How To Keep Your Family Healthy This Winter

This blog is short and sweet about avoiding illness this sick season, but has links to dig deeper as desired.

It's not a big secret. We know the best ways to stay healthy, but it takes everyone to participate to make it work.

Practice the following routinely and help stop the spread of illness!

1. Wash hands or use hand sanitizer (sanitizer is not helpful at eliminating all germs - see the link for more information on how and when it is appropriate) 
2. Eat healthy and drink water (infants under 6 months should drink breast milk or formula)
3. Sleep
4. Get vaccinated
5. Don't touch your face - this is where germs enter our bodies!
6. Probiotics might help (recent meta analysis)
7. Wipe down objects regularly: learn the difference between cleaning, disinfecting, and sanitizing.
8. Safely prepare and serve food 
9. Cover your cough and sneeze with your elbow.
10. Avoid sick people
11. Stay home when sick

Things that haven't been shown to help:

1. Mega doses of vitamins
2. Cough and cold medicines have limited benefits, if any at all
3. Homeopathic medications
4. Essential oils
5. Antibiotics for viral illnesses (most cold and coughs)
6. Using an improper medication dosing device

Related blogs:

How Long Will a Cough or Cold Last?

Cough Medicine: Which one's best?

My Child's Cough Sounds Like...

But the snot is green...

Sick, sick, and more sick

Holidays and family spoiled by illness... It's that time of year!

To Tamiflu or Not to Tamiflu?

Tamiflu: Guest Blogger Dr. Mark Helm

Adenovirus Infections

Evolution of Illness

Fever Is...

New High Risk Child RSV Prevention Guidelines

Getting kids to swallow pills

Kids fighting to take medicine is a commonplace occurrence. They don't like the taste. They're already sick so they don't want to do anything you want them to do. They want to wait 5 more minutes. There are as many reasons they don't want to take it as there are reasons we think they need it.

One of the biggest challenges for some people (not just kids) is swallowing pills. At some point transitioning to pills is important. They are easier to store. Some medicines do not come in liquid or chewable form. Some kids simply get so big that the volume of liquid they need to choke down becomes difficult.

When my son was a preschooler, I realized that he swallowed some things whole ~ usually things he didn't like, like a piece of meat. He sometimes needed oral steroids for wheezing. Steroids in liquid form are notoriously nasty. He would vomit it back up most of the time. The tablets are really small, so I decided to have him try those once. Easy as pie for him! I don't think we even had to practice. I just told him to not chew because it would taste bad and he knew what to do. I think he was so young, he didn't know that he should be scared of choking.

If only most people could teach themselves like that... Despite it being difficult to learn, most people can learn to safely swallow pills. Once the technique is learned, the size and the shape of the pill is not usually an issue.

There are many tricks people use to swallow pills. What works for one doesn't work for another. If your child isn't willing to give it a try, it's really not worth it. Since this is a mind over matter thing, it will be impossible if they're not on board. If they're not ready, every once in awhile you can mention how big of a bite of food they just ate and comment that they swallowed it easily. Remind them to let you know when they want to try to swallow a small piece of candy. (For many the temptation of extra candy is an automatic selling point.) Don't wait until they have an illness to start because no one wants to learn anything new when sick. Once they get the technique, be sure to do it often enough that they don't forget until they need to use it.

Never practice with real medicine, even if it's over the counter stuff. Kids should know that they are practicing without real medicine. At the same time as teaching them to swallow pills you can talk about medication safety: only take it when an adult says it's okay, keep it away from other children, never share medicine with others, take it as the doctor prescribed if it is a prescription, and how and when to use over the counter medicines. It's a great skill for kids to know all of these things, and good to review until they have it all down. I am sometimes surprised at nearly college aged kids not knowing what common medicines are used for if they have aches and pains or illness. They need to know!

When I had to teach my daughter to swallow pills, I bought a container of Tic Tacs and told her that when she could swallow 3 in a row without choking, she could have the rest and eat them without permission unless she already brushed her teeth at night. She loved that idea and took to the challenge excitedly!

If you try one of these methods and it isn't working, you can try another. You can practice with both round and oval shaped candies since medicines come in both forms. Avoid having your child take huge gulps because that can cause them to lose control of the swallow. There are special cups that you put the pill in and then drink from them. I have no experience with them, so will not review them here. Commonly used methods to learn pill swallowing:

Starting small and working up

photo source: Shutterstock

For kids who are very hesitant, it is possible to start very small and work up to a standard pill size. Start with cake decorating beads, balls or sprinkles. Avoid the ones that are very lightweight because they might float and not go down as easily. Most kids agree that something very small will be easy to swallow. Have them show you they can. Build confidence by starting really small so they have a good first try. After they do it enough that they feel confident moving up (usually 3-5 successful swallows), use a bigger piece. Keep working your way up to a size that resembles most medicines. If a child fails a size, go back down to the smaller size to gain confidence. Don't spend more than 10-15 minutes each session. If the child tires or the stomach fills with too much water, it will be non-productive. Remember to praise any successes. Always end on a positive note by having the child swallow whatever size he can. So if it is unsuccessful to move to a larger size, have him go down a size, swallow successfully, then don't go up again at that session. You can always try again another day.

Straw Method

Different people like different positions for swallowing pills. Some do best with their head back, as is typical with drinking from a cup, so the pill has a straight shot down. Others do best with the head turned to one side or another. Some even change their preference over time. For those who prefer to have the head neutral or a bit forward, using a straw avoids having to tilt back to drink. Have your child put the candy on the front half of the tongue, then drink out of a straw with the straw at the front of the tongue so the liquid comes out in front of the pill. Tell them to focus on the drink, not the tablet. Some people say to put the tablet as far back as possible, but I think that can trigger the choking reaction, which is not helpful at all. Most of the time the pill will naturally go down with the liquid without even thinking about it. If you like to be green and don't want to fill a landfill with plastic straws, check out these fantastic glass straws. (I don't typically endorse products, but this is an entirely unpaid endorsement. We've had these straws for years. They go in the dishwasher daily. We've dropped them from table height. They still look brand new. We love them for many reasons, and since we use straws all the time, I don't feel guilty about our environment.)

Hidden pills

Some people feel more comfortable swallowing food than pills, so putting a pill in a soft food helps. Common foods are yogurt and applesauce. I've even heard of parents putting the pill at the top of a yogurt tube, and having the child suck down the yogurt. The biggest issue with this method is that if a child takes too long to take it, the tablet or capsule might start to break down, and then the child can notice the taste (which is often bitter). Another problem is if the child tries to chew the food first because most medicines meant to be swallowed should not be chewed.

Research proven techniques

For more help on learning to swallow pills, check out these videos that show how to swallow pills (link fixed 7.22.17) in different positions. Kids might like to see the techniques themselves before they practice.

Learning and Behavior Series Part 5: Medications

This is the 5th post in a series of blogs on Learning and Behavior. It will focus on prescription treatments used primarily for ADHD.

There are many parts to the treatment of ADHD including behavior modifications; school accommodations; optimizing nutrition, sleep, and other healthy habits; and supplements -- all covered in previous posts in this series. This one will cover common medications that have been approved or are commonly used for the treatment of ADHD. I am not going to go into how to diagnose ADHD here, but it is of course of utmost importance to have the correct diagnosis before medication is considered.

There are many treatments out there that are not approved for the purpose being used, but if done properly might be a good consideration. Physicians sometimes use treatments that have not been approved for the purpose because they know from experience that it works or they are at a loss from approved treatments failing and they need to try something else.

One example is using a shorter acting form of guanfacine (Tenex) that has not been approved to treat ADHD, but is less expensive than the longer acting form (Intuniv) that is approved for ADHD.

Another common example is the use of albuterol, a medicine that helps breathing with conditions that cause wheezing. It is not approved for use under 2 years of age, but it is commonly used for younger children with difficulty breathing -- and it helps them breathe, which might keep them out of the hospital and off of supplemental oxygen.

I do not think that all non-approved medicines are good or bad. It is a very individual decision of what medicines to use. Discuss with your doctor if a treatment is approved or if they are using something that is not. Although this is relatively common among people who treat children because many drugs have not been tested in children and have been "grandfathered" into use through experiences that show benefit, be sure the provider is not picking something that has no basis or supporting evidence, especially if he or she profits from the treatment.

Be very wary of anyone who promises a cure - if one really existed everyone would use it.

Medications approved to treat ADHD

Medications to treat ADHD fall into the following categories:

• Stimulants

• Methylphenidates (Ritalin©, Focalin©, Concerta©, Daytrana©, Metadate©, Quillivant©) 

• Amphetamines (Adderall©, Vyvanse©, dexedrine) 

• Non-stimulants

• Atomoxetine (Strattera©) 

• Guanfacine (Intuniv©) 

• Clonidine (Kapvay©) 

• Others are used off-label (no FDA approval for the purpose of ADHD treatment): Tenex, Catapres patch, antidepressants, and antipsychotics

When a medication is needed to control symptoms of ADHD, the first line medications are the stimulants unless there are contraindications. Non-stimulant medications are not found to be as effective as stimulants in the majority of children, but they do have a place in the treatment plan for some children. They are sometimes used in addition to stimulants for optimal results. For information on how these medicines, see A Guide to ADHD Medications. It reviews how stimulants act on dopamine and norepinephrine and various time release patterns of different medicines.

Side Effects

Parents usually worry about medication side effects, which is a very legitimate concern. Overall the medicines listed above are very well tolerated. If a child has side effects to one stimulant, they can usually do well on a different class (methylphenidate vs amphetamine). I often hear concerns that parents don't want their kids changing their personalities or becoming "zombies". If the right medicine is used at the appropriate dose, this is usually not a problem. Finding that right medicine and right dose might take some trial and error, but work with your prescriber to get to the right one for your child.

The most commonly observed side effects of stimulants are:

• Decreased appetite – Appetite is often low in the middle of the day and more normal by supper time. Good nutrition is a priority, so encourage kids to eat the healthy "main course" first and leave the dessert out of the lunchbox. Short acting meds improve mid day appetite since they wear off around lunch time. Kids are often very hungry in the evenings when medicines wear off, so encourage healthy foods at that time. I have also seen some kids who have a really hard time off medicine sitting down to eat actually gain weight better on medicine because they can finish the meal.
• Insomnia – Trouble sleeping is common with ADHD, with or without medicines. If it is due to the stimulant medicine, trouble sleeping may be relieved by taking it earlier in the day.
• Increased irritability -- Moodiness is especially common as the medication wears off in the afternoon or evening and in younger children. It makes sense if you consider that all day they are able to focus and think before acting and speaking, but then suddenly their brain can't focus and they act impulsively. Typically kids learn to adjust to the medicine wearing off as they mature. Sometimes just giving kids 30 minutes to themselves and offering a healthy snack can help. Cognitive behavioral therapy can help. 
• Anxiety -- Anxiety does occur with ADHD and might be under-appreciated before the ADHD symptoms are treated. When kids can focus better, they might focus more on things that bother them, increasing anxiety. It is also possible that anxiety is misdiagnosed as ADHD, which is one reason for stimulant medication failure.
• Mild stomach aches or headaches -- Stomach aches and headaches are occasionally noted with stimulant medications. It is my experience that they are most common with a new medication or a change in dose. Because these have many causes, it can be hard to determine if they are really from the medicine or another cause. If they persist with the medicine, it might be needed to change to another.
• Tics - Tics are related to treated and untreated ADHD. People with ADHD are more likely to have tics than the general population. It was once thought that tics were caused by the stimulant medicines, but it is now thought that they happen independent of the medicine, and medicines might even help treat the tics.
• Growth -- Weight gain can be difficult for some kids on stimulant medications due to the appetite suppression on the medicine. Studies have shown a decreased final adult height of about 1-2 cm (1/2 - 1 inch), which most agree is not significant compared to the benefits in self esteem, academics and behavior children gain on stimulants.

Rare side effects of stimulants include hallucinations and heartbeat irregularities

• I have only seen two children who could not tolerate stimulants due to hallucinations, but it is very scary for the family when it happens. Unless there is a significant family history of them, I don't know a way to predict which child is at risk. These are a contraindication for continuing that medication, but another type of stimulant or medication can be considered. 
• Cardiac (heart) problems are overall a rare complication of stimulants and often times are not a contraindication to continuing the stimulant medicine. There is a small increase in blood pressure and heart rate, both of which should be monitored regularly while on treatment and if the treatment is stopped. 

A cardiologist should be considered to further evaluate a patient prior to starting a stimulant if there is any of the following:

• Shortness of breath with exercise not due to a known non-cardiac cause, such as asthma
• Poor exercise tolerance compared to children of the same age and conditioning 
• Excessively rapid heart rate, dizziness, or fainting with exercise 
• Family history of sudden cardiac death or unexplained death (such as SIDS) 
• Family or personal history of prolonged QT syndrome, heart arrythmias, cardiomyopathy, pulmonary hypertension, implantable defibrillator or pacemaker 

Common side effects for the non-stimulants include the following:

• Atomoxetine can cause initial gastroesophageal complaints (abdominal pain, decreased appetite), especially if the dose is started too high or if it is increased too rapidly. It can also cause tiredness and fatigue when it is first started or if the dose is increased too quickly. It can increase the blood pressure and heart rate, both of which should be monitored regularly during treatment with atomoxetine. There is an increased incidence in suicidal thoughts, though uncommon, so children should be monitored for mood issues on this medication. A rare complication of atomoxetine is hepatitis (inflammation of the liver with yellow jaundice and abnormal liver function labs). The hepatitis resolves with stopping the atomoxetine. 
• Guanfacine and clonidine both cause fatigue and tiredness, especially when first starting the medication or with increases in dose. Clonidine is often used at bedtime to help kids with ADHD sleep. Both of these medications can lower the blood pressure and heart rate, and these should be monitored closely while on guanfacine or clonidine.


Getting Started

The first step in treating ADHD is getting a proper diagnosis. This should be done with input from parents and teachers since symptoms should be present in at least two settings. ADHD symptoms overlap with many other conditions, and if the diagnosis is not correct, medications are more likely to cause side effects without benefit. Do not jump into medication until the symptoms have been fully evaluated and a proper diagnosis is made according to DSM criteria.

Stimulant medicines are considered first line treatment for ADHD in kids over 5 years of age. There are short acting and long acting formulations available for each type of stimulant. There are advantages and disadvantages to each. Short acting medications tend to last about 4 hours, so can be given at breakfast, lunch, and after school, allowing for hunger to return as each wears off to help kids maintain weight. They are often used later in the day after a long acting stimulant wears off for teens who need longer coverage. Long acting medicines tend to last between 6 and 12 hours, depending on the medicine and the person's metabolism. The benefit is that people don't need a mid-day dosing, which for school kids means avoiding a daily trip to the school nurse, which can be socially non-acceptable for older children. It is also easier to remember once/day medication versus multiple times/day dosing. The downside is that some children don't eat well mid-day with long acting medicines.

In general it is recommended to pick one of the stimulant medicines and start low and titrate to best effect without significant side effects. Feedback on how the child is able to focus and stay on task, and reports of other behavioral issues that were symptoms in the first place should be received from teachers and parents, as well as the child if he is able. There are many things to consider that affect focus and behavior that are not due to the medicine: sleep, hunger, pain, illness, etc. It takes at least a few days to identify if the medicine is working or not or if other issues are contributing to the focus and behaviors. The younger the child the longer I usually advise staying on a dose so a parent has a chance to hear from the teacher how things are going. I usually don't increase faster than once/week. I rely more on the student's report in middle and high school, since those students can be more insightful and they have so many teachers throughout the day that most teachers are not as helpful. Older students who are in tune with their problems and how they are responding to the medicine might be able to increase every few days, as long as there are no confounding factors that could influence symptoms, such as change in sleep pattern, big test or other stressor, or illness.

Which medicine to choose?

As you see above, there are two classes of stimulants, methylphenidates and amphetamines. While some children respond better to methylphenidates, others to amphetamines, some do equally well on either, and some cannot tolerate either. It is not possible to predict which children will do best on any type, but if there is a family history of someone responding well (or not) to a medicine, that should be taken into consideration of which to start first.


Another thing to consider is whether or not a child can swallow a pill. Some of the medicines must be swallowed whole. If you aren't sure if your child can swallow a pill, have them try swallowing a tic tack. Use a cup with a straw, since the throat is narrowed when you tilt your head back to drink from an open cup. Another option is to put it in a spoonful of yogurt or applesauce and have your child swallow without chewing. If your child cannot swallow a tic tac, you can choose a medicine that doesn't need to be swallowed. Some come in liquid or chewable formulations. Some capsules can be opened and sprinkled onto food, such as applesauce or yogurt. There is a patch (placed on the skin) available for the methylphenidate group.


I would love to say that cost shouldn't matter, that we pick the medicine based purely on medical benefit, but cost does matter. Before you go to the doctor to discuss starting medicine (this or any medicine for any condition) look at the formulary from your insurance company. All other things being equal, if one medicine is not covered at all (or is very expensive) and another is covered at a lower tier, it is recommended to try the least expensive option first. Of course, if the least expensive medicine fails, then a more expensive one might be the right choice. Also check to see if a medicine requires a prior authorization, which might require that other medicines are tried first.

The ADHD Medication Guide is a great resource to look for generics (marked with a "G"), which must be swallowed whole or can be opened or chewed (see the key on page 2). The age indications listed on page 2 are those that have FDA approval at the ages listed, but there are a lot of times that physicians use medicines outside the age range listed. Some do not even have an age indication listed. These ages are due to testing results, and can be limited because one age group might not have been tested for a specific medicine. Note that the 17 year and adult medicines are different. Is there really a difference between a 17 and an 18 year old? Not likely.

Finding the right dose

It is recommended to start with one of the two main classes of stimulants with a low dose, and slowly increase to find the best dose. If that stimulant doesn't work well or has side effects that are not tolerated, then change to the other class of stimulant. If that one does not work, you can try a different medicine from the class of stimulant that worked best. If the third medicine doesn't work, then a non-stimulant can be tried. I also recommend re-evaluating the original diagnosis at this point, since ADHD might not be the cause of the issues and finding the right cause can lead to a better treatment.

Titrating the medicine goes something like this:

• If symptoms are well controlled and there are no significant side effects, the medicine should be continued at the current dose. 
• If symptoms are not well controlled and there are no side effects that prohibit increasing, the dose should be increased as tolerated. 
• If symptoms are not well controlled (i.e. room for improvement) but there are side effects that prohibit increasing the medicine, consider a longer period of watching on this dose versus changing to a new medicine.

Things to consider

Time Off: Once a good dose is found, parents often ask if medicines need to be taken every day. Drug holidays off stimulants were once universally recommended to help kids eat better and grow on days off school. Studies ultimately did not show a benefit to this, and some kids really can't take days off due to behavior issues, including safety issues while playing (or driving for older kids). It also seems that when kids are off medicine they do not have good self esteem due to repeated failures, so taking medicine regularly is important to them.

When kids can manage their behavior adequately, it is not wrong to take days off. Stimulants work when they work, but they don't build up in the body or require consistent use. (This is not true for the non-stimulants, which are often not safe to suddenly start and stop.) Some kids fail to gain weight adequately due to appetite suppression on stimulants, so parents will take drug holidays to allow better eating. Days off the medicine also seems help to slow down the need for repeated increases in dosing for people who are rapid metabolizers.

Talk to your child's doctor if you plan on not giving your child the medicine daily to be sure that is the right choice for your child.

Remembering the medicine: It is difficult to get into the habit of giving medicine to a child every day. I wrote an entire blog on remembering medicines. My favorite tip is to put the pills in a weekly pill sorter at the beginning of each week. This allows you to see if you're running low before you run out and allows you to see if it was given today or not. These medicines should not be kept where kids who are too young to understand the responsibility of taking the medicine have access.

Controlled substances: Controlled substances, such as stimulants, cannot be called in or faxed to a pharmacy. They cannot have refills, but a prescriber can write for either three 30 day prescriptions or one 90 day prescription when they feel a patient is stable on a dose. Stimulants are not controlled substances because of increased risks to the individuals it is prescribed for, but because they have a street value -- teens often buy them from other teens as study drugs. This can be very dangerous since it isn't supervised by a physician and the dose might not be safe for the purchaser. It is of course illegal to sell these medicines. The DEA does monitor these prescriptions more closely than others. If the prescription is over 90 days old, many pharmacists cannot fill it (this will vary by state), so do not attempt to hold prescriptions to use at a later time.

Acids and Stimulants: It has been recommended that you shouldn't take ascorbic acid or vitamin C (such as with a glass of orange juice) an hour before and after you take medication. The theory is that ADHD stimulants are strongly alkaline and cannot be absorbed into the bloodstream if these organic acids are present at the same time. High doses of vitamin C (1000 mg) in pill or juice form, can also accelerate the excretion of amphetamine in the urine and act like an "off" switch on the med. In reality  have never seen this to be an issue. If anyone has noticed a difference in onset of action or effectiveness of their medicine if they take it with ascorbic acid or vitamin C, please post your comment below.

When Mom and Dad disagree: It is not uncommon that one parent wants to start a medication for their child, but the other parent does not. It is important to agree on a plan, whatever the plan is. Have a time frame for each step of the plan before a scheduled re-evaluation. If the plan isn't working, then change directions. If kids know it is a disagreement, they might fear the medicine or think that needing it makes them inferior or bad. Do not talk about the diagnosis as if it's something the child can control - they can't. Don't make the child feel guilty for having this disorder. It isn't fair to the child and it only makes the situation worse.


Having the medicine when you need it-- 

Refills: There is nothing more frustrating for a parent and child than to realize that there's a big test tomorrow and you have no medicine left and you're out of refills. Be sure to know the procedure for refills at your doctor's office. By federal law we cannot give more than 3 month's worth of a stimulant medicine. They cannot be called in to a pharmacy. In my office we see patients at least every 3 months (more often when starting a medicine or if changes are needed). I advise that they schedule the next appointment as they leave the office so they don't forget to schedule. I make these appointments longer than standard "sick" appointments, so it is hard to sneak one in on the same day. 

Travel: It is very important to plan ahead prior to travel. If you forget your child's stimulant, no one can call out a prescription since it is a controlled substance. You must plan ahead so that if a refill will be needed during the trip you will either be able to fill a prescription you have on vacation or you will need to fill the prescription in advance. Most people can get a prescription 7 days prior to the 30 day supply running out, but not sooner, so you might need to fill a couple prescriptions a few days earlier in the month each to have enough on hand to make it through your vacation. It takes planning! If you are out of town and you realize you forgot your child's non-stimulant, call your doctor to see if they will call it out. Many of the non-stimulants are not safe to suddenly stop, so they are likely to call it out. Insurance is not likely to pay for these extra pills though if it was recently filled. 

Lost prescriptions: We are able to give up to three prescriptions at one time, but most pharmacists will not keep the prescriptions. This means that you must know where the prescriptions are and not lose them for 3 months. Lost prescriptions are handled differently by different prescribers, but all should take them seriously due to the controlled substance rules of the DEA. If a parent reports losing them frequently, that usually leads to consequences, so be sure you know how your doctor handles this situation. I will generally allow a parent to write a letter documenting the lost prescription and I document this in the medical record in a way that is easy to see at future visits. If this repeats, I will not be able to continue to prescribe a controlled substance for that family, which only makes the child suffer. 

Mail order: Some insurance companies will allow mail order 90 day prescriptions. Some not only allow, but require them on daily medicines. Others do not allow it. In general I advise against a 90 day prescription if the dose is not established or if there are any concerns that it might not be the perfect dose. If there is any concern that it might need to be changed, a 30 day prescription is a better option. If you will need to do a mail order, be sure you schedule your appointment to get the prescription early enough to account for the lost time mailing. 

Before your visit:

Before you meet with your physician to discuss a new ADHD diagnosis or a possible change in treatment plan, be sure to get the following information and have it available at the visit or the visit will not be as productive as you desire:

• Insurance formulary
• Standardized testing from teachers, parents, and other significant adults 
• Verify if your child can swallow a tic tac or pill 
• Any contributing family history (family member responses to medications, family history of heart issues, etc)

More Quest for Health blogs on ADHD:

• Why get diagnosed?
• Who's Who in ADHD Treatment
• Nutrition, Elimination Diets, and Vitamins
• Alternative Treatments
• Medications
• Generic Methylphenidate HCl ER (for Concerta)
• Red Dye #40 and Hyperactivity
• Homework Battle Plan

References and resources:

ADHD: Clinical Practice Guideline for the Diagnosis, Evaluation, and Treatment of Attention-Deficit/Hyperactivity Disorder in Children and Adolescents

ADHD Medication Guide

Parents Med Guide

Risk of serious cardiovascular problems with medications for attention-deficit hyperactivity disorder.

What does plumbing have to do with pediatrics?

This post has nothing to do with pediatrics, yet everything to do with how the process of medicine is like plumbing.

photo source: Shutterstock

We have lived in our house about 15 years. Shortly after we moved in I suspected a leak behind our  shower wall. The floorboard in the bathroom was molded and the drywall above it warped. The tile would be dry, but the grout one tile out would get wet -- so it seemed unlikely the shower door wasn't closed properly. We had a plumber evaluate it but he didn't find anything amiss. I think he thought I was crazy.

Years went by and I still thought there were issues every once in awhile, but irregularly enough that I wasn't concerned to do anything about it. My engineer husband didn't seem too concerned. I think he also assumed we were being careless in the shower and allowing the door to leak.

We had another plumber look at it about 5 years ago when we were updating our bathroom. He confirmed that there is no leak, fixed the drywall, and replaced the floorboard. He bragged that our new caulking shouldn't mold due to a special something they put in it that makes it mold resistant.

I still had my suspicions, but what do I know? I'm not a plumber.

The new floorboard is again moldy. The new caulk seems to get moldy from behind -- I clean the outside very carefully and it only looks discolored from behind. It has started to crack, so I thought maybe the water gets trapped behind and allows it to mold.

Over the summer I was cleaning out my daughter's closet. We decided to remove a bookcase that was there. The carpet underneath was completely moldy. Since her closet abuts our shower, this confirmed my leaky pipe suspicion despite two qualified plumbers saying they are fine. (My daughter had a blast breaking down the bookcase so we could dispose of it!)

Recently I dumped a bucket of water after mopping into the bathtub that never gets used in the same bathroom. (I usually dump mop water into the kitchen sink.) When I moved on to clean the shower, I saw something unusual: there was dirty water seeping from behind the caulking and dripping into the shower. No one had showered yet that day. I brought my husband up to show him. I was convinced that the tub leaked. That would explain the intermittent nature of the problem! He said it's not possible for the water to go uphill and into the shower caulking above the base rim.

Hmmm....

It's been 15 years and it can't be a bad leak since the floor hasn't completely rotted out. We only see signs of water leakage intermittently. We know it will be an expensive repair, so we are saving up and waiting... a few more months won't matter, will it? And two plumbers have looked for a leak without success. I'm closely monitoring to see if I find a pattern to help find the leak when we open up the wall.

We still have several theories going on with pipe and roof leaks being the top two. But no definitive answer.

So. What does this have to do with medicine?

It parallels complex diagnoses. Most people are not informed consumers when it comes to how their body works. I'm not saying patients are not smart. I'm a well educated person, but I know nothing about plumbing. I am an uninformed consumer. My husband is an engineer, so has a little knowledge of how our house is put together, but it's just enough to give him false confidence. He has been in denial of a problem for most of the 15 years we have lived here. Two qualified plumbers failed to see a problem, despite my concerns. I didn't follow through on suspicions based on their expertise and recommendations.

Physicians spend many years learning anatomy, physiology, pharmacology, and more. Years more are spent fine tuning diagnostic processes with actual patients. We continually learn throughout our careers based on new research and experiences. Despite all this training, one physician can't know everything and sometimes must refer to a sub specialist to sort things out. And I know they sometimes don't figure it out. We all can't be the genius doc from House, who seems to figure out every obscure diagnosis in one short hour.

What does that mean for patients?

If you think there is a problem, be as specific as you can with your symptoms. This is really hard when kids are the patient. They often can't describe what they are feeling in significant detail. Write down any possible associations that you can come up with and have your physician review the list with you. If your physician doesn't come up with a source or diagnosis, keep asking questions if you are still worried. (Don't take 15 years to sort things out with a human body!) If you don't find answers despite persistence of symptoms, ask for a second opinion.

Sometimes what worries parents and patients really is nothing to worry about. Maybe it's a common issue that needs no treatment (like a newborn rash or intoeing). Maybe what you're already doing is the best known treatment there is. Depending on the severity and duration of symptoms, more or less might need to be done. I'm not advocating for the multi-million dollar workup for every symptom, but if you think something's wrong, be sure to talk to your doctor about it! Make sure they hear your concerns and if they don't have an explanation for things, ask more questions to find answers.

Generic Concerta Not Working Like the Brand Used To?

Note: there is an update of this post here. It is much easier to follow, since the original post has so many updates.

I used to be a huge fan of generics. They save money, right? They are equivalent to the brand name, right?

That's what I've always been taught and what I teach taught.

I've been jaded by many problems and now disagree with the above.

Generics aren't always cheaper than the brand name.

Some generics are not equivalent to the name brand.

A recent discussion on a psychology/pharmaceutical listserv I follow brought up the issue of generic Methylphenidate HCl not working as well as the brand name Concerta. Several members had some great insight into why this is. The discussion peaked my interest in the issue and I started looking online for information earlier this week.

Ironically today I went to pick up a family member's medicine. We have filled at the same pharmacy previously for generic "Concerta" and have always gotten the equivalent generic. When I looked at the pills in the bottle today, I told the pharmacy tech they weren't OROS (see below). She looked confused. She had no clue what I was talking about.  (Lesson to all: if you have any questions, ask to talk to the pharmacist. Hopefully they will understand the pharmacology better than the tech.)

Generics for Concerta (Methlyphenidate HCl) might have the same active ingredient, but have a completely different time release system, resulting in varying drug peaks in the bloodstream. The original generic for Concerta (from Watson pharmaceuticals) uses a special technology to time-release the active drug. This time release technology is called OROS (osmotic controlled release oral delivery system). There are several other time release methods. The active ingredient may be imbedded in various substances from which the medicine must exit slowly or a gel cap is filled with beads that dissolve at different rates. With the technology used by Concerta, the capsule IS the time release. It doesn't dissolve. The medicine is slowly released through a small hole in one end of the capsule. The pill works like a pump, pulling in water from the intestines, pushing the medicine out of the tube slowly throughout the day. See this photo from Medscape.

from http://www.medscape.org/viewarticle/547415_10

I have recently learned that not all generic formulations of Methylphenidate HCl are using this technology. This alters the time-release nature of the active medicine.  For some people this substitute might be just fine, or even preferable. But if it seems like your medicine isn't lasting long enough, has times that it works well followed by times it doesn't until the next peak, or any other problems -- check your pills!

You can tell the difference by closely looking at the capsules. The OROS capsules are a unique shape, a little more blunted than a standard capsule. If you look really closely at the ends, you will find that one has a "dimple" where there is a small hole covered by a thin layer matching the rest of the capsule. I just happen to have at least one of three dosages:

Photos of the Mallinckrodt brand are now listed under "Updates."

So if any medicine doesn't work like it used to, look closely at the pill itself to see if it is the same as previously. If you don't have any left, ask the pharmacy for the company / maker of the medicines you've filled over the past several months. Let your doctor know if you can't use a substitution so they can specify "Watson brand only."  If the new "brand" works better, be sure to ask for that manufacturer.

Better yet, call ahead and see who the manufacturer is of the generic for Concerta sold at your pharmacy. Watson Pharmaceuticals is the one that makes the OROS system. If they don't use that generic and you plan to shop elsewhere, be sure to let them know why!

Let me know your experiences with generics... See the Updates below if you want to report your experience to the FDA.

Update 4/29/13:

Reporting Adverse Events: A pharmacologist from the listserv I mentioned above suggests that if you have an issue with the duration of action of a different brand of Methylphenidate HCl you should report it to the FDA. This will allow them to review cases and possibly stop the substitution of these non-equivocal products. Click on this link for the MedWatch Report. Thank you SS!

Manufacturer Clarification: Watson Pharmaceuticals is authorized to market Concerta in the US for Ortho McNeill Janssen Pharmaceuticals, the original manufacturer.

Teva markets another type (not OROS) in Canada and Mallinckrodt markets another type (not OROS) in the US.

Update 5/27/13:

Photos of the Mallinckrodt pills (from www.mallinckrodt.com):

As a comparison, the pill shape of the OROS pills (Janssen Pharmaceuticals, McNeil, and Watson all look identical -- from www.goodrx.com):

Update 10/5/13:

I just learned another company is making a generic for Concerta. A patient suddenly found the medicine to be not effective. It looked entirely different, so suspected it was the wrong medication. The pharmacist confirmed that it is another generic for Methylphenidate HCl ER from Kremers Urban Pharmaceuticals. The parent sent me this picture of the 18mg pill and I found the 27mg on the Kremers website:

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

If your pharmacist says he can't order a drug because of a shortage, you can check to see predictions of how long the shortage will last at ASHP.org. Be sure to look closely for the generic name and if it is an extended or immediate release form because it can be confusing.

Update 12/12/13:

Watson Pharmaceuticals will now be called Actavis, so ask for the OROS pill instead of a brand. I think I will do a whole new blog on this topic since there are so many updates since April. Watch for it!

This is a great resource on the difference in authorized vs true generics: An Update on Generic Concerta.

Update 5/1/14:

I'm excited to hear that the FDA has this issue on their watch list. Please read Gina Pera's We Did It! Concerta Generics on FDA Watch List.

Update 11/16/14:

Generics that are non-OROS will no longer be automatically substituted. They will still be available. See ADHD Roller Coaster's blog on the topic for details.

Resources:

The Pre-MMA 180-Day Exclusivity Punt? What Gives? A legal blog explaining how medicines lose their exclusivity and can become generically available, specifically the Concerta dispute.

How To Tell The Difference Between Concerta and Generic Concerta A Canadian ADHD blog provided the picture of how to recognize the difference. Generic formulations have been available in Canada years prior to in the US.

Special thanks to the members of the Child-Pharm listserv!

Evolution of Illness

When kids are sick, parents understandably want them to feel better quickly. They want a sound night's sleep. They want to be able to return to work/school. They want to see a happy, healthy child again. They come to our office hoping for answers and a cure.

Sometimes there is no quick fix, just treating symptoms and time.

This is the season we are seeing a lot of sickness. It's been about 11 years, but I remember the frustrations of having a sick baby when my daughter had bronchiolitis. Some of the details are muddy, but I remember the feelings of inadequacy because I couldn't help her feel any better any faster. I knew the illness tends to get worse before it gets better and there is little we can do to alter its course, but knowing this it didn't make me feel any better as the mom who was helpless.

I lost sleep for several nights as I watched her pant (not breathe, but pant). I resorted to giving asthma-type breathing treatments (because my son had wheezing so we had everything we needed to give a treatment at home) despite the fact that they didn't seem to help her much. It was probably the humidified air that helped more than anything. But the vaporizer in her room and the saline to suction her nose wasn't helping, so I wanted to at least try the asthma medicine. She kept wheezing. We brought her in to the office 3 days in a row to have someone else check her. I can't check oxygen levels at home and needed someone to objectively examiner her.  So three days in a row we went in for repeat exams. She was able to maintain her oxygen level and stay hydrated despite breathing 60-70 times/minute for days. I still don't know how. I remember wishing her oxygen level would drop enough that we could hospitalize her, not critically, just enough. Then she'd be on monitors, and maybe I could sleep a bit knowing someone else was watching her. Thankfully she never got that sick, and eventually we were all sleeping again, but it took a long time for that.

So I understand the frustration when we tell parents things to do at home and ask that they come back in  __ days or if ___, ____, ___ symptoms worsen. It really isn't that we are holding out on a treatment that will fix the illness, it's just that we don't have a quick fix for many illnesses. We need to be able to examine at different points in the evolution of the illness to get a full picture of what is going on.

The exam can tell us a lot, but it doesn't predict the future. One minute ears can look normal, the next they develop signs of an infection. I cannot say how many times I've heard a parent complain that someone else "missed" something on exam that I now see. Yes, sometimes things can be missed, but I suspect that most of the times the exam has simply changed.

I learned this phenomenon as a resident on the inpatient unit. I had a patient who had been admitted for an abdominal issue. I did a physical on the child in the morning before rounds, including looking at ears, which were normal. Late that afternoon the nurse called because a fever had started. New symptom, so another exam was done. This time the ears were red and full of pus. Within hours this child had developed a double ear infection. I examined the ears both times and they were definitely different.

I understand the frustration (and expense) to take kids back in to be seen if symptoms worsen, change, or simply just don't resolve at home. If symptoms change, we need to re-evaluate, which includes an exam. Medical providers cannot look into the future to see what will develop. It is not appropriate (or effective) to put kids on an antibiotic or iv fluids to prevent the illness from taking its natural progression. Sometimes we need time to see how the illness progresses to see what other treatments might be needed.

When parents call back and want something else done, they are often upset that we want to see the child again. I hear many types of complaints.

Money is probably the biggest issue. It is not because we want your co pay. The "we" I use here is not just my office and I am not speaking of any particular situation. With online doctor rating sites, social media sites, and knowing doctors around the country, I write with many examples in mind. I've seen online complaints that doctors are just money hungry, trying to get someone to come back in just so we can charge more money. It is true that we charge for every visit. We are not able to waive the co pay because we did "something wrong" or "missed a diagnosis" the first time. Each is a separate visit with updated information and a separate exam. Insurance contracts dictate that a separate co pay is charged. We must adhere to legal contracts or it would be considered insurance fraud.

Increasing our numbers for "production" is sometimes brought up. It is not because we want to fill our waiting room with more children to increase the waiting time for everyone else. We don't want to waste your time or ours. But we need to see a child to know what is happening at that moment to be able to give any valuable advice and treatment.

We want to see your child again because we need to see your child to know what to do. Maybe now the child's symptoms have changed.  Maybe not, but without the history and exam we do not know. The exam might now show wheezing, low oxygen levels, a new ear infection or sounds of pneumonia. Sometimes the exam still is overall normal, but the fever's been going on long enough without any identifiable cause, which requires lab and/or xray evaluation. 

Please remember that if you get a different answer at a different visit, it doesn't mean that the first assessment was wrong. Usually it is due to a progression of the illness, and things change. Human bodies are not static.

Remembering Vitamins and Medications

Compliance taking a daily medication (or vitamin) can be troublesome for many.  I find myself counseling parents and kids how to remember medicines often.  Here are my favorite tips:

• Use a pill box for pills. They come in various sizes and either single daily dosing or am/pm dosing, depending on your needs.  Pill boxes allow you to: 

1. be sure you have enough for the upcoming week,
2. remember if they were taken today,
3. keep several types of pills for each day together if taking more than one pill.  

• Liquid medicines: Wash the syringe after each use. Empty the dish drain of all contents daily so you find the syringe and remember to use it.  Or put a clean syringe in visible sight where you often look (tape it to the milk jug, in a glass next to the kitchen sink, in a glass near your coffee pot).  Remember the medicine needs to be out of reach from kids... not necessarily the syringe! 
• Refrigerated medicines: Put the medicine on a shelf that is eye-level, right in front. Don't let it get pushed to the back. Return the bottle to the fridge before giving the medicine to lessen the chance you leave it on the counter.  Remind older children that can access the refrigerator that the bottle is off limits!
• Keep medicine next to something you do daily (coffee, toothbrush). *Always keep out of reach of young children.*
• Use a specific glass that is unique that goes from table to dishwasher to table and never is put away.  Every time you empty the dishwasher, put water in the glass and set it on the table for medicine.
• Refill the medicine 1 week before you run out.  This allows you flexibility in case you forget to pick it up. It also allows recognition that there are no refills if that was missed, giving one week to see your doctor.  You can have enough for vacations if you routinely do this, since you can only fill one week earlier than the last fill... plan ahead if travelling!
• Keep tabs on number of refills left. The pharmacist should let you know with each refill how many are left. If there are none, call right then to set your next appointment if you haven't already.
• Set your phone or watch to alarm at the times the medicine is due.  Change the tone to one that is unique to remind you.
• Put a reminder on your calendar to call for refills and/or schedule appointments before the last minute.
• Leave sticky notes around the house or in your bathroom and kitchen if necessary!
• Keep some medication in your purse (or at the school nurse) to take if forgotten in the morning if this might still be a problem.  Remember to not leave your purse in the car or other places the medicine will get too hot or cold.  If the school nurse will keep some, be sure to ask for a nurse's note when getting the prescription.
• If you travel often, it helps to keep an empty pill box in your toiletry bag, so when packing it you see the empty box that needs to be filled.  Or you could put a sticky note in the toiletry bag reminding you to pack them.
• Grab a pen/marker and draw a "calendar" (Mon am/pm, Tues am/pm, ...) on the bottle with space to check off when you've given the medicine each day. 

Regular prescription medications goes hand in hand with regular follow up with your doctor to manage the medication dosing. This is important for many reasons, so I try to give as many refills that will be needed until the next visit.  Ask your doctor how they handle refills before the medicine runs out so there are no delays in treatment.  Remember to schedule your next visit!

• If able, schedule the next visit before you leave the doctor's office.  Bring your calendar to each visit!
• Call as soon as you can to schedule if you don't have your calendar available at the doctor's office or you were unable to schedule for any reason.
• If you notice no more refills on the bottle when picking up your medicine, call that day to schedule an appointment.  The later you wait, the fewer appointment times will be available. Early morning and later in the day fill first!
• If you are filling the prescription at a time that your doctor's office is closed, look for options for them to call you.  Some offer online appointment requests.  You can request appointments from our website at any time day or night. Leave the best numbers for us to call during business hours.  Many offices have a voice mail that allows leaving a message for them to call you to schedule an appointment.

Once habits form, it is easier to remember, but until then be sure to set reminders-- especially if the medication must be taken at a certain time each day or if missed doses can be dangerous.  Learn what to do if you forget a dose by talking with your doctor or pharmacist. Some medicines are fine to skip a dose, others are not so forgiving and must be taken as soon as remembered.  

I hope this helps!  What tricks have you learned to remember your medicines?

How to get kids to take medicine

A recent facebook post discussed how to give medicine to children, but left out how to give liquid medicine. A reader asked for advice, and I wanted to expand my original answer.

The article:   Medical Mom: A spoon full of sugar helps the medicine go down

The facebook question:   She gives great advice on pills, but what about liquid medications that kids just WON'T swallow? I've tried putting it in his cheeks, but the flavor they mixed it with he hates :(

Of course, there is so much to giving medicine to kids.  They already feel sick for most of the medicines we give, and anything is distasteful when you feel sick, regardless of the flavor the pharmacist adds.  Some medicines have a horrible aftertaste that is difficult to mask.  Some upset the stomach.

If medicine is vomited within 30 minutes, it generally can be given again. If your child vomits more than 30 minutes after the medicine is swallowed, do not offer it again.

I don't miss the days of liquid medicines! My son (who suffered from many ear infections) spit out most medicine (and often vomited what he swallowed).  My daughter didn't need as many medicines as him, but as the expert vomiter (she would vomit whenever she didn't get her way as an infant) and expert manipulator, she had unique issues to get the medicine down.


Needless to say, I learned a lot of tricks trying to get them to keep medicines down.


Most liquids taste better cold, so check with your pharmacist if the medicine can (or should) be refrigerated.  Also ask if it can be mixed with juice or foods.  Some should be given on an empty stomach without food and only sips of water. 


Be sure you have a properly sized medicine syringe or medicine cup for all liquid medicines.  Shake the bottle well before dispensing.


If it can be mixed into juice, jelly, or yogurt, be sure to mix in a small enough volume that you can ensure your child will take the entire amount.  You can measure the amount of medicine in a syringe, then fill the remainder of the syringe with drinkable yogurt, juice, or whatever liquid is okay to mix with the medicine.  (Always ask your pharmacist first!) 

Sometimes using a medicine that comes in a capsule that can be sprinkled onto a spoon of yogurt, jelly, or applesauce works well.   Yogurt tubes are especially great for this if your child eats these. Put the contents from the capsule on the top of the open tube, and they suck it down as they enjoy the yogurt.  Ask your pharmacist if you can mix the medicine with foods first!  

For infants: Try squirting it in the inner cheek and blowing on the face. I don't know why, but it seems to make infants swallow.  You can also put it in a nipple and allow them to drink from the nipple, which bypasses most of the taste buds on the tongue! After the medicine is swallowed, use the nipple for water or formula/milk to rinse all the medicine down as long as it does not need to be given on an empty stomach. 


Preschoolers: This age might feel "big" if allowed to hold the medicine cup themselves.  Supervise closely so they don't spill it.  Praise when they did it!


Preschool and up: Offer a chocolate syrup chaser. Syrup is thick and masks a lot!  Another trick is to offer a popsicle (or ice) first.  This numbs the taste buds, making the medicine taste less noticeable.


Holding the child's cheeks to make them pucker their lips until swallowed sometimes works (though I found kids can still spit it out that way!) 


You can also have the pharmacist flavor most medicines, and if you pick the right flavor, it can help. Ask for suggestions, since the flavor added might not be the best for the particular medicine. 


Bribery works with preschoolers and up. (A thing I promised myself I would NEVER do... but once I had kids and realized bribery works, I reserve it for the really important things.)


As for most of my behavioral advice: praise a job well done! If they took the medicine, tell them you are happy they did.


When you think your child is able to swallow pills without choking, teach with small candies, such as Tic Tacs or mini M&Ms.  I always suggest using a cup with a straw, since when you drink out of a cup you tilt your head back, narrowing the throat.  A straw allows you to keep your neck neutral. Once swallowing a small candy is mastered, you can use real medicine capsules or tablets, as long as the dose is correct for the child's weight.


Sometimes making a game of it works. My husband came up with this trick for our daughter when she was 5-6 years old.  Remember she was the expert manipulator.  She threw a fit about taking a medicine and made getting out of the house for school on time difficult a couple of days. He suggested that if she was ready for school by 7:15, she could throw a fit for 10 minutes. If she wasn't ready until after 7:20, she could only throw a fit for 30 seconds.  Either way we would set the timer for her fit, then she would take the medicine.  Of course we knew she'd never be ready early (and she really couldn't tell time well in kindergarten) so when it was time for medicine, we set the timer for 30 seconds and told her to throw a good fit.  She threw a great fit, then took the medicine without a problem. It was as if owning it worked for her, and she then took the medicine each day for the rest of the week after setting the timer for a fit.  By the end of the week she could hardly throw a fit she was giggling so much!


The most important thing is to remember why you are giving the medicine.  If it is an antibiotic or other medicine that is important to completely take, then it is more important than if you are simply trying to give a fever reducer.  A fever reducer might make your child feel better, but it really isn't required.  If it is required, then you need to play hard ball and do whatever it takes to get the medicine down.  


What has worked for your kids to take medicine?  Please share your tips!

Cold and Flu Season is Upon Us!

photo source: Shutterstock

As cold and flu season approaches, I have been thinking about how our kids are managed when they become sick.  Not only what we do to treat symptoms, but how, when, and where patients get medical advice and care.


We are a busy society.  We want things done now.  Quickly. Cheaply. Correctly.  Resolution so we can get back to life.


Illness doesn't work that way.  Most childhood illnesses are viruses and they take a few weeks to resolve. There's no magic medicine that will make it better.

Please don't ask for an antibiotic to prevent the runny nose from developing into a cough or ear infection.  

Don't ask for an antibiotic because your child has had a fever for 3 days and you need to go back to work.  

Don't ask for an antibiotic because your teen has a big test or tournament coming up and has an awful cough.  

Antibiotics simply don't work for viruses.  They also carry risks, which are not worth taking when the antibiotic isn't needed in the first place.

Many parents in this community have grown accustomed to using after hour urgent cares  because they are convenient.

Convenient isn't always the best choice.  Many times kids go to an urgent care after hours for issues that could wait and be managed during normal business hours.  I know some of this is due to parents trying to avoid missing work or kids missing school, but is this needed?  Can it hurt?

Some kids will get unnecessary tests, xrays, and treatments at urgent cares that don't have a reliable means of follow up.  They attempt to decrease risk often by erring with over treating.  Our office does have the ability to follow up with you in the near future, so we don't have to over treat.  

Urgent cares don't have a child's history available.  They might choose an inappropriate antibiotic due to allergy or recent use (making that antibiotic more likely less effective).  They might not recognize if your child doesn't have certain immunizations or if they do have a chronic condition, therefore leaving your child open to illnesses not expected at their age.  We know that parents can and should tell all providers these things, but our own new patient information sheets are often erroneous when compared to the transferred records from the previous physician... parents don't think about the wheezing history or the surgery 5 years ago every visit.  It is so important to have old records!

There is some evidence that treating things too soon does not allow our bodies to make immunity against the germ.  A great example of this is Strep throat.  Years ago we would go to a doctor when our sore throat didn't get better after a few days.  They would swab our throat and send the swab for culture, which took 2 days. We would treat only after that culture was positive.  That delay in treatment allowed our bodies to recognize the Strep and begin making antibodies against it.  Now kids are brought in the day they have symptoms, and if the rapid test is positive, they immediately start antibiotics.  The benefit? They are less likely to spread Strep to others and they can return to school 24 hrs after starting the antibiotic.  The negative? They might be more susceptible to recurrent illness with Strep, so in the end are potentially sick more often and end up missing more school.

Receiving care at multiple locations makes it difficult for the medical home to keep track of how often your child is sick.  Is it time for further evaluation of immune issues?  Is it time to consider ear tubes or a tonsillectomy?  If we don't have proper documentation, these issues might have a delay of recognition.

Urgent cares and ERs are not always designed for kids.  I'm not talking about cute pictures or smaller exam tables.  I'm talking about the experience of the provider.  If they are trained mostly to treat adults, they might be less comfortable with kids.  They often order more tests, xrays, and inappropriate treatments due to their inexperience.  This increases cost as well as risk to your child.  We have been fortunate to have many urgent cares available after hours that are designed specifically for kids, which does help.  But this is sometimes for convenience, not for the best medical care.

Cost.  As previously mentioned, cost is a factor.  I hate to bring money into the equation when it comes to the health of your child, but it is important.  Healthcare spending is spiraling out of control.  Urgent cares and ERs charge more.  This cost is increasingly being passed on to consumers.  Your co pay is probably higher outside the medical home.  The percentage of the visit you must pay is often higher.  If you pay out of pocket until your deductible is met, this can be a substantial difference in cost.  (Not to mention they tend to order more tests and treatments, each with additional costs.)

What about our urgent care in our office?  We offer a walk in urgent care as a convenience for parents who are worried about their acutely ill child.  It is within the medical home, which allows us access to your child's chart. We can keep all treatments within this medical record so it is complete.  Our staff follow the same protocols and treatment plans as scheduled patients, so your child will be managed with the protocols our physicians and midlevel providers have agreed upon.  Essentially we have a high standard of care and want your child to receive that great care.

So what kinds of issues are appropriate for various types of visits?  
(note: I can't list every medical problem, parental decisions must be made for individual situations)

After hours urgent care or ER:

• Difficulty breathing (not just noisy congestion or cough)
• Dehydration
• Injury
• Pain that is not controlled with over the counter medicines
• Severe abdominal pain
• Fever >100.4 rectally if under 3 months of age
  

Pediatric Partner's Urgent Care:

• Fever 
• Ear ache
• Fussiness
• Cough
• Sore throat
• Vomiting and/or diarrhea
• Any new illness

Issues better addressed with an Appointment in the Medical Home:

• Follow up of any issue (ear infection, asthma, constipation) unless suddenly worse, then see above
  
• Chronic (long term) concerns (growth, constipation, acne, headaches)
  
• Behavioral issues
  
• Well visits and sports physicals (insurance counts these as the same, and limits to once/year)
• Immunizations - ideally done at medical home so records remain complete 

If your child gets a vaccine at any other location, please send us documentation (including the date, brand, lot number, and place administered) so we can keep the records complete.

Remember our website offers answers to questions and many treatments to try at home for various illnesses and conditions!