Tuesday, September 29, 2015

Prescriptions for Flu Shots

We have started to get requests for pharmacists again this year to give flu vaccines to our patients.

THIS MAKES ME FURIOUS! (Can I be any more clear with this? I am not usually alarmist, but it really is frustrating.) Let me try to explain. I apologize in advance for complaining, but...


The pharmacy is essentially wanting to put the onus on me to verify that the child is healthy enough for the vaccine and doesn't have any contraindications. Of course this is getting very difficult to do even in my office now that walk in clinics are conveniently located everywhere, so continuity of care is lost. If I haven't seen the child in many months, I might not realize that he had a wheezing episode last week but went to another urgent care center to manage. The pharmacy wants me to spend the time looking at the child's chart to verify the health of the child without seeing the child, write the prescription, and have unused flu vaccine sitting in my office (or waiting to be shipped to my office) that I must pay for but not use. Really???

Cost of care

And all of this for free, since the patient is not coming to my office for a visit, but spending his money at the pharmacy. My time needs to be valued somehow in this. A lawyer would charge for the time spent, but I cannot get reimbursed for this. Pediatricians are famous for being nice and giving free advice and care.

Now don't get me wrong. I didn't go into pediatrics to get rich. Medical students who want to get rich don't go into primary care. But I do need to cover my costs and support my practice by earning income with patients who come into the office. Primary care offices are struggling to survive. Many are selling out to hospitals, which increases healthcare costs. 

Continuity of care in the medical home: special dosing for kids, live viruses, and chronic illness

Flu vaccines in kids, especially under 9 years of age, have different rules than older kids and adults. They must have two vaccines of the same strain once before getting a simple yearly booster. If we don't have proper documentation of previous flu vaccines, they need two doses. Until we have a nationwide vaccine database, the pharmacy is unlikely to have the complete vaccine record for these kids and if they give some of the vaccine, the primary care office might not have records of the vaccines.

Parents often don't remember which of their children have been vaccinated -- let alone the specific dates and which particular vaccines were given. If kids get live virus vaccines, they must be given at least 28 days apart from one another or on the same day. This can cause issues if a child gets the kindergarten vaccines at their doctor's office and then a FluMist at the pharmacy or other walk in center (or vice versa). It is easy to see how mom and dad might each take the child to one of the places and not realize the contraindication. If all vaccines are given in one location (or if a person transfers records to another physician for continuing care at a new location) then this type of mistake can be more likely avoided. I try to remember to warn parents to wait at least 28 days before giving the FluMist to their child at the well visit if they get the MMR and/or chickenpox vaccines around flu vaccine time, but sometimes I forget and parents often forget when the time comes at the pharmacy. These kids don't suffer from harm, but the vaccine is not effective and must be given again. I've seen more than one frustrated family suffering from this scenario...

Another issue with getting vaccines outside the medical home is when there is a chronic issue, such as asthma, and parents don't accurately remember the severity. Even in my office when I've talked to parents and given a written Asthma Action Plan, they sometimes tell my nurse the child doesn't have a history of asthma. The nurse can question further because it's in the chart. The pharmacist won't know to question in a different way, especially if the family hasn't filled medications for that child at that pharmacy.

Inventory issues

We have been ordering and giving flu vaccines for longer than the 16 seasons I have been a part of Pediatric Partners. Each year there has been some frustration with the flu vaccine season.

See here and here and here for some of our headaches -- I wasn't blogging at the time of the novel H1N1 outbreak, but you all remember that, I'm sure.

Now that some kids get vaccinated at the parent's workplace, others at pharmacies, and others not at all it is getting more and more difficult to predict how much flu vaccine to order. If we over order, we are stuck with vaccine that can't be used (in other words, we stand to lose a lot of money). If we under order, parents are upset that we run out. Some years we can get more, others we can't.

We offer flu vaccines in our office, or at least we do when we have the vaccine in our office. For the second year in a row we are experiencing shipping delays. This is frustrating because we love to take advantage of the school aged kids (especially college aged "kids") being in the office in late summer and getting the flu vaccine out of the way. We can't give it at well visits if we don't have it, so we must pay nurses for more overtime having more flu vaccine clinics when we finally get the vaccines in stock. It's much easier for all to get it at an already established visit, but we do not have control of when the vaccine arrives at our office.

Pharmacies giving vaccines is a relatively new thing. I am frustrated that they are getting their supplies before us and offering them to our patients before we even have a chance. We have more and more difficulty ordering flu vaccines because we have no idea how many kids will get them elsewhere versus our office. We must pre-order during the winter before the next season, often when we are still offering vaccine for the current season, so we don't know if we will run out early or have leftovers. That makes it really hard to predict use for the next season.

Prescription requests 

Thankfully when I get a faxed request for such a prescription, I have an easy answer: No.

Our malpractice carrier has advised us to not write prescriptions for over the counter medications unless we are seeing the child in person. We have interpreted vaccine prescriptions to be in a similar category. If we cannot assess how sick or well a child is, we should not make the decision for any medicine (or vaccine) to be given. If the pharmacist wants to do an evaluation and order it, great. Otherwise, we are more than happy to vaccinate our patients.

Another reason to get the vaccine at your doctor's office

I just saw in a Slate article that vaccines might be better covered by insurance by an in network provider: "Pediatrician Walter Orenstein of Emory University, who chairs the National Vaccine Advisory Committee and formerly was the country’s assistant surgeon general, notes that the Affordable Care Act now requires that insurers cover vaccines against flu and several other diseases with “no co-payments or other cost-sharing requirements,” but, again, the catch is “when those services are delivered by an in-network provider.”"

Getting the vaccine

Please be patient with us. It wasn't that long ago that it was recommended to hold off on giving flu vaccines until October, thinking that the vaccine wouldn't last the season if given too early. Now that we know it is okay to give it earlier, that doesn't mean we must give it earlier. It isn't even October yet and people are panicking that they won't be able to get the vaccine. As far as I know, there's plenty of vaccine. It just hasn't all shipped yet. We are getting small allotments and giving it to kids whenever possible if they're in the office when we have stock. Unfortunately we can't schedule any vaccine appointments yet because our stock is too limited and we might run out before that appointment. We will be getting more soon. When we have enough in stock to schedule flu vaccine clinics we will let our patients know.

We're not alone in this. Most pediatricians I've asked are in the same boat. Please be patient with us all.

Dr Mellick got a FluMist in a previous season

Sunday, September 6, 2015

All about ears

When babies and children have ear infections everyone in the house suffers because they cry all night and no one sleeps. They hurt. Especially at night. Parents don't want to see their children in pain and they don't want to see it happen again and again, so they often wonder if tubes are the answer.

Why do babies get so many ear infections?

The eustachian tube helps to equalize pressure in the middle ear. If it is swollen or blocked it does not allow the pus in the middle ear to drain (think of how the tissues in your nose swell with a cold or allergies). Infants and young children are more prone to ear infections than adults because their eustachian tube is flatter, which inhibits drainage (see picture below).
photo credit: MedlinePlus

Let's start with what an ear infection is and what it's not.

A healthy ear drum is grey and shiny and we can see the small ear bones behind it. (See eardrum on the right.)

photo source: Medscape

Correctly diagnosing an acute ear infection (otitis media, OM) can be more difficult than it seems. The child must have significant pus behind a red eardrum, making it appear to bulge out, as in the left image above, or pus draining out of the ear canal from pressure causing a hole in the eardrum allowing pus to drain (perforated eardrum) or ear tubes.

If there is pus behind the eardrum without redness or other symptoms, it is not an acute ear infection but rather otitis media with effusion (OME). This fluid can range from clear to white or yellow and may accumulate in the middle ear as a result of an upper respiratory infection or a resolving acute ear infection. Many kids have no symptoms, so is probably often never seen. OME is often found at "well" visits during the winter months. It typically self resolves within a month or two. If it persists beyond 3 months and causes hearing loss, tubes will drain the fluid (see below). Sometimes removing the tonsils or adenoids are recommended, since removal might help the eustachian tube drain the middle ear. Decongestants and other medicines have not been found to help OME. OME can get mistaken for an ear infection if the child is crying during an exam, which reddens the eardrum.

Many kids cry when being examined, and the eardrum can turn red just from crying (just like their face and ears turn red when they're mad). This is not an ear infection. It's just a crying kid. Yet many less experienced (or just busy) doctors and nurse practitioners call it an ear infection even if there's no pus so they can quickly write a prescription and move on to the next patient. Parents are happy with "knowing" and that they can do something about it. This is incorrect on several levels. There must be pus involved. It is easy to over diagnose an ear infection if you're just looking at the color of the eardrum.

Swimmer's ear is a different type of infection entirely and is covered in depth in Swimmer's Ear.

Are ear infections that rupture the eardrum more serious? 

I've had several parents worry that their child had a hole in the eardrum allowing pus to drain out. They automatically think this child is at higher risk of ear problems and should get tubes. This isn't exactly the case. Many factors can lead to ear drum perforation (or rupture). In general, when the eardrum perforates, a hole allows the pus to drain (much like tubes), which allows for faster healing of the infection and pain. This does not necessarily mean the child is prone to ear infections or needs tubes. In days before antibiotics, a treatment for ear infections was to put a needle into the ear drum to draw the pus out. This helped relieve pain and was very effective to clear the infection. I find that many kids who have eardrum ruptures feel better faster than those who don't. Occasionally the hole lasts for years and it becomes recommended to patch it closed, but typically the hole closes up very quickly -- sometimes too quickly before the infection is cleared and pus re-accumulates behind the eardrum.

How are ear infections treated?

First manage the pain.

Ear pain should be managed with pain relievers, whether it's a true infection or simply pain from the congestion that comes with a cold. You can begin pain relief at home whether or not the ear infection is confirmed with standard doses of either acetaminophen or ibuprofen.

Ear drops for pain work fast but the relief doesn't last long, so I recommend also giving acetaminophen or ibuprofen per standard dosing recommendations. Ear drops can include both over the counter options and prescription options as long as the eardrum doesn't have a hole or tube in it. Do not put anything in the ear if you suspect a hole or know your child has a tube unless your doctor recommends it. Olive oil works pretty well and most of us have that in our kitchen. Saturate a cotton ball with oil (not hot oil) and squeeze the cotton over the ear canal, putting 2-4 drops in the canal. There are many over the counter ear drops for pain, but I find that the oil you already own is not only cheaper, but works just as well. Prescription numbing drops are an option if your doctor thinks they are appropriate.

Safely elevating the head can help the pain associated with the increased pressure laying down. For young infants, elevate the head of the bed by putting risers under the legs of the bed or by wedging something under the mattress. Be sure it is stable, whichever you do. Never put an infant under 1 year of age on a pillow or other soft bedding. For older children, propping up on several pillows is often helpful. Many toddlers and young children will not stay on pillows, so this is less effective.

Treat associated issues.

When kids have ear pain, they often have a runny nose, cough, fever, and other symptoms. Each of these should be managed as discussed on previous blogs: green snot, cough, generally sick. How long symptoms will last are discussed here.

If there is a true ear infection, treatment varies by age of the child and severity of the infection:

  • Pain relief for anyone with an ear infection is the first treatment. (See above.)
  • Monitor for the first 2-3 days without antibiotics in many instances, since most ear infections will self-resolve.
  • Antibiotics can be used if symptoms persist more than 2-3 days ~ earlier for children under 6 months of age, those with significant illness, those who had another ear infection within the past 30 days, or for those who have an increased risk of ear infection (such as immune deficiency or an atypical facial structure or chromosomal defect known to affect hearing or immune function).
  • If a child has tubes and develops an ear infection, pus will drain out of the tube. Antibiotic ear drops are the first choice for this type of infection. Antibiotics by mouth are not typically needed.
  • Prevent the next ear infection. See below.

Why not use antibiotics for every ear infection?

The large majority of ear infections are caused by a virus, for which antibiotics are ineffective. About 80% of ear infections self resolve without antibiotics. Not only are antibiotics not needed, but they also carry risks. About 15% of kids who take antibiotics develop diarrhea or vomiting. Nearly 5% of children have an allergic reaction to antibiotics -- this can be life threatening. So when you look at the benefits vs risks, you can see that most of the time antibiotics should not be used as a first treatment.

When bacteria are exposed to an antibiotic but don't get completely killed, they learn to avoid not being killed the next time they see that same antibiotic. This is called bacterial resistance, also known as "superbugs". Superbugs can be shared from one child to another, which explains why some children who have never had antibiotics before have an infection that is not easily taken care of with the first (or second) round of antibiotics and why if a child needed several different antibiotics to clear an ear infection might get better with generic amoxicillin with the next. It's the bacteria in the ear that become resistant, not the child. The more we use antibiotics, the more resistance builds up and the less likely antibiotics will work for serious infections.

What are tubes and how do they work?

Tympanostomy tubes are small plastic tubes that are placed in a surgically made hole in the eardrum (tympanic membrane). They keep the hole in the eardrum open so that if pus develops in the middle ear it can drain out through the tube. This helps prevent the pain caused by the pus filling the middle ear area and pushing out on the eardrum. It also helps prevent the hearing loss that happens when the eardrum can't move due to pus behind it.

photo from USAToday (Rosenfeld RM. A Parent's Guide to Ear Tubes. Hamilton: BC Decker Inc., 2005)

Pus behind the eardrum causes many symptoms, which may include balance problems, poor school performance, hearing difficulties, behavioral problems, ear discomfort, sleep disturbance, and/or decreased appetite with poor weight gain. The benefits of tube placement for these children must be compared to the cost and risks of anesthesia and having an opening in the eardrum.

The majority of ear infections resolve completely without complication. The longer the pus remains behind the eardrum the less likely it will go away. If the pus is there longer than 3 months, it is less likely to resolve without treatment.

When are tubes recommended?

Since placing tubes does involve risks, they are not recommended for everyone. Guidelines recommend the following evaluation for tubes:
  • If pus or fluid has been in the middle ear for over 3 months (OME or OM that never clears), a hearing test should be done.
  • If the hearing test is failed, tubes should be considered.
  • If fluid has been there longer than 3 months but hearing is normal, recheck the hearing every 3-6 months until the fluid clears. If the hearing test is failed on rechecks, then tubes are warranted.
  • Children with higher risk of speech issues or hearing loss may be considered for tubes earlier. This would include children with abnormal facial structures, such as cleft palate, or certain genetic conditions that predispose to developmental delays, hearing concerns, or immune problems. 

What about recurrent ear infections?

I know parents get frustrated with recurrent ear infections, and I've seen many families who are happy that they got tubes for their child after recurrent ear infections, but studies show they aren't really necessary. If each ear infection clears, that shows that the eustachian tube (the tube that drains the middle ear into the throat) can do its job. As long as the pus is there less than 3 months with each infection, the risk of tubes does not usually outweigh the benefits.

Are there kids who should be considered tube candidates earlier?

Some kids are more sensitive to the problems associated with OME. These kids might have sensory, physical, cognitive, or behavioral issues that increase his or her risk of speech, language, or learning problems from pus in the middle ear. Children with known craniofacial abnormalities or chromosomal abnormalities who are at higher risk for speech and hearing impairment will also be considered for tubes more liberally. These kids might benefit from tubes even if they don't have pus for 3 months in the middle ear or hearing loss.

What are complications and risks of tubes?

Tube placement requires anesthesia, which is overall safe, but not without risk. 

Tubes keep a hole in the eardrum, which can allow water and bacteria to get into the middle ear, leading to infection. This leads to pus draining out of the ear canal, called otorrhea. This pus can be treated with antibiotic ear drops initially, and oral antibiotics if it last more than a month.

Some ENTs recommend earplugs when kids with tubes swim, but studies do not show that they are needed in most cases. If kids get recurrent otorrhea, they might be candidates for earplugs when swimming. Kids who swim in lake water or do deep water diving might also benefit from earplugs.

What can be done to prevent ear infections?

  • Avoid all smoke exposure. Tobacco smoke is known to predispose children to ear infections, upper respiratory infections and wheezing.
  • Do not bottle prop. Keeping a baby's head elevated a bit while bottle feeding can help prevent ear infections.
  • Breastfeed. Breast milk is protective against many types of infection, including ear infections.
  • General infection prevention. Avoid taking your infant to places where there are a lot of people. Wash hands often. Attempt to limit sharing of toys that young children mouth, and wash them between children. If your child attends daycare, try to find one where there are fewer children per room.
  • Vaccinate. One of the biggest causes of bacterial ear infections is pneumococcus. Your child will be vaccinated against this as part of the standard vaccine schedule.
  • Keep the pacifier in the crib. When kids play, they often drop their pacifier, which can encourage germs to accumulate on it before they put it back in their mouth.
  • Xylitol. There are several studies that suggest chewing gum with xylitol as its sweetener helps prevent ear infections in children who can chew gum. For younger infants, there are nose sprays with xylitol. Xylitol is a naturally occurring substance that is used as a sweetener is many products, many of which are reviewed here. I do not endorse any of these, but do find this a helpful resource. 

For More Information:

Middle Ear Infections: Summary of the AAP ear infection guidelines
Xylitol sugar supplement for preventing middle ear infection in children up to 12 years of age