Tuesday, December 31, 2013

Top 10 Posts of 2013

My last post of 2012 was my Top 10 Posts of 2012. I think I'll keep the tradition going with the Top 10 of 2013.

photo source: Shutterstock

This past year I have written about everything from insurance to illnesses to common parental concerns. My most influential blog has been about the generic formulations of Concerta, with 11,875 readers. It has been shared on ADHD blogs, various Facebook and Twitter feeds, and found on Google searches. I never thought over 1,000 people would read one of my posts, let alone over 10,000! Thank you to all who are reading and sharing!

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From #10 to #1:

10. My Child's Cough and Breathing Sounds Like… is a collection of videos I compiled to help parents describe their child's cough.

9. Allergy Tips reviews ways to avoid allergens when possible and how to treat symptoms.

8. Flu Vaccine 2013: The Story Unfolds discusses how coding and billing issues impacted our office use of flu vaccines this season.

7. But the Snot Is Green… once again argues why the color of mucus does not make the diagnosis of bacterial sinusitis and gives information on treating colds and coughs.

6. To Tamiflu or Not to Tamiflu  might be a little intense for some readers because it reviews the research on Tamiflu risks and benefits. I am happy it is among the top 10 because I want people to see that Tamiflu isn't that miraculous of a drug for influenza. I get far too many requests for it this time of year. 

5. Flu Shot Information 2013-14 Season explains the different types of influenza vaccine available for the season. 

4. Help! My Child Has ______ Up His Nose! shares a "secret" tip I use to get some unwanted objects out of a child's nose. 

3. Screen Free Week is a challenge to readers to go Screen Free for a week. I have no idea why it is ranked so high. That is a surprise to me. 

2. Cough Medicine: Which One's Best reviews various cough medicines and other treatments of cough.

1. Generic Concerta Not Working Like the Brand Used To?  was read about 10 TIMES as much as any other post. It was found most often by a search engine, not direct shares, which tells me that many families are struggling with this issue. This is the post I am most passionate about. Any of my ADHD patients who are treated with Methylphenidate ER/Concerta know how angry I am that the FDA allows this substitution. I am thankful that the blog can help spread the word so that parents who are concerned about their child's sudden altered response to a medication can learn what might be the cause. I had so many updates to the original post, I wrote a follow up: Update on generic Methylphenidate HCl ER.

Blogs that missed the Top 10 that I wish more people would read include: 

Evolution of Illness - I wish people would read this because we often fall into the trap of wanting a quick fix. Too many parents bring kids into the doctor for a fast remedy only to find that there isn't one.  Resolution of illness takes time. Sometimes kids get worse, only to have the parent accuse a doctor of missing something. It happens to all good docs once in awhile…

First Period Q&A with a Tween - I wish people would find this one because it has questions every young lady thinks about but is often afraid to ask.

It's [Sports, School, Camp, Yearly] Physical Time - I wish people would read this so they understand the value of well exams and the scheduling constraints most pediatricians face. Don't call at the last minute!

Insurance Confusion - I wish people would read this because dealing with insurance is one of the most stressful parts of my job. I want people to learn about insurance to avoid financial surprises and to be responsible with insurance use.

Private Discussions with the Pediatrician - I wish people would read this because I am often uncomfortable (and sad for a child) when a parent wants them to leave the room for us to discuss something privately. Pre-planning with a quick phone call or secure message before the visit can save the child from excess worry.

What kids need to be able to do to leave the nest - This is one of my favorites because it was written at a very emotional point of my life. My kids are growing up and I reflected on what I really want them to know.

New Ideas

While most of my blogs were article-style writings, I introduced a few different types of blog this year. 

My first (and to date only) attempt at a video blog was Nutrition For the Picky Eater. It was born from a talk I gave at an ADHDKC.org parent meeting. 

I also did a picture blog with Lawn Mower Safety

I had one guest blogger. Sleep expert, Kerrin Edmonds, wrote Common Sleep Myths

Busy times…

April was my busiest month blogging. Seven posts that month. It tends to be a slow month in the office.  Ironically it was also Screen Free Week, a time I should have been off the computer!

Saturday, December 28, 2013

"But the snot is green…" Or "How can we treat cough and colds?"

This time of year it seems everyone is at least sniffling. Many have annoying coughs. Coughs are annoying to others who wonder why that cougher isn't staying at home keeping his germs to himself. They are annoying to the cougher who is up all night coughing (and his parent who also hears it all night long.)

cough, cold, uri, upper respiratory infection, mucus, green mucus, sinus

And then there's all the mucus. We normally make about a liter of mucus a day. Yes, a liter of the stuff. On a good day. It helps moisturize our airway and collects the dust and germs that enter our body. It has antibodies that help fight off the germs it catches. We swallow most of what is made, but when we're sick we make even more. When we're sick it plugs up our noses and makes our head hurt. It drains down the back of our throat, causing us to cough. In kids it drips down the face. It changes color from clear to yellow to green. Sometimes it even gets bloody. It can be thin or thick and sticky. Don't be fooled that the color or thickness means it is for sure "just allergies" because it's clear, or a sinus infection because it's green. These change based on how long it's been in the sinuses, how dry the air is, and other factors. Yellow or green color does not come from bacteria or guarantee that antibiotics will help get rid of the mucus.

Colds and coughs seem to continue forever. Especially since kids get recurrent viral infections this time of year, and they each run into the next illness. I often joke that it doesn't matter if kids get sick in October or January, it will go away by April. Bad joke, but it often seems that once kids start getting sick for the season, they stay sick most days until April.

Here's a graph from way back in 1967 that shows the timeline of a typical upper respiratory illness in an adult:

Remember that kids tend to stay sick longer (and are contagious longer) than adults, so if 20% of adults are still coughing on day 14, you can bet at least that many kids still are coughing with a cold or the flu.

So what can you do to help make kids feel better? As I always say: water, water water.

Water in the air helps thin the mucus, so increase the humidity in the bedroom during the dry winter months. Use a humidifier or vaporizer in the bedroom during illnesses even if your home has a humidifier attached to the heater. Humidifiers with a cool mist are safest with young children. Be sure to follow package directions for cleaning and changing the filter. Vaporizers are generally less work to use, but the steam comes out very hot and can burn young children. Again, follow package directions for proper cleaning and use. Allow it to dry out a bit during the day to avoid build up of mold. 
Water in the nose in the form of saline can really help. The salt in the saline draws the fluid out of the swollen nasal passageways, decreasing the swelling and opening the airway to allow more mucus to be blown (or sucked) out.
Increase fluids that kids drink. Really push water. And unless a child is allergic to milk, it is an old wive's tale that milk will make the mucus worse. If that's what they want, they can have milk with a cold. 
I think what really needs to happen is to get the mucus out. Using saline along with a strong blowing (or suctioning) of the nose is important.

For infants and younger children it can be hard to blow forcefully to get the mucus out. I have been disappointed in the use of a bulb suction because it is very difficult to make a seal and to have enough air to really get a good suction. They tend to cause trauma to the nose because you need to stick it up so high to make a seal. I like nasal aspirators that seal outside the nose and have a continuous flow of air. Check out How to use the Nosefrida. A similar nasal cleaner is available from Nasopure. (Note: I am not tied to either of these companies and do not get any payment from either company.)
For kids over 2 years old, washing the nose is one of the best ways to treat (and prevent) nasal congestion. Check out this video from Nasopure for an easy how to use. (Note: I do not get payment from this company, I simply love the Nasopure company. Not only does the product work well, it is also an all American company. Bottles are made in Kansas City and assembled by disabled adults in Columbia, Missouri.)

What medicines work?

If you choose to use medicines, pick one that has a single active ingredient. Many cold and flu medicines include several active ingredients to treat different symptoms. This increases the likelihood you will use a medicine that isn't needed (because you don't have that symptom) as well as increases the risks of side effects. Also if there is an allergic reaction, you won't know which component was the culprit.

I don't recommend decongestants most of the time. They can make the mucus more thick, which plugs the nose more. If a child is old enough to say if it helps or not (generally over 6 years) and it helps, then it is okay to use a decongestant for a short term. Side effects are trouble sleeping, shakiness, nervousness, increased blood pressure and increased heart rate.

Antihistamines block the histamine that is triggered from allergies. It helps decrease the amount of mucus made when allergies flare, but don't help with the typical cold. Side effects are drowsiness, impaired coordination, excitability in children, and dry mouth.

Guaifenesin is supposed to help thin out mucus to help cough it up. Some studies say it works, others disagree. Again, if a child is old enough to say it helps and it does, use it. Otherwise don't. Side effects can include dizziness, drowsiness, confusion, blurry vision, or lightheadedness.

Studies do not show that any cough suppressant works very well. Honey has actually been shown to help better. Use honey only in kids over 1 year of age due to risks of botulism.

For influenza many people request Tamiflu. Here's my blog on Tamiflu describing why I will be forced to use a medicine I don't like. (It's too long to explain here.)

Another blog going in depth on cough medicines is Cough Medicine: Which one's best?

Thursday, December 26, 2013

My Child's Cough and Breathing Sounds Like...

Parents often bring in kids with a cough but can't describe what it sounds like. I sometimes get to hear it if they cough, but Murphy's Law also says that a child who coughs often throughout the night and frequently during the day will have a 15 minute period of no cough at the exact time the doctor is in the exam room.

photo source: Shutterstock
In all seriousness -- coughs, regardless of the source -- are usually worse at night, which means your  doctor won't usually get to hear the worst of it.

I often wish there was one place I could refer parents to so they could see what various coughs sound like, so I decided to put a list together. The internet is ripe with videos now, but I have spent many hours watching videos that weren't very helpful in order to find these. I'm sure I missed some of the best ones, so if you have one that you really like, please post in the comments below.

My next blog will be on how to treat cough and colds.

Regardless of how the cough sounds, if you are worried about your child's breathing or the sound of the cough, bring your child in to be seen.

Disclaimer: I have no ties to any of the videos below and am not responsible for any of the opinions or errors within them. Some are professionally done and others are videos parents uploaded. Some have advertisements which I do not necessarily endorse.


The initial seconds of this baby with croup stridor video show the typical croupy cough. At about 0:55 it shows the stridor that many kids with croup have. Stridor is a whistling sound as the baby breathes in (often confused with wheezing, which happens when you breathe out). It is common in croup and is caused by the swelling near the voice box. (Older kids and adults who get the same viruses that cause croup in younger kids often get laryngitis from the swelling near the voice box in a larger neck.)

This ER physician of TheEDExitVideo spends the first couple of minutes discussing what causes croup. At 2:27 sounds of stridor in an otherwise happy looking baby are shown. At 3:44 is a picture showing intercostal retractions (also seen with wheezing or other types of respiratory distress).

Dry Cough

Dry cough can be from an irritation in the throat, asthma, acid reflux, or any common cold. It can also come from a habit cough (often seen after an illness and goes away with sleep only to return when awake).


Laryngomalacia wasn't on my original list because it isn't from a virus or bacteria causing illness, but it is a cause of noisy breathing in infants. It is caused by floppy tissues near the voice box (i.e. larynx). Linden's Laryngomalacia - 3 Months shows this breathing. It is often worst when baby is excited or fussy.

For more information on this (even a video of a scope into the airway), check out Children's Hospital of Philidelphia's Laryngomalacia page. 


The cough with pneumonia can sound like a wet cough or dry cough, so no specific videos are for this cause of cough. The clues to pneumonia include a fever with cough, difficulty breathing between coughs, shallow breathing, shortness of breath with brief exertion, pain in the chest, rapid breathing, or vomiting after cough. Pneumonia can be caused from viruses and bacteria and can range in severity. Walking pneumonia generally means that the person is not sick enough to require hospitalization. Some pneumonias lead to severe difficulty breathing and require oxygen support.

Wet Cough

Wet cough can be from pneumonia or bronchitis, but also from postnasal drip with a common cold or allergies.

When kids "cough stuff up" it is usually the postnasal drip being coughed up, not mucus from the lungs coming up. The same is true if they "cough up blood". This blood is usually from a bloody nose draining into the throat, not from lung tissue. (Note: bloody mucus can be from more serious causes and if your child has no signs of blood in the nose or is otherwise ill, he should be properly assessed by a physician.) 


Wheezing is typical in asthma (and bronchiolitis). Many parents mistake the upper airway congestion sound that many kids make with postnasal drip as wheezing. Wheezing can sound like a whistle as a child breathes out. Ethan's wheezing shows a baby with noisy breathing without distress. This Wheezing - Lung Sounds Collection video has the sounds one would hear with a stethoscope, but if you put your ear against your child's back (without a shirt) you might be able to hear them. If you don't hear wheezing, but your child is struggling to breathe, it does not mean there is no wheezing! Treat like you would if you hear the wheeze.


Asthma Attack in a child starts with information on asthma, then at 1:50 video of what retractions look like. 

Asthma attack shows the typical short breathing in phase with long exhale seen with an asthma attack. Also you can see the airway pulling in at the neck (retractions).

Bronchiolitis, often simply called RSV, but caused by many viruses

Bronchiolitis Cough, 3.5 months old shows a baby with a wet sounding cough, typical of bronchiolitis. 

Bronchiolitis is a video from the ER physician Dr Oller. He reviews causes of bronchiolitis, how it's spread, and how it affects the body. At 1:40 he discusses the natural progression of the simple cold into bronchiolitis. At 3:04 there is a picture of how we collect a nasal swab to help with diagnose of any viral illness.

Sick with Bronchilitis shows an infant with suprasternal retractions (sucking in at the base of the neck) and the typical cough associated with bronchiolitis. The man erroneously says "croupy", see below for croup.

RSV and Infant Treatment shows the best treatment for babies with RSV (or any bronchitis): suctioning. Some babies need this deep suctioning in the doctor's office or hospital. Others can get by with nasal aspirating at home. (Note, the next blog will be about treatments, but I have to say here that the bulb syringe is fairly useless for this.)

Whooping Cough

Pertussis - Whooping Cough: A Family's Story is an informational video on pertussis with the classic whooping cough in a child and pictures of a newborn with pertussis.

Silence the Sounds of Pertussis - Whooping Cough is a commercial for vaccinating, but it starts with the typical whooping cough sound.

Pertussis (whooping cough) shows a young infant with a cough from pertussis. Young infants do not always whoop, they stop breathing.

8 Year Old With Pertussis (Whooping Cough) shows a typical cough for an older child. Her positioning in front of the toilet shows that these kids often vomit from the force of the cough. The 2nd video from this same girl shows how normal and healthy kids can appear between episodes.

Tuesday, December 17, 2013

Update on generic Methylphenidate HCl ER (name brand = Concerta)

My previous post on Generic Concerta has been very popular, but it has so many updates that it has become difficult to read. I'd like to highlight the important points to make it easier for all.

What makes Concerta unique?

Concerta is the branded formulation of methylphenidate HCl Extended Release that has a unique time release system. This time release technology is called OROS (osmotic controlled release oral delivery system).  Unlike many slow releasing medications that are released as the capsule parts dissolve, the OROS capsule doesn't dissolve. The medicine is slowly released through a small hole in one end of the capsule. The pill works like a pump, pulling in water from the intestines, pushing the medicine out of the tube slowly throughout the day. This allows for a consistent drug release. See this photo from Medscape:

The companies that make the OROS pills include the original maker, now Janssen Pharmaceuticals, Inc., and Actavis (formerly Watson). They are marked with "alza" and the number signifying the strength. They have a distinctive marking on one end that is the exit port (as above).
photo source: goodrx.com

see the "exit port"

What generics are available?

There are now several generic extended release Methylphenidate HCl ER formulations approved by the FDA to substitute for Concerta. Generics must have the same active ingredient, but can vary with how it is made and the fillers.

One company, Actavis (formerly Watson), makes an OROS Methylphenidate HCl generic. It is the same OROS pill as the branded pill, but it is sold as an authorized generic. These look identical to the pictures above.

I'm sure more generics will be made, but the two companies that make a non-OROS generic are Mallinkrodt and Kremers Urban. It is easy to see that the pills of each of these are different from the OROS above.

For more information on authorized vs true generics, visit ADHD Rollercoaster's blog on the subject.

From Kremers Urban:

photos from http://www.kremersurban.com/products/Product_Details.aspx?ProdName=MetaT&ProdID=62175-311-37

How will my child react to different formulations?

This is a difficult question because everyone responds to medicines differently. For some people the formulations that are not OROS might work better. For some either might work well. For others they might respond best to the one with OROS. It is important to know which brand is taken so that if there are variances in how it works you can identify if it might be due to a change in the formulation.

What can I do if my child is not tolerating a new formulation?

There are several things to do if your child is not responding well to a new formulation.

  • Identify which brand and strength it is and write it down in a place you will remember so you won't buy it again. Keep a list of all medications and general reactions (both good and bad) in case of future issues. 
  • Tell the prescribing physician about the reaction and be sure to let them know the brand your child did well with and the one that has negative effects. Your physician might not know about the different generics available, so let them know it is not the OROS pill. Otherwise they might assume a higher strength will fix the issue, and your child might not need that higher strength, just a different time release. Ask your physician to write "OROS only" on the prescription. State laws vary about how they must do this. A nice summary is found on the Epilepsy.com. (We are not specifically taught these things in medical school or residency, so you might need to share state laws with your physician.)
  • Tell the pharmacy that the medication they substituted is not working and see if they can exchange for the brand your child was previously doing well on. You might need to go "up the chain" at a big name pharmacy, since the local pharmacists don't have much say in what is purchased for the company. (They likely won't be able to substitute, but after enough phone calls to the pharmacists who might complain to the administrators, and directly to the people responsible for choosing the company through which they order, they might reconsider the substitution.)
  • Tell the pharmacy you will take all your business elsewhere because you cannot buy their substitution. Local "mom and pop" pharmacies are more likely to order your preference than any chain pharmacy. You might pay more, but if you can afford it and your child's response is better, it might be worth it.
  • Call ahead before picking up prescriptions. Ask the pharmacy which type of methylphenidate HCl ER they have for the strength you need. (It may vary between 18mg, 27mg, 36mg, etc.) Let them know you will or will not be filling at their store based on what they stock. 
  • See if your insurance company participates with a mail order pharmacy. Be sure that they use the OROS pills BEFORE getting a 90 day supply. Mail orders are often less expensive options, so it might be helpful if you are unable to find a generic OROS pill and must buy the name brand. Keep in mind that shipping time will delay getting the medicine, so think ahead and schedule your ADHD visits to get new prescriptions about 2 weeks before you need the refill!
  • Tell your insurance company about the issue. They are contracting with pharmacies for certain formularies, and if they don't know that their clients don't like a particular brand, they will keep going for the cheapest contract. They still might because money talks, but keep pressuring them!
  • Tell your HR department if your insurance through the office requires you to use a certain formulary drug or particular pharmacy that purchases a brand your child does not thrive on. They can take this into consideration when renegotiating contracts. Again, this only works if a big enough number of people complain.
  • Ask your physician if he would be willing to write a letter to your insurance company on your behalf.
  • Report adverse events to MedWatch. This can help everyone if they hear enough complaints. You can read about the program then click on the consumer - friendly reporting form. From that link click on the "consumer/patient" button on the right. This is how the FDA learns of drug problems. Hopefully if enough people submit reports they will look into the issue. They have looked at data from each of the generic companies prior to approving the distribution of these pills and they found the data supportive that the medicines were equivalent. They need to hear post-marketing concerns from use in real people.
  • Share information. Many people are struggling with new formulations and they don't realize why. 
  • UPDATE May 1, 2014: I'm excited to see that the FDA has the generics this on their watch list. Gina Pera's "We Did It! Concerta Generics on FDA Watch List" gives a great summary of how the process works and what we can all do to continue the fight. 
  • UPDATE Nov. 16, 2014: Generics that are non-OROS will no longer be automatically substituted. They will still be available. See ADHD Roller Coaster's blog on the topic for details.