Traveling with Kids

Many families travel when school's out of session, which over the winter holiday season means traveling when illness is abound. I get a lot of questions this time of year about how to safely travel with kids.

Sleep disturbances

Sleep deprivation can make everyone miserable, especially kids (and their parents). Make sure your kids are well rested prior to travel and try to keep them on a healthy sleep schedule during your trip. 

Bring favorite comfort items, such as a stuffed animal or blankie, to help kids relax for sleep. If possible, travel with your own pillows.

If you're staying at a hotel, ask for a quiet room, such as one away from the pool and the elevator. 

Be sure to verify that there will be safe sleeping areas for every child, especially infants, before you travel.

Try to keep kids on their regular sleep schedule. It's tempting to stay up late to enjoy the most of the vacation, but in reality that will only serve to make little monsters of your children if they're sleep deprived.

If your kids nap well in the car, plan on doing long stretches on the road during nap time. If kids don't sleep well in the car, be sure to plan to be at your hotel (or wherever you're staying) at sleep times so they can stay in their usual routine.

Some families leave on long trips at the child's bedtime to let them sleep through the drive. Just be sure the driver is well rested to make it a safe trip!

If you're changing time zones significantly, plan ahead. Jet lag can be worse when traveling east than when going west. Jet lag is more than just being tired from a change in sleep routine, it also involves changes to the eating schedule. Kids will often wake when they're used to eating because the body is hungry at that time. Try to feed everyone right before they go to sleep to try to prevent this. Breastfed infants might have a harder time adjusting because mother's milk production is also off schedule. 

Tired, sick, and hungry all make for bad moods, so try to stay on track on all accounts. Sunlight helps regulate our circadian rhythm, so try to get everyone up and outside in the morning to help reset their inner clocks. Keep everyone active during the day so they are tired at the new night time.

Keeping track of littles

Toddlers and young kids love to run and roam. Be sure that they are always within sight. Use strollers if they'll stay in them.

Consider toddler leashes. I know they seem awful at first thought, but they work and kids often love them! I never needed one for my first - he was attached to parents at the hip and never wandered. My second was fast. And fearless. She would run between people in crowds and it was impossible to keep up with her without pushing people out of the way. She hated holding hands. She always figured out ways to climb out of strollers - and once had a nasty bruise on her forehead when she fell face down climbing out as I pushed the stroller. She loved the leash. It had a cute monkey backpack. She loved the freedom of being able to wander around and I loved that she couldn't get too far.

Parents have a number of ways to put phone numbers on their kids in case they get separated. Some simply put in on a piece of paper and trust that it will stay in a pocket until it's needed. Others write it in sharpie inside a piece of clothing or even on a child's arm. You can have jewelry engraved with name and phone number, much like a medical alert bracelet. Just look at Etsy or Pinterest and you'll come up with ideas!

It's 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.

Airplane issues

The great news is that air travel is much safer from an infection standpoint than it used to be. Newer airplanes have HEPA filters that make a complete air change approximately 15 to 30 times per hour, or once every 2-4 minutes. The filters are said to remove 99.9% of bacteria, fungi and larger viruses. These germs can live on surfaces though, so I still recommend using common sense and bringing along a small hand sanitizer bottle and disinfectant wipes to use as needed. Wipe down arm rests, tray tables, seat pockets, windows, and other surfaces your kids will touch. After they touch unclean items sanitize their hands. Interestingly, sitting in an aisle seat is considered more dangerous, since people touch those seats during boarding and when going to the restroom, so if you're seated in the aisle pay attention to when surfaces need to be re-sanitized. Sitting next to a sick person increases your risk, so if there is an option to move if the person seated next to you is ill appearing, ask to be moved. 

Most adults who have flown have experienced ear pain due to pressure changes when flying. Anyone with a cold, ear infection or congestion from allergies is more at risk of ear pain, so pre-medicating with a pain reliever (such as acetaminophen) might help. If you have allergies be sure to get control of them before air travel. The best allergy treatment is usually a nasal corticosteroid. 

It has often been recommended to offer infants something to suck on (bottle, breast or a pacifier) during take off and landing to help with ear pressure. Start early in the landing - the higher you are, the more the pressure will change. Older toddlers and kids can be offered a drink since swallowing can help. Ask them to hold their nose closed and try to blow air out through the closed nostrils followed by a big yawn. If your kids can safely chew gum (usually only recommended for those over 4 years of age) you can allow them to chew during take off and landing. 

Airplane cabin noise levels can range anywhere from 60 - 100 dB and tend to be louder during takeoff. (I've written about Hearing Loss from noise previously to help you understand what that means.) Use cotton balls or small earplugs to help decrease the exposure, especially if your kids are sensitive to loud noises.

The Car Seat Lady has a great page on knowing your rights when flying with kids.

Cruise ship issues

Learn about cruise-specific opportunities for kids of various ages. Many will offer age-specific child care, "clubs" or areas to allow safe opportunities for everyone to hang out with people of their own age group. Cruises offer the opportunity for adventurous kids to be independent and separate from parents at times, allowing each to have a separate-yet-together vacation. Travel with another family with kids the same ages as yours so your child knows a friendly face, especially if siblings are in a different age group for the cruises "clubs".

Talk to kids about safety issues on the ship and make sure they follow your rules. They should always stay where they are supposed to be and not wander around. There's safety in numbers, so have them use a buddy system and stick with their buddy. Find out how you can get a hold of them and they can get a hold of you during the cruise. 

Of course sunscreen is a must. Reapply often!

Be sure kids are properly supervised near water. That means an adult who is responsible for watching the kids should not be under the influence of alcohol, shouldn't read a book, or have other distractions. 

Car seats (for planes, trains and automobiles)

I know it's tempting to save money and not get a seat for your child under 2 years of age on a plane, but it is recommended that all children are seated in a proper child safety restraint system (CRS). It must be approved for flight, but then you can then use the seat for land travel. 

I always recommend age and size appropropriate car seats or boosters when traveling, even if you're in a country that does not require them. Allowing kids to ride without a proper seat will probably lead to problems getting them back in their safe seat when they get back home. Besides, we use car seats and booster seats to protect our kids, not just to satisfy the law.

So... my section header was meant to be cute. Trains don't have seatbelts, so car seats won't work. But they are a safe way to travel. Car Seat for the Littles has a great explanation on Travel by Train.

Motion sickness

I have an entire blog dedicated to this common issue. See Motion Sickness. 

Dr. Charmaine Gregory, an emergency physician, has written specifically about preventing seasickness at 7 Top Tips To Avoid Seasickness While Cruising.

When should pregnant women and new babies avoid travel by air?

A surprising number of families either must travel (due to a job transfer, death in the family, out of state adoption, or other important occasion) or choose to travel during pregnancy or with young infants. 

Newborns need constant attention, which can be difficult if the seatbelt sign is on and needed items are in the overhead bin. New parents are already sleep deprived and sleeping on planes isn't easy. New moms might still have swollen feet and need to keep their feet up, which is difficult in flight. Newborns are at high risk of infection and the close contact with other travelers can be a concern. And traveling is hard on everyone. But the good news is that overall young infants tend to travel well. 

It is advisable to not travel after 36 weeks of pregnancy because of concerns of preterm labor. Pregnant women should talk with their OB about travel plans. 

Some airlines allow term babies as young as 48 hours of age to fly, but others require infants to be two weeks - so check with your airline if you'll be traveling in the first days of your newborn's life. There is no standard guideline, but my preference would be to wait until term babies are over 2 weeks of age due to heart circulation changes that occur the first two weeks. Waiting until after 6 weeks allows for newborns to get the first set of vaccines (other than the Hepatitis B vaccine) prior to flight would be even better. Infants ideally have their own seat so they can be placed in a car seat that is FAA approved. 

Babies born before 36 weeks and those with special health issues should get clearance from their physicians before traveling.

Overall traveling with an infant is not as difficult as many parents fear. Toddlers are another story... they don't like to sit still for any amount of time and flights make that difficult. They also touch everything and put fingers in their mouth, so they are more likely to get exposed to germs.

Illness prevention

Who wants to be sick on vacation? No one. It's easy to get exposed anywhere during the cold and flu season, so protect yourself and your family. 

• Teach kids (and remind yourself) to not touch faces - your own or others. Our eyes, nose, and mouth are the portals of entry and exit for germs. 
• Wash hands 

• before and after eating. 

• after blowing your nose. 

• before and after touching your eyes, nose, or mouth. 

• before and after putting in contacts. 

• after toileting or changing a diaper.
• when they're obviously soiled. 

• Cover sneezes and coughs with your elbow unless you're cradling an infant in your arms. Infants have their head and face in your elbow, so you should use your hands to cover, then wash your hands well.
• Make sure all family members are up to date on vaccines. 

• Everyone over 6 months should have a flu shot if it's flu season (fall-winter). 

• Kids and adults should have all their routine vaccines. 

• If you're traveling internationally, check out the country-specific recommendations for vaccines (and other interventions, such as insect repellents and prophylactic antibiotics). I've written more on this at Traveling Around the World. Stay Safe and Healthy! For personal accounts of traveling with a baby internationally, see International Travel with Baby and Not a Cruise from Dr. Dawn Baker at Practice Balance.

Keep records

Take pictures of your passport, vaccine record, medicines, insurance cards, 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

Enjoy!

Last, but not least: Enjoy your vacation! 

Be flexible. 

Don't overschedule. Your kids will remember the experience, so make moments count - don't worry if you don't accomplish all there is to do!

Take a look at some of the Holiday Health Hazards that come up at vacation times from Dr Christina at PMPediatrics so you can prevent accidents along the way. 

Take pictures, but don't make the vacation about the pictures. Try to stay off your phone and enjoy the moments!

Which Supplements Help Prevent and Treat Infections?

I don't know anyone who wants to get sick, so most of us try our best to avoid illnesses. We do this by washing our hands and encouraging our kids to cover their coughs. We avoid sick people as much as possible (though we don't always stay home when we should). We should routinely get enough sleep (most Americans fail in this regard) and eat more fruits and vegetables (again, most of us fail to get the minimum recommended amounts of plants in our diets).

All of these measures can help, but can we get more help from nutritional supplements or other natural remedies? What will boost our immune system?

I'm often asked if vitamin C, zinc, or essential oils will help various ailments or boost our immune system. I know that many people try natural products that are promoted to boost or support the immune system. They're hopeful that stimulating immune system activity will help the body fight off a virus. But research doesn't show that our immune system works that way. A virus can cause illness even in healthy people. If you want to read an in-depth summary of how our immune system works, the Skeptical Raptor has done a nice job discussing the complexities and why it's not as easy as eating healthy and taking supplements. Not to mention the fact that we don't necessarily want an overactive immune system, which is associated with allergies and autoimmune diseases.

One thing we need to remember first and foremost in the discussion of supplements is that this is an under-regulated industry. The FDA is not authorized to review dietary supplement products for safety and effectiveness before they are marketed. For this reason I hesitate to recommend supplements at all. Even though I do recommend Vitamin D supplements because studies support the need for additional Vitamin D in most people, I cannot endorse one particular product. Over the years many supplements, homeopathic products and herbs have been reported to have significant variances in amounts of product and unnamed contaminants, including lead and other hazards.

Summaries of supplement and other "natural treatment" effectiveness:

• Probiotics may actually help prevent the number of infections. There are many, many types of probiotics, so further studies are needed on how to choose the best strain.
• Zinc has been shown to help prevent upper respiratory tract infections in children and teens and to decrease the duration of the common cold symptoms. It is best given as a lozenge to help with absorption. Intranasal zinc has been linked to a permanent loss of smell and should not be used. High doses can cause significant side effects, so talk to your doctor and pharmacist before supplementing.
• Nasal saline rinses show benefit in treating symptoms of upper respiratory tract infections. Learn how to do these correctly before trying it though. I often recommend Nasopure products as an unpaid endorsement. They're a local company with a very helpful website. Use their library to learn how to properly use nasal rinses in kids as young as 2 years of age.
• Honey may reduce the frequency of cough and improve the quality of sleep for children with the common cold. Honey should never be used in children younger than 1 year of age because of the risk of botulism.
• Echinacea has consistently been shown to be ineffective in many studies. I know that many people have heard of its benefits, so if you aren't convinced that you shouldn't waste money on it, see the NCCIH's Echinacea page.
• Garlic shows overall low evidence of benefit.
• Vitamin C can shorten the duration of illness mildly with daily supplementation. 
• Chinese herbal medicines do not have high quality studies so effectiveness is unknown.
• Geranium extract (Pelargonium sidoides) has insufficient evidence of benefit for cold and cough symptoms.
• Turmeric's supposed anti-inflammatory properties have not been shown to be effective by research.
• Essential oils have the potential for beneficial effects – but they also have the potential for adverse reactions. Although they are touted as a cure for many ailments, published studies regarding the uses of aromatherapy have generally focused on its psychological effects on stress and anxiety or its use as a topical treatment for skin conditions. Both Young Living and dōTERRA have received warning letters from the FDA about improper marketing and unsubstantiated claims for uses of their oils. While many people think essential oils are safe, they can lead to significant problems. Some people suffer from allergic reactions to oils. They can increase sensitivity to the sun when applied topically. Tea tree oil and lavender have estrogen-like effects and caution should be used with these. Some of these substances can even lead to seizures, liver damage, and death if used improperly. Ingestion of the oils is a growing concern - as more households have them, more children are ingesting them.

Alice Callahan's “Immune-Boosting” Supplements Won’t Protect You from Back-to-School Germs is a great review of many of the supplements touted to prevent or treat illnesses. Her background in nutrition provides a solid base for reviewing claims that many of us don't understand completely. 

Generally supplements are not recommended, but if you choose to use them, use them cautiously.

• Supplements contain a wide variety of ingredients - including vitamins, minerals, amino acids, and herbs. Research has confirmed health benefits of some dietary supplements but not others. The woo can be strong in this area, so be cautious where you get your information. 
• Supplements have been known to include unlisted ingredients and to have inconsistent levels of product. When they are recalled, there is no mechanism in place to identify and notify people who have purchased affected products. 
• Find a reliable source to evaluate effectiveness and risks. Some reports have shown that people who take supplements have higher risks of cancer, liver damage, birth defects, bleeding, and other health problems. When looking for information, use noncommercial sites (National Institutes of Health, Food and Drug Administration, US Department of Agriculture, National Center for Complementary Health) rather than depending on information from sellers.
• Natural does not mean safe. I've always said that I wouldn't give my picky eater marijuana to stimulate his appetite and encourage him to eat. Not even if it was organic. That usually gets the point across. You need to know the risks of a product, even if it's natural. 
• If supplements will be taken, talk to your doctor and pharmacist about drug interactions. Sometimes it's difficult to know the risks because not all ingredients are included on the label and not all ingredients have been well studied, especially in combination with other supplements and medications. 
• Most dietary supplements have not been tested in pregnant women, nursing mothers, or children. Remember just because something's natural doesn't mean it's safe. Arsenic is natural but I wouldn't advise taking it in high doses.
• If something sounds too good to be true, it probably is. There are no miracle cures. Avoid being manipulated by advertising. It's easy to fall prey because we all want to feel better quickly and parents want their kids to be healthy. But if it claims to be 100% effective or to have no side effects, it's probably false advertising. Personal accounts of something working are as likely to be based on bias or coincidence as to be from real benefit. Rely on large clinical studies that have been reproduced by other researchers. Dr. Chad Hayes has a very long, but wonderful post on how many of the integrative medicines are not simply not beneficial but potentially dangerous - Citations Needed: The curious “science” of integrative medicineMy experience at "Get Your Life Back NOW!"

This post isn't about antibiotics, but they don't work against viral illnesses any better than supplements. They don't prevent the development of ear infections or pneumonia, so even if your child seems to always develop these complications, your doctor should not prescribe them preventatively. Don't use antibiotics for routine upper respiratory infections, stomach bugs, and other viral illnesses. 

Do you know what really boosts your immune system?

Vaccines

A Working Parent's Guide to Being There

As a working mom myself, I have at times struggled with the guilt of not being around for every new milestone, class party, or other occasion.

There are the stay-at-home vs working mom "Mommy Wars" that I don't want to get into because these options are unique to every family. I know that working is the right choice for me on many levels. I like that my kids have two hard-working parent role models that also spend quality time with the family.

Do things always flow smoothly?

Of course not. We have a crazy, hectic life. Every stage has had it's own problems to conquer, and once we get into a routine it settles for a bit. Then the life stage changes and we adapt. At this point I thought my life would be less crazy (my oldest is away at college and my youngest drives), but it's still crazy aligning schedules.

When my children were younger, it was really hard to get home, get dinner on the table, and get them to bed on time for a good night's sleep. Young children need 11-12 hours of sleep, and when we get home at 6:30 pm, it's really hard to do anything. I became the queen of 15 minute meals and love my crock pot. My quick cooking is probably even healthier than fancy casseroles because it's a basic heated frozen vegetable, stovetop cooked chicken or a quick fish, and noodles or rice. No fancy cream sauces or cheesy goodness weeknights. Sometimes my kids ate leftovers from the previous night so they could eat within minutes of getting home. Whatever worked at the time to get dinner served quickly so the bedtime routine could start was what happened.

We only have two kids, and are fortunate to have two parents, but sometimes we still needed help from friends to get kids to scheduled activities on time. I am a big believer in being there at games or shows, but it's impossible with more than one child and overlapping schedules to be at everything. We tried to alternate which child's activity we do, though my husband went to more hockey games and I went to more dance activities because, well, we're human and he can only watch so many dances and I had a hard time watching my son get thrown against the boards.

It is important that kids know parents are there for them, even if they aren't physically able to be there all the time. The best way to do that is to show kids. When you're together, really be together. Don't keep checking your phone. Make conversation. Make eye contact. Have fun.

Sneak in quality time any way you can, even if it's just a minute or two.

• Talk on car rides. Make routine trips no-screen rides. On longer trips consider an audiobook that you can all listen to and discuss along the way.
• Make eye contact when your kids ask for your attention. Even if you're busy making dinner or doing the dishes, be considerate enough to look at them when you're speaking to them. So often we get upset by our children's manners, but we forget who they're modeling after. 
• Bed time. Definitely at bedtime make the time to connect. Those night time stories, back rubs, and cuddles are the perfect time to bond. Even when your kids can read, take time to read to each other.
• Find quick games to play after dinner. Many games list the time it takes to play right on the box. No one has time for Monopoly after dinner if they plan on getting the kids to bed on time, but family games are a great way to connect, and kids learn many skills from playing. 
• It sounds silly, but kill two birds with one stone. Have a family "clean time"- and make it fun. The house needs to be cleaned or picked up regularly and if everyone pitches in with age-appropriate chores, it gets done more quickly. Brag on your children's effort and build their confidence. 
• Try to be at activities as much as possible. If they're in a recital, they want you there. If they have a big game, they want you to see it. Even if they say, "it's okay" when you can't go, they want you there. I know it's not possible to be there for everything, especially if you have more than one child and you need to alternate between which activity you go to, but try to be at as many things as you can. Even when it's painful to watch the first season of kid-pitch baseball. And if you must take a pain reliever before going to the band concert for your 4th grader. Still go. 
• Make the time with them with them. Turn off your cell phone. Don't check e-mail. Set a good example and talk with the people you're with. So many studies are being done that show parents ignoring their kids due to electronics. You have time to check email after your kids go to bed when they're young. When they're older and their bedtime rivals yours, you can find time when they're doing homework or when they're at an activity. No need to ruin family time with work, social media, or other things that can be done when you're alone. I cannot stress the importance of this. Don't miss your real life and your children's lives by wasting time on screens.
• Family meals are important. Study after study shows benefits. Take the time to talk. Turn off the tv. Keep the phones away from the table. If your family gets stuck with conversation, try some conversation starters or the story game where someone starts with a sentence, then the next person takes it from there.
• Slow down. So often we have a list of tasks we know we must accomplish, but our kids can sense the rush. Take a deep breath and enjoy the moment with your kids.
• Take 10 minutes to do whatever your child wants. Read a book. Run outside. Color a picture together. Just 10 minutes a day can make a difference. Make it a tradition, something your child looks forward to every day.
• And finally, remember that no one is perfect. Some days just won't work out as planned. That's okay. Just don't let every day become that over-rushed day.

I see far too much guilt in parenting. Guilt because you choose to give baby a bottle. Guilt because you want your baby to sleep through the night. Guilt because... it never ends. I think one big driver of guilt is social media. We see into other people's lives on Facebook, Pinterest, Instagram or Twitter and compare it to our own. The posts are usually the best parts of their life, but we forget that everyone has the parts they aren't showing. Everyone wants to be like someone else on some level. We all have dreams and aspirations to improve. Great. Keep bettering yourself. But don't suffer from guilt of choices you've made. If they are working, great! Keep them. If they aren't working, investigate other options and make a positive change. In 4 S's of Being a Confident Parent, Dr. Escalante discusses the trials parents face and errors parents make and why that's okay.

I came across this great post on the problems with Attachment Parenting. I think that when people have such strong opinions about anything, it is a set up for failure. Attachment Parenting can lead parents to feel guilty because they aren't always there for a child. You know what? It's healthy to have alone time. Parents need to do things with other adults and leave the kids with a trusted adult or mature teen babysitter. It's just healthy. If you don't take care of yourself, you won't take as good of care of your family as you can if you are healthy in mind, body, and spirit.

Enjoy time with your kids. They won't be little forever. Make the time to be present in their lives.

One last thought... Here's an old song that I always think of when I think of busy lives: Cats in the Cradle from Harry Chapin. 

New Allergy Guidelines for People Over 12 Years Old

If you or your kids suffer from allergies, I'm sure you want to know how to best manage them. In addition to limiting exposure, medications can be a big benefit. 

The American Academy of Allergy, Asthma, and Immunology and the American College of Allergy, Asthma, and Immunology (AAAAI and ACAAI) have published new guidelines in the Annals of Internal Medicine for the initial medical treatment of seasonal allergies in people 12 years and older.

The recommendations essentially state:

• Use steroid nasal sprays first without an oral or nasal antihistamine. Many intranasal steroids are available over the counter without a prescription. A great list is included on the AAAAI website. (Be careful to not to confuse them with the nasal antihistamines, which are in the same chart but identified in the column titled "Class".) 
• In those over 15 years, the nasal steroid is preferred over a leukotriene receptor antagonist (ie Singulair or montelukast). For those with asthma, the leukotriene receptor antagonist might offer an additional benefit for asthma, but it is not the preferred treatment in either allergies or asthma. (I think the age change is simply due to the ages studied but it was not specified.)
• In moderate to severe allergic conditions, a combination of nasal steroid and nasal antihistamine can be considered. 

These recommendations are based on a review of many studies to show what treatments worked and what didn't. They also took into consideration the fact that oral antihistamines can cause sedation and the nasal antihistamines do not. In general the nasal steroids worked better than other treatments. They did note that for people who do not tolerate nasal sprays, alternates would be oral antihistamines or leukotriene receptor agonists.

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