What Doctors Want You To Know About Treating Colds (but are afraid to say)

This is a change from my usual blogging style because I want to share a Facebook post. I follow a few private Facebook Groups and in one for physicians the following post was shared. I tracked down the original author for permission to share publicly. He was not intending for this to reach a wide audience, but authorized me to share without his real name. He asked that I refer to him as Dr. Nate. 

I did not write anything in the post or the comments I posted below, but I see value in it. It highlights the fears and desperation of many parents and the frustration that even doctors have in treating coughs and colds. 

It might offend some because of its snarkiness, but it might help parents who are frustrated that their child is sick... again. 

As you can see, Dr. Nate answers questions about treating a child's cold and cough rather bluntly, but from the many, many positive responses, rather accurately. It's a behind-the-scenes look at what doctors really want to say but can't.

I'll first post screenshots of the post and some of the replies (there were also GIFs and more comments of essentially the same "love it" responses) and then I copied the wording below for ease of reading.

Saw this posted over on ********* and figured this group would appreciate it the most given the snarkiness! 😏 #ParentingIsHard#TrueStory

"Shamelessly and unapologetically plagiarized from ***********:

And now, for a pediatric URI Q & A session with your friendly neighborhood doctor.

Q: My kid has had a cold for four days now, and he isn’t getting any better! What should I do?
A: most colds spent 4-5 days getting worse and 4-5 days getting better. Call me if it’s been consistently worsening for a week, and we’ll talk. Otherwise, regular supportive care is all we do for a cold.

Q: He’s coughing up green and yellow junk! My friend Becky says that mean he needs antibiotics.
A: normal viral colds involve a full rainbow of sputum colors. Green, yellow, and white junk tells you nothing about whether it’s viral or bacterial, especially in babies.

Q: My baby has had a cold for 3 weeks. What now?
A: probably not really. Your kid can have a cough that lingers for up to 4-6 WEEKS after recovering from a viral infection like RSV. If there’s no fever, and no other symptoms of infection, a cough alone is expected.

Q: But he’s been coughing for 3 weeks!!!
A: You will notice that 3 is less than 4-6. This does not surprise me.

Q: But that’s a long time!
A: tough. #ParentingIsHard

Q: But it’s really interfering with his sleep!
A: Oh, well in that case, let me go get the cure for the common cold and post viral cough that we doctors have been keeping secret. Lol, J/K - #PIH

Q: My friend Becky told me to come to the hospital because my baby had a fever of 99 degrees.
A: First off, in babies, a fever is 100.4 degrees. A temperature of 99 is not legally a fever. Second off, stop listening to Becky.

Q: does my child have a sinus infection?
A: since kids don’t really have sinuses, probably not. They may have small ethmoid sinuses that don’t often get infected, but they don’t have fully formed adult sinuses until they’re middle school aged. Those are the ones that get sinus infections.

Q: does my baby have bronchitis?
A: no. Just, no. Babies can get bronchIOLItis, but almost never get true bronchitis. And if they did, the treatment for bronchitis is not usually antibiotics.

Q: it’s been 30 days and he’s STILL coughing!
A: Wow, parenting really does suck. Nothing to do about it though.

Q: I want antibiotics
A: does your kid have strep, pneumonia, an ear infection, or a UTI? If not, tough.

Q: My kid has a runny nose, a sore throat, and a cough. Becky says it’s strep.
A: WTF did I say about listening to Becky?! Strep doesn’t cause runny nose and cough (except in babies under a year, which is a different entity than strep throat).

Q: My toddler has been sick for the last two months.
A: your kid, at this age, can get a dozen viral respiratory infections a year. Each one can last up to two weeks. You do the math - toddlers are sick almost just as often as they’re well.

Q: what about vitamin C and zinc?
A: MAYBE vitamin C prevents colds in certain subsets of the population, but not for everyone, and once you have a cold they won’t stop it. And don’t give your kid zinc.

Q: (something something essential oils or coconut)
A: the only natural treatment for a cough with good data is honey, and never give honey to a baby under 12 months.

Q: what over the counter medicine is best for a kid with a cold?
A: none of them. They all suck for kids. Tylenol and Motrin are good for fevers in general, but stay away from “cold and flu” medicines.

Q: Well, _I_ had a different experience than one of the above scenarios. I actually DID need antibiotics/ have a kid with a sinus infection/ found a worrisome reason for a lingering cough / got better with essential oils.
A: 1) that was likely a coincidence if it happened at all. 2) this is called an “outlier” and does not nullify the general rule 3) is this Becky? Go away Becky.

Q: All 6 of my kids are sick. What can I do?
A: Mirena, Nexplanon, and Depo-Provera are all good options for you.

Q: You’re a mean pediatrician
A: that’s not a question. But yes, yes I am."

New 2017 Generics for Concerta

Deja vu. I feel like I've been through this before.

Two of my most-read blogs were about generic forms of Concerta available in 2013-14. The FDA had allowed companies to manufacture and sell tablets that were not the same as Concerta. People across the country noticed the change immediately. I started seeing patients who had been well controlled on Concerta for a long time who suddenly were not able to focus, were more angry, and had other focus and behavior problems. Initially I had no idea there was a new generic, but one mother sent me a picture of the new pill and I knew instantly it could not be the same.

Now I've heard there will be new generics from Trigen Laboratories, Mylan and Impax Laboratories that do not use the special delivery system of Concerta once again. I'm worried because it took many many months of people filing reports with the FDA through MedWatch before the FDA finally stopped allowing the substitution. I hope the newly approved versions work better than the previous editions, but am worried not only because they don't use OROS technology, but there are several new versions coming to market and each could be different.

I have heard that the previously available OROS generic (made in the same factory as the name brand Concerta and the same exact pill but with a different label) will no longer be available. If this is true, options will be to pay for the name brand or go with a new version of the medicine.

These are all OROS type methylphenidate HCl ER (Concerta)

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. There is a little active medicine that is released immediately and then 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:

Source: https://www.medscape.org/viewarticle/547415_10

You can tell if you have the OROS tablets if they have a small dimple in one end:

The new generics

The same active ingredient (methylphenidate) is used in the new pills. I have heard that at least one version of the pills is round, so I know they don't use the OROS system. I cannot tell what type of delayed release they will have based on the information in their package inserts.

I find it very frustrating that each of the package inserts appear to be nearly identical to the one for Concerta (including the initial US approval date of 2000, which is not correct for this form). Older warnings, including a contraindication in those with tics, has been found in newer studies to not be a contraindication. The fact that they did not push to remove it makes me wonder if they did not want to have to change other parts of the document.

Figure 1 and Table 6 are identical with the exception of changing the word "CONCERTA" to "methylphenidate hydrochloride extended-release" and Trigen added an easy-to-read table format: 

Concerta

https://www.janssenmd.com/pdf/concerta/concerta_pi.pdf

Trigen's Methylphenidate HCl ER

Impax's Methylphenidate HCl ER

This makes me wonder if they were somehow able to get permission to make their new tablets based on Concerta's data, not their own. 

We'll see how it works in people who have previously taken OROS methylphenidate ER. Sadly, one version might work better than another, so you will have to keep track of which brand you are using.

What's good about the new generics?

If it's true that the currently available generic OROS form of methylphenidate ER is no longer going to be available, it's good that there will be other options to help keep costs down. Maybe. Sometimes insurance companies prefer branded products. It's all how they contract the cost. If you don't know how to use your insurance company's prescription formulary, you should learn. Also check out GoodRx for pricing information.

One might work as well (or better) than the OROS formulation in any individual. You won't know until you try it. 

One benefit I am excited about if these work: 

The Trigen version is available as a 72 mg tablet. The original Concerta is not able to be made at that strength. You can see from the photos above that the pills get bigger with increasing dosages, and the OROS system has limits to how much it can hold. For people who need 72 mg, they must take two of the 36 mg OROS tablets. Since patients pay by the pill and they need 60 pills/month instead of 30, this can be quite a bit more expensive.

What should you do if the pills change - especially if they don't work? 

Check each bottle when you pick up new medicine and ask if you can return unused tablets if they don't work for any reason. 

Keep track of what each pill looks like and the brand (which should be on the label) so you know which versions work and which don't. 

Talk to your kids about how they think and feel on and off their medicine - some will be more in tune with themselves than others.

Keep in touch with teachers as the pills change so you know if there are school-related issues you're not seeing at home.

If the pills don't work or have new or worsening side effects:

• Talk to your HR representative who deals with the insurance company. 
• Call your insurance company directly. Send them e-mails and snail mail. 
• Ask your physician to write a letter on your behalf. 

In each of the above situations, include why your family member needs the OROS technology. Give examples of how it works better than the other extended release methylphenidates and why the amphetamine class of medication failed (if tried). 

• People were able to get the FDA to look into the issue the last time a different tablet was substituted by submitting complaints to MedWatch. It took a long time, but the FDA finally agreed that there are significant differences and the other substitutions were no longer allowed. It's easy and free. Please submit to MedWatch if you have any concerns!

If you need to change medications because the new generics don't work well, it helps to know what other medicines are in the same class so you can look up your formulary coverage. The ADHD Medication Guide has an easy-to-read format of ADHD medicines. Just look for other medicines in the same colored box as Concerta to find similar drugs. (To limit plagiarism of this wonderful chart, you must click on the user agreement in the center of the page. It is free and easy.) Medications have been arranged on the card for ease of display and comparison, but dosing equivalence cannot be assumed. Talk with your doctor about what medicines will be best for your child (or yourself). *The ADHD Medication Guide was created by Dr. Andrew Adesman of the North Shore-LIJ Health System.

Related Posts:

Generic Concerta Not Working Like It Used To?

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

Sleep Deprived Teens: Health, Safety, & Mental Well Being Are At Significant Risk

Teens do not get enough sleep. Most teens need 8.5-10 hours of sleep each night. Not 6 hours. Not even 8 hours. Most don't get even close to meeting their needs and that's a bigger deal than many realize. Sleep is very undervalued, but we need to prioritize it.

Why don't teens get enough sleep? 

One of the most common reasons is that their biological clock (AKA circadian rhythm) makes it hard to fall asleep before 11 pm and school starts too early to allow them to sleep until 8 am, which would allow for 9 hours.

In addition to their circadian rhythm, some of their habits and activities can interfere with a healthy bedtime.

• Screens are a big problem. The light interferes with our natural melatonin rising. I regularly ask teens (and parents) to limit screen use for at least an hour before bedtime, but most teens say that's impossible because they have to finish their homework at that time and they need their computer or tablet to do homework. If you can't turn off the screen, at least use a program that limits the blue light that prevents the rise of melatonin. I personally use f.lux. (It's free and works on PC, Mac, ipad, android, and Linux). I find that it really helps. (This is not a paid endorsement, just a personal statement.)
• Phones. On a similar note, phones distract kids from what they're doing, delaying falling asleep. It takes longer to finish homework when there are distractions from the phone. Kids often are tempted to check in one more time on all their social channels, which delays sleep time. And then friends who are still up will text to see who's up (or who they can wake up). 
• Activities are too late. I'm not talking about kids just out and about on a school night. I'm talking about regularly scheduled activities that otherwise help build a well rounded person. It's not uncommon for activities to be scheduled to run until 9:30 or 10 on school nights for middle and high school aged kids. They get home and are hungry, need a shower, and are ramped up so not ready for sleep. 
• Activities start too early. I know many kids who must be at school before school actually starts. Whether it's band practice, church study groups, sports, or taking a missed test before school, they all interfere with sleeping in, which is what teens need.
• School starts too early. Most school districts around the country start school well before the recommended 8:30 earliest start time. School districts that have initiated later start times have shown improved test scores, fewer absences and tardies, less depression, improved athletic performance, and better graduation rates. Unfortunately, those schools are still in the minority. 
• Medical causes of sleep deprivation and fatigue can also occur. If you suspect any of these, you should schedule a visit with your doctor.

• Anxiety 

• Restless leg syndrome 

• Sleep apnea - pausing of breath, often associated with snoring 

• Medications that affect sleep cycles

• Heartburn or acid reflux  

• Hormone imbalances, such as thyroid problems 

• Anemia, or low red blood cell counts 

• Depression  

• Nutrition: not eating enough, or eating foods that are not nutritious. If you eat foods that cause spikes in your blood sugar, as those sugars drop you feel fatigued.

• Infections 

• Celiac disease   

• Chronic pain conditions 

• Chronic sleep deprivation - I know this is counter-intuitive, but being tired can make it harder to sleep.

What happens with too little sleep?

Sleep deprivation can lead to many problems that are often not attributed to poor sleep, such as irritability, poor academic performance, accidents, obesity and more.

• Moodiness. We all associate the teen years with angst, so we can easily attribute a teen's moodiness to just being a teen. But being chronically tired can lead to emotional dysregulation. This will look like irritability, frustration and anger. 

• School problems. It has been well established that getting proper amounts of sleep can help with focus and learning. When our teens fail to get enough sleep, they often report problems with attention, memory, decision making, reaction time, and creativity. It's no surprise that teens report problems paying attention to a lecture or trouble completing homework in a reasonable time with full accuracy. Grades can easily fall, which leads to anxiety and depression, which in turn leads to more moodiness and trouble sleeping. 

• Sleep deprivation mimics ADHD. Whenever I see a teen who wants to be evaluated for ADHD because of new loss of focus, falling grades, problems with behavior, or similar issues, I always look at sleep. Most often they don't have ADHD if this is a new problem. They need more sleep, not a stimulant medication. You can't put a band aide on a broken bone. Fix the problem, not the symptoms! (The same goes for a teen with ADHD who thinks the medicine that's worked for years suddenly isn't sufficient. Unless the medicine recently changed, they need sleep.)

• Injuries. Teens with chronic sleep deprivation are more likely to be accidentally injured. 

• Drowsy driving is comparable to drunk driving. Teens are at the highest risk for falling asleep at the wheel. Drowsy driving is the most likely to occur in the middle of the night (2-4 am), but also in mid-afternoon (3- 4pm) as teens drive home from school. 

• Athletes are more likely to be injured while playing their sport, so it is in the best interest of the team to let players sleep. 

• Risky behaviors. Teens with chronic sleep deprivation have been shown to participate in more risk taking behaviors, such as driving without a seatbelt, drinking alcohol, skipping the bike helmet and tobacco use. 

Pros and Cons of later school start times for our economy

There are many temporary issues with changing school start times. Parents might have to find solutions to child care of younger kids if they rely on teens babysitting after school. New bus schedules need to be started. Sports programs will need to change practice times. After school job availabilities will change.

Despite these common arguments, economic analysis from the Brookings Institution shows that a one hour delay of school start times could lead to a $17,500 earnings gain for students, compared to a cost of $1,950 during the student's school days.

Another study that presumed all students start school at 8:30, with a year-by-year economic effect. The study did not take into account other potential benefits of later school start times, such as decreased depression and obesity rates. They found an average annual gain of about $9.3 billion due to fewer automotive accidents, improved graduation rates, and other factors. 

What can teens do to get more zzzz's?

• Go to bed when tired at night. Fighting sleep initially will make it harder to go to sleep when you finally go to bed. 
• Attempt to follow a regular sleep schedule. Going to bed and getting up at about the same time every day helps. While sleeping in on weekends can help repair a sleep deficit, it can make it harder to get to sleep Sunday night and getting sufficient sleep every night is better than just getting more sleep a few days/week. Try to sleep in no more than 2 hours past your school day wake up time.
• Follow the same routine each night at bedtime. Brush teeth, read a book or color, take a bath or shower -- do whatever helps you wind down and relax. Repeating this every night can help your brain get ready for bed. 
• Nap to help make up missed sleep. A short 15-20 minute nap after school can help revitalize the brain to get homework done. Just don't sleep too long or it can interfere with bedtime.
• Turn off the screens an hour before bedtime. This includes tv, computer games, computer/tablet use for homework, and smartphones for socializing. Use night mode screen lighting and apps that dim the screen (like the f.lux app I mentioned above). 
• Avoid caffeine in the later afternoon. The time it takes half of the caffeine to be removed from your body is 5-6 hours. Ideally teens would sleep and never drink caffeine, but I know that isn't reality. Any caffeine in the later afternoon can make it harder to fall to sleep. Don't forget "hidden" sources of caffeine, such as chocolate, energy bars, and workout supplements.

• One interesting concept that has scientific backing (but goes against the "no caffeine after 3 pm" rule) is the coffee nap. Basically, you drink coffee then quickly nap for 15-20 minutes. Sodas and teas don't work as well as coffee due to too much sugar and too little caffeine. The coffee nap has been shown to be more effective than either a nap or caffeine alone. Don't do this often -- use it at times you really need it. Don't do this too late in the day or the caffeine will inhibit your regular night's sleep.

• Skip the snooze button. Set your alarm for the last possible moment you can, which allows your body to get those extra minutes of sleep. If you need to get out of bed by 6:45, but set your alarm for 6:15 and hit snooze several times, you aren't sleeping those 30 minutes. Set your alarm for 6:45!
• Skip the late night studying. Studying too late is ineffective. When the brain's tired it won't learn as well and you will make mistakes more readily. It takes a lot longer to get anything done when you're tired. Go to bed and get up a little earlier to get the work finished if needed. Of course you should also look at your time management if this happens too often. Are you involved in too many activities? Do you work or volunteer too many hours? Did you waste too much time on tv, games, or socializing? Do you put off big projects until the last minute? Homework needs to take priority when you're more alert in the afternoon and evening. If you have problems with this, talk to parents and teachers about what you can do.
• If you lay awake for hours or wake frequently, try these techniques to help fall asleep: 

• mindfulness (see my Mindfulness Pinterest page with many free apps) 

• deep breathing 

• a sound machine 

• listen to Weightless - music that's been shown to help initiate sleep 

• coloring 

• journaling 

• If these fail, talk to your parents and doctor to help find a solution.

• Charge your phone in another room. Friends who decide to text in the middle of the night keep you from sleeping. Even phones on silent have blinking lights that can spark your curiosity. It's too tempting to look at your social media apps one more time. 

• Don't use the excuse that you need your phone as an alarm. Alarm clocks are cheap. Get one and put your phone elsewhere!

• Use your bed for sleep only. Stop doing homework in bed. Stop watching YouTube and Netflix in bed. Train your brain that your bed is where you sleep.
• Exercise. Exercise helps our bodies sleep better, but it should ideally be earlier in the day. Too close to bedtime (which is common with athletes and dancers) wires us up.
• Get natural sunlight in the morning. This helps to set your circadian rhythm. 
• Keep the bedroom cool and dark. 
• Keep pets out of the bedroom. Your animals might love you and you love them, but if they keep you up, it's just not worth having them around at night.
• Nicotine and alcohol affect sleep. These should not be used by teens in an ideal world, but I know teens will not always follow the rules. Teens should know that if they are using nicotine or alcohol, their quality of sleep will be affected. 

• Nicotine is a stimulant (like caffeine), which leads to more time sleeping lightly and less time in deep sleep. And yes, vaping and chewing lead to this problem too, since it's the nicotine that causes the problem. 

• Alcohol reduces the time it takes to fall asleep but it increases sleep disturbances in the second half of the night, often leading to early wakening. Alcohol relaxes muscles, which can lead to sleep apnea (often noted as snoring). Sleep apnea does not allow the body to have restful sleep. Alcohol is also a diuretic, which might increase the need to wake to go to the bathroom during the night.

We all need to prioritize sleep: for our kids and for ourselves. Our bodies and minds will thank us.

Resources:

• Later school start times in the U.S.: An economic analysis
• Sleep Duration and Injury-Related Risk Behaviors Among High School Students — United States, 2007–2013
• School Start Times for Adolescents: (AAP) ADOLESCENT SLEEP WORKING GROUP, COMMITTEE ON ADOLESCENCE, AND COUNCIL ON SCHOOL HEALTH
• Melatonin for Children? A guide for parents by Dr. Craig Canapari
• I Just Want To Go To Sleep! How to Sleep Better (According to Science)I Just Want To Go To Sleep! How to Sleep Better (According to Science) by "Hey Sigmund"
• Start School Later, Inc.
• Back to Sleep Basics by Dr. Melissa Welby

Active Shooters: Reflections and Talking to Kids

Area flags are at half mast today as we are mourning the loss of innocent lives from another mass shooting at a Texas church over the weekend. We are sad for grieving families once again. What we can do to protect ourselves and our loved ones from random violence and acts of hate?

My generally safe town has had two incidents of violence that have made national news in recent years. A man opened fire at a Jewish Community Center and a Jewish Retirement Home and killed three innocent people. Another man shot two men eating at a local restaurant after yelling racial slurs and telling them to leave his country. One of the men died.

My kids have been on lockdowns at their schools on several occasions over the years. Our kids are getting used to lockdown drills and even real events. Thankfully none of the local school lockdowns turned tragic. Being a parent who cannot do anything while a school is in lockdown is stressful. Not knowing what is happening during a lockdown when my children are most likely sitting on a floor of a crowded dark room is terrifying. My kids have never felt that scared, even when it's a real lockdown, probably because they've practiced and feel prepared. For many kids this seems to be the case, but I'm sure there are some who start having separation anxiety or other manifestations of trauma-related stress. 

Today my front office staff saw policemen with weapons in hand enter our building and run down the hall. They did not come into our office. 

We locked our front door, closed the blinds, and kept patients in exam rooms. We saw several police cars in the parking lot for our building and those near ours. 

Our office manager called the police department to find out what was happening and not a lot was learned, but there was a potential active shooter in the area, so they recommended lockdown. 

Because I was only in the office for meetings on my "day off" I was able to help tell staff and patients what we knew. I helped bring some of the families into the office. I checked Facebook and Twitter repeatedly to find out what was going on. (But I didn't grab these screenshots until hours later.)

 I had planned on updating our social media, but couldn't find any real information to post.

At one point we were told they apprehended someone in a creek area behind our building and got the all clear to open back up and let people leave. 

41ActionNews

A few minutes later we were told to put our building back on lockdown. No one knew what was going on.

Our receptionists covertly monitored the parking lot for patients so they could get the door for them - we didn't want families stuck in a potentially dangerous parking lot. Several patients called that they would be late to their appointments because police had blocked one of the roads into our parking area. 

I am very proud of my staff and the families that were in the building. Everyone remained calm. No one complained that they were told to not leave the building. I didn't hear anyone complain when the rooms started to fill, which affected the flow of seeing patients. I must admit that I didn't really feel scared during all of this, since it seemed like police were all over and our office felt secure. It was frustrating not knowing what was going on, but the anxiety was much worse when the potential shooter was near my children's school and they were on lockdown.

It is sad that a false alarm like this must be taken seriously. I've heard that it was just a man with a stick. Or maybe it was just a prank. No one really knows at this time.

But what I do know is that there are many good people in this world. We can help each other in times of need. We can support one another. Mr. Rogers says: 

When I was a boy and I would see scary things in the news, my mother would say to me, “Look for the helpers. You will always find people who are helping.”

When you have to explain these things to your children, remember to keep it simple. Answer their questions, but don't go deeper than they're ready to go. Find out what they already know and help them to understand it in ways that mean something to them. Try to keep the news off when kids are in earshot and monitor their screen time online. It's okay to share your feelings, but try to reassure their safety and list some positives, like Mr. Rodger's mother did.

Resources for parents to talk to kids about tragic news: 

Common Sense Media: Explaining the News to Our Kids
PBS: Talking with Kids About News - sorted by ages
HealthyChildren: Talking to Children About Tragedies & Other News Events
American Psychological Association: How to talk to children about difficult news