformation: Dry Drowning and Secondary Drowning

Drowning is never dry: Two ER doctors explain the real swimming danger kids face

New Juice Guidelines!

Juice that comes from fruit is not the same thing as eating fruit. It’s missing the fiber and even the feeling of fullness that comes from eating foods rather than drinking. Too many kids drink excessive juice, which fills them with empty calories and can contribute to obesity and tooth decay. The American Academy of Pediatrics has updated their juice guidelines to help families limit juice intake to more appropriate amounts.

How much juice should kids have?

  • Juice is not recommended at all under 1 year of age in the new guidelines.
  • Toddlers from 1-3 years can have up to 4 ounces of 100% juice a day.
  • Children ages 4-6 years can have 4-6 ounces (half to three-quarters of a cup).
  • Children ages 7-18 years can have up to 8 ounces (1 cup) of 100% fruit juice as part of the recommended 2 to 2 ½ cups of fruit servings per day.

General tips and tricks:

100% juice

Offer only 100% juice if you’re giving juice at all. Fruit flavored drinks are not the same thing as juice.

Water

Water is always healthy!

If your kids want it flavored, cut up fruit and put it in the water.

There are many recipes online to get ideas, but kids don’t need anything fancy – just put cut up pieces of their favorite fruit with water in a glass container. Put the container in the refrigerator for 2-4 hours and then pour the infused water into their cup without the fruit (which could pose a choking risk). The infused water will stay fresh in the refrigerator for up to 2 days.

Water bottles

Some kids like to start the day with a frozen water bottle. Simply put a 1/2 to 3/4 full water bottle in the freezer overnight – don’t fill it too much because ice expands! Add a bit of water in the morning to help it start melting so it’s drinkable when they want a sip. Adjust the amount of water to freeze as needed depending on how insulated your water bottle is.

water it down

If your kids demand more than the recommended amount of juice for their age per day, water it down. By mixing water (or sparkling water for a bit of zip) with juice, you decrease the amount of sugar in every serving. You can give 1/2 the recommended daily maximum amount of juice with water twice and still stay within the daily limit.

Never let kids drink juice out of a bottle

Kids tend to drink more volume when it’s in a bottle. Infants who take bottles are too young for juice anyway. As they get into the toddler years, transition onto cups.

Bedtime!

Never put kids to bed with juice. They should brush teeth before bed and be allowed only water until morning.

Pasteurization

Offer only pasteurized juice. Unpasteurized juice can cause severe illness.

Real fruit

Give kids real fruits and/or vegetables with every meal and snack.

Make smoothies!

Putting fruits and vegetables in a blender to make a smoothie is a great way to give the full fruit or vegetable instead of juice.

Consider adding plain yogurt**, chia, flax, oats, nuts, and other healthy additions to increase the nutritional components of the smoothie! **Flavored yogurts often have added sugars. Look for just milk and cultures in your yogurt.

Juice box: not recommended!

Most juice boxes have more than a day’s supply of juice. Don’t use juice boxes. Offer juice in cups so you can limit to the age appropriate amount.

What about organic?

Organic juice is not healthier than other juice. Many parents presume it has less sugar or more nutrients, but it doesn’t.

Vegetable juice

Vegetable juices may have less sugar and fewer calories than in the fruit juice, but are often mixed with fruit juices so you must read ingredients. They also lack the fiber of the actual vegetable, so eating the vegetable (or pureeing veggies into a smoothie) is healthier.

Read labels

Beware of labels that look like juice but aren’t 100% juice.

The label might say “juice cocktail,” “juice-flavored beverage” or “juice drink.”

Most of these have only small amounts of real juice. Their main ingredients are usually water, small amounts of juice, and some type of sweetener, such as high-fructose corn syrup.

Nutritionally, these drinks are similar to most soft drinks: rich in sugar and calories, but low in nutrients. Avoid them.

Sports drinks?

Sports drinks are not healthy substitutes for water.

They are sugar-sweetened beverages that contain sodium and other electrolytes. Unless one is doing high intensity exercise for over an hour (such as running a marathon, not playing in a baseball tournament), water and a regular healthy diet provide all the calories and electrolytes we need.

water (again)

Water’s the best drink for our bodies.

Buy fun reusable water bottles and challenge your kids to empty them throughout the day.

The old rule of “8 cups a day” is outdated, but we should get enough water (from the water content in foods + drinks) to keep our urine pale.

We need more water when it’s hot, when we exercise, when we’re sick and when the air’s really dry.

Once we feel thirsty we’re already mildly dehydrated, so drink water to prevent dehydration.

juice guidelines
The AAP’s 2017 Juice Guidelines

 

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

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

Symptoms of Allergies: 

allergies

Allergies are more than just sneezing.

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

Some kids get a crease across their nose from wiping.

Others get purple circles under their eyes called allergic shiners.

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

Treatments: 

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

Medications:

I don’t want kids with outdoor allergies to be afraid to go outside, so taking medicines to keep the symptoms at bay while out can help.

Antihistamines

Antihistamines work to block histamine in the body. Histamine causes the symptoms of allergies, so an antihistamine can help stop the symptoms. Some people respond well to one antihistamine but not others.

In general I prefer the 24 hour antihistamines simply because it is impossible to cover the full day with a medicine that only lasts 4-6 hours. Different antihistamines work better for some than others. Personally loratadine does nothing for me, fexofenadine is okay, but cetirizine is best. I have seen many patients with opposite benefits.

You will have to do a trial period of a medicine to see which works best. If they make your child sleepy, giving at bedtime instead of the morning might help.

Prescription antihistamines are available, but usually an over the counter type works just as well and is less expensive. Insurance companies rarely cover the cost of antihistamines these days.

Antihistamine and decongestant combinations

Antihistamine and decongestant combinations are available but are not usually recommended by me. Once control of the mucus is achieved, a decongestant isn’t needed.

If you need a decongestant initially, you can use one with your usual antihistamine. Most decongestants on the market are ineffective. If you ask the pharmacist for pseudoephedrine, it is available behind the counter. It was replaced by phenylephrine years ago due to concerns of methamphetamine production, but works a little better than phenylephrine.

Decongestants do NOT fix a cold, they only dry up some of the mucus. Decongestants can cause dizziness, heart flutters, dry mouth, and sleep problems, so use them sparingly and only in children over 4 years of age.

Nasal Spray steroid and antihistamine

Nasal spray steroids and antihistamines are available over the counter or as a prescription. An office visit to discuss the value of these for your child and proper use is recommended.

Nasal steroids are often the preferred treatment based on effectiveness and tolerability.

Eye drops

Eye drops can help alleviate eye symptoms. They are available both as over the counter allergy drops and prescription allergy eye drops. If over the counter drops fail, make an appointment to discuss if a prescription might help better.

Most insurance companies don’t cover prescription allergy eye drops well, so you might want to check your formulary before asking for a prescription. This is usually available on your insurance website after you log in.

Tips to administer eye drops include washing hands before using eye drops, put the drop on the corner of the closed eye (nose side) and then have the child open his eyes to allow the drop to enter the eye.

Montelukast

Montelukast (commonly known as Singulair) works to stop histamine from being released into the body. It helps control both allergies and asthma and is best taken in the evening. Once a person has been on montelukast for a couple of weeks, they usually don’t need an antihistamine any longer. It is available only by prescription, so make an appointment to discuss this if your child might benefit.

Steroids

Steroids decrease allergic inflammation well. These can include both oral steroids for severe reactions (such as poison ivy on the face or an asthma attack) and inhaled corticosteroids for the nose (or lungs in asthma). These require a prescription, so a visit to your provider is recommended to discuss proper use.

Limiting Exposure:  

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

Wash off pollen

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

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

keep pollen out of the house

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

Wash towels and sheets weekly in hot water.

Vacuum and dust weekly. Consider cleaning home vents. Consider hard flooring in bedrooms instead of carpeting.

Wash stuffed animals and other toys regularly and discourage allergic children from sleeping with them.

There are many types of air filters that have varying benefits and costs. For information on air filters see this pdf from the Environmental Protection Agency: Aircleaners.

Keep the windows closed. Sorry to those who love the “fresh air” in the house. For those who suffer from allergies, this is just too much exposure!

Think about pets

Keep pets out of bedrooms. If you know a family member is allergic to an animal, don’t get a new pet of this type! If you already have a loved pet someone in the home is allergic to, consider allergy shots against this type of animal.

Contact lens wearers

If itchy eyes are a problem for contact lens wearers, a break from the contacts may help. Talk with your eye doctor if eye symptoms cause problems with your contacts.

Smoke is an added irritant

Keep smoke away. Smoke is an airway irritant and can exacerbate allergy symptoms. Remember that the smoke dust remaining on hair, clothing, upholstery, and other surfaces can cause problems too, so kids can be affected even if you don’t smoke near them.

What if all of the above isn’t helping?

Maybe it’s really not allergies.

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

Viruses can cause very similar symptoms to allergies.

Allergy testing is possible by blood or skin prick testing, but can be costly. In most cases I don’t find it very helpful for environmental allergens because you can’t avoid them entirely and you can always limit exposures as above. I think that tracking seasonal patterns over a few years can identify many of the allergens. You can still treat as needed during this time. Reports of pollen and mold counts are found on Pollen.com. Note also animal exposures and household conditions. Write symptoms and exposures weekly (or daily). It often doesn’t take long to see patterns. Testing is important if allergy shots are being considered.

Need help tracking allergy symptoms?

There’s an app for that! Here’s one review I found of allergy apps. I don’t have any personal experience of any, so please put your favorite in the comments below to help others!

Wrong medicine or wrong dose.

Some people have more severe allergies and need more than one treatment. Allergies tend to worsen as kids get older. Switching types of medication or adding another type of medicine might help. If you need help deciding which medicine(s) are best for your child, an office visit for an exam and discussion of symptoms is advised.

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

Is Nothing working?

Consider allergy shots (immunotherapy) to desensitize against allergens if symptoms persist despite your best efforts as above. Schedule an appointment with your pediatrician to discuss if this is an option for your allergy sufferer.

 

Traveling Around the World

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 might lead to yeast infections, allergic reactions, or even a chronic carrier state (colonization) or irritable bowel syndrome.
  • 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.

Mosquitos…

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.

Non-Infectious Risks

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.
  • For more safety tips, see this helpful brochure.

Keep records

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

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 Fever

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.

Hepatitis

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

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.

Prevention medications might be recommended, depending on when and where you will be travelling. The medicines must begin before travel starts, continue during the duration of the travel, and continue once you return home. There is a lot of resistance to various drugs, so area resistance patterns will need to be evaluated before choosing a medication.

  • 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.

Measles

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.

Meningitis

  • 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

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

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

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.

Zika Virus

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.

Nutrition for the Picky Eater

I am frequently asked about how to get kids to eat, especially about how to ensure healthy nutrition for the picky eater.

A few quick “rules” to healthy eating

Don’t offer junk

Don’t make it easily available at home… most kids can’t drive to the store!

Hungry kids will eat what’s offered

Let them get hungry between meals. No grazing.

Use snacks

Not every food group will be eaten at every meal, so use the day to space foods to incorporate a range of nutrition over time.

Think of snacks as mini-meals.

Keep meal time fun

Turn off the tv and have a family conversation about something other than the food.

Plant + Protein

Offer a “plant and protein” every meal and snack to get kids to the 5 a day of fruits and veggies and to give a protein for “staying power”.

This also fills kids up with the good things so they aren’t hungry for junk.

Try it

Enforce “Taste a bite without a fight” after 3 years of age.

Kids should at least taste a bite before they decide if they like it or not.

Forcing more than the bite might cause more problems, so start with just a bite.

Hide it

It’s okay to be tricky and fun: add pureed vegetables to things, use yogurt or hummus dips, put food on a stick, arrange food into fun shapes, be creative.

Limit juice

Juice is not a food. It is mostly sugar – even if it’s 100% fruit juice.

Offer the fruit instead. It comes with more benefits than the juice alone!

Videos

This is my first attempt at adding video to my blog.

I apologize for the tilted view… it looked straight on my camera! YouTube limits the length to 10 minutes, and I ended up at 11 minutes, so it is broken into two shorter segments.

Part 1:

Part 2:
Resources mentioned at the end:

My Pinterest page has several boards with recipes and nutritional information, in addition to other kid-friendly ideas! (Warning: if you don’t use Pinterest, it can be addictive. Tons of great project ideas and recipes, educational sites, and other time wasters…)

Kids Eat Right: The Academy of Nutrition and Dietetics’ page on scientifically based health and nutrition information you can trust to help your child grow healthy.

Guidelines for treatment of strep throat: Is it viral or strep?

New guidelines for treatment of strep throat were published in the Oxford Journals of Clinical Infectious Diseases this month.  They attempt to decrease the overuse of antibiotics to treat sore throats caused by a virus, since antibiotics are ineffective against viral illnesses. Streptococcus (AKA Strep) is a bacteria, and antibiotics do treat infections with Strep. (See Clinical Practice Guideline for the Diagnosis and Management of Group A Streptococcal Pharyngitis: 2012 Update by the Infectious Diseases Society of America for the full report.)

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:
  • sore throat
  • fever
  • rash
  • headache
  • abdominal pain
  • nausea
  • vomiting
  • swollen glands

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.