Prescriptions for Flu Shots

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

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

Risk

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

Cost of care

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

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

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

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

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

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

Inventory issues

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

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

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

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

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

Prescription requests 

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

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

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

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

Getting the vaccine

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

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

Dr Mellick got a FluMist in a previous season

All about ears

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

Why do babies get so many ear infections?

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

photo credit: MedlinePlus

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

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

photo source: Medscape

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

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

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

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

Are ear infections that rupture the eardrum more serious? 

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

How are ear infections treated?

First manage the pain.

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

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

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

Treat associated issues.

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

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

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

Why not use antibiotics for every ear infection?

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

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

What are tubes and how do they work?

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

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

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

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

When are tubes recommended?

Since placing tubes does involve risks, they are not recommended for everyone. Guidelines recommend the following evaluation for tubes:

• If pus or fluid has been in the middle ear for over 3 months (OME or OM that never clears), a hearing test should be done.
• If the hearing test is failed, tubes should be considered.
• If fluid has been there longer than 3 months but hearing is normal, recheck the hearing every 3-6 months until the fluid clears. If the hearing test is failed on rechecks, then tubes are warranted.
• Children with higher risk of speech issues or hearing loss may be considered for tubes earlier. This would include children with abnormal facial structures, such as cleft palate, or certain genetic conditions that predispose to developmental delays, hearing concerns, or immune problems. 

What about recurrent ear infections?

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

Are there kids who should be considered tube candidates earlier?

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

What are complications and risks of tubes?

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

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

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

What can be done to prevent ear infections?

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

For More Information:

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

Treatments for hair pulling (trichotillomania) and other body focused repetitive behaviors

I see several kids each year who pull hair from their scalp, eyelids, or eyelashes. This is called trichotillomania (sometimes shortened to trich). Because I see families struggle with this and other similar issues, I am breaking my general rule of blogging within the realm of standard guidelines and am going outside of conventional medical advice to talk about an interesting new treatment that is showing positive benefit with studies (many of which are linked into the post). I say this only to caution the reader that you should discuss this with your (or your child's) doctor about it and to remind you not to take this (or anything else I write) as medical advice.

Trichotillomania is more common in children who have anxiety, and it can also lead to more anxiety from the social isolation and bullying that result from hair loss. It is a vicious circle where the self-inflicted hair loss is in itself distressing, but that distress leads to more pulling. You can see from the following picture that cutting hair short is not an effective treatment. Skin picking and nail biting are similar body focused repetitive behaviors (BFRB).

Do dietary changes help?

There have been conflicting studies that suggest avoiding certain foods can help prevent the urges to pull hair. Some people report that avoiding sugar and caffeine helps. Since added sugar and caffeine are not parts of a healthy diet, I think whether or not it helps, avoiding added sugar and caffeine is a good idea for all kids.

What help is available?

The first treatment recommended for trich (as well as other body focused repetitive behaviors- BFRB) is therapy. Treating BFRB should involve cognitive behavioral therapy or habit reversal therapy from a trained therapist with experience in this issue. During therapy they will learn to identify emotions, label them, and appropriately address them. In habit reversal therapy they learn to do another action instead of the hair pulling (or nail biting/skin picking). This might mean clenching fists, playing with play doh, or another activity. Family support can help ease the anxieties that are caused by the behavior itself and it is important that family members praise the positive steps along the journey. There are support groups available in many areas. 

Are there supplements that help?

A relatively new development in the treatment of trichotillomania and other BFRBs is a supplement called N-acetylcysteine (NAC), a glutamate modulator. NAC is available over the counter in stores that sell supplements and online for a relatively low cost. How NAC might work is not completely understood and well beyond the scope of this blog, but is reviewed in the Journal of Psychiatry and Neuroscience.

I've been recommending NAC for awhile now for trichotillomania (as well as nail biting and OCD) and have had mixed response, but overall positive. For those who did not find it helpful, I suspect they did not use it long enough since it can take over a month to see benefit. I think parents like the fact that it is a supplement, which is easier to provide than behavioral therapy, but therapy is still an important part of the treatment. Those who have the best results do therapy along with the supplement.

How long does it take to see results with NAC?

It takes about a month or two (studies show 4-9 weeks) of NAC to show benefit. Taking a supplement for that length of time without benefit can be difficult and might cause some to quit prematurely, but I'd recommend at least two months before deciding it doesn't work. Talk with your child's doctor before starting any supplement and before stopping it.

How much NAC do you give?

Most studies have been done in adults, so the best pediatric dose is not known. For adults and children over about 45 pounds, 600 - 2400 mg has been studied, but no ideal dose is known. It has been suggested about 60mg/kg/day for younger children, but there is no standard dose.

It may also be difficult to give to a child who cannot swallow the capsules. While in theory the capsule could be opened (and the powder is available in bulk), the taste and smell is of rotten eggs, so I cannot imagine a child taking it mixed in food or drink. Tips on teaching kids to swallow pills is covered here.

Talk with your child's pediatrician before beginning any supplement, even though they are sold over the counter. This helps your child's doctor know more about what is going on, what works and what doesn't for your child, and to help monitor for possible reactions if they are known (especially if your child is on prescription medicines).

One dosing strategy for children over 45 pounds is to give a 600 mg capsule twice per day (1200 mg) for a week and increasing to 2 capsules twice per day (2400 mg) after 4 weeks if needed. I have also seen titration methods, beginning with one capsule daily for the first week (600mg), then one capsule twice a day for the 2nd week (1200mg), then 3 capsules divided in 2 unequal doses (1800 mg) for the 3rd week and 4 capsules divided in 2 doses (2 capsules twice per day = 2400 mg) thereafter.

Is NAC safe with other medicines?

NAC might interact with other medicines, so it is recommended to discuss interactions with your doctor and pharmacist. Since antidepressants are often used in anxiety disorders such as trichotillomania, I have tried to see what interactions might be known. Research has shown that rats need lower doses of imipramine (a tricyclic antidepressant I don't use in kids) and escitalopram (Lexapro, an SSRI antidepressant) when taking NAC, but NAC doesn't affect the dose of desipramine (another tricyclic antidepressant) and bupropion (Wellbutrin). In contrast, NAC in the rats actually made fluoxetine (prozac) less effective, so higher doses were needed. Obviously people are not rats, and this is an area that needs to be further studied, but if your child is on any prescription medicines, be sure your doctor and pharmacist know that he is starting NAC.

If anyone knows of human studies or more information, please post in the comments below!

How long will NAC be needed?

It is thought that NAC is safe long term and might be needed long term since the underlying anxiety does not go away, only the symptoms are controlled with the NAC. This is an important reason to do the therapy too, since learning techniques to identify and appropriately deal with stressors can help life long without side effects. When NAC is stopped, symptoms might return. I will often suggest a trial off NAC once all habits being treated have been gone for at least a month. Weaning to a lesser dose for a few weeks is one way to test without going completely off, and I find many families feel more comfortable with a wean versus sudden stopping. If symptoms resume, restart the NAC. (Note: This is my own version of what to do -- I have not found guidance in the studies I've read. If anyone knows anything more specific, please comment below so we can all learn!) I did see one case report of a person treated for 6 months with NAC and the symptoms did not return for a full month after stopping NAC.

Is NAC safe?

Side effects are rare, but may include gastrointestinal upset, diarrhea, nausea, rash, vomiting and fatigue. One study of AIDS patients used 8000 mg of NAC per day, showing overall safety at high doses. This is NOT the dose recommended for hair pulling, skin picking, and most psychiatric and neurologic disorders. Some studies suggest kidney stones are more common at higher doses, but taking high doses of Vitamin C at the same time as each NAC dose can help prevent kidney stones from forming. A supplement of Vitamin B6 has also been recommended by some because NAC increases the body's use of Vitamin B6, but most children can get plenty of this vitamin from a healthy diet. Many foods are rich in B6, including fish, beef, poultry, fruits (not citrus fruits), vegetables, and grains. Vitamin B6 is also in most multivitamins, so if you choose to supplement, a standard multivitamin would be considered safe. Talk with your child's doctor if you plan on doing mega doses of vitamins, as that can sometimes be harmful.

What else is NAC used for?

When I was a pediatric resident, we used NAC for acetaminophen (Tylenol) overdoses. I hadn't thought of it for many years, then a few years ago I started to hear of it being used for other things. Research for using NAC for a variety of psychiatric and neurologic disorders in addition to trichotillomania is promising. There is evidence that NAC works for some symptoms involved with autism, Alzheimer's disease, cocaine and cannabis (marijuana) addiction, bipolar disorder, depression, nail biting, skin picking, obsessive-compulsive disorder, schizophrenia, drug-induced neuropathy and progressive myoclonic epilepsy. Disorders such as anxiety, attention deficit hyperactivity disorder and mild traumatic brain injury also have preliminary studies supporting NAC use but require larger confirmatory studies.

Suggested NAC 

I do not typically recommend any brand over another, but supplements present a problem due to the lack of regulation. Investigations have shown that there is variability of what is actually in the product from bottle to bottle. I recommend Swanson Vitamins. During the study on BFRB’s done by Jon Grant, MD, JD, MPH, Swanson products were used because they were the only company in the US that would provide a certificate of purity and batch to batch sameness. For this reason I recommend Swanson’s for NAC as well as their other products if you will be taking a supplement.

Update 11-3-17: I just heard of an effervescent tablet that gets good reviews from specialists. PharmaNac has 900 mg per tablet, and their website recommends 2-4 tablets per day. Note: Their website mentions a potential issue with some antibiotics and NAC, but those claims have been disputed. It would not be wrong to separate dosing of antibiotic and NAC, but it might not be an issue.

For More Information:

For more information, see Experts Consensus Treatment Guidelines for Trichotillomania and Skin Picking and the many other resources found on The TLC Foundation for Body-Focused Repetitive Behaviors.

KidsHealth has a Trichotillomania page for teens.

"It's just my allergies." Is it?

I've seen many parents over the years who complain that their allergies are really giving them (or their children) problems. They insist it's just allergies though when I suggest that maybe they're sick. Why do they think it's allergies and I think they might have a virus-- and why does it matter?

Allergies can cause runny nose, watery eyes, sneezing, headache, ear pain or popping, cough and sore throat from postnasal drip.

Viruses can cause the same symptoms, so it's very confusing which is the culprit sometimes. If there's a fever or body aches, it is more likely from illness, not allergy, but not everyone with an infection gets a fever, especially older kids and adults. Not everyone with fever needs an antibiotic. Many people think clear mucus is certainly allergies and discolored mucus is bacteria, but that isn't always the case. The color of mucus depends on how long the mucus is in the nose and sinuses and how much your immune system is fighting back. It is common after a few days for the mucus to be yellow, even if it's not a bacterial sinus infection.

I've seen people treated by allergists for years for allergies only to find out with allergy testing that there aren't any allergies. It's hard for even the experts to know sometimes!

Why do I suspect these parents (or kids) have a virus and not allergies?

• Time of year. Allergies can occur year round, but there are typical times that various pollen counts go up. If it's not a high pollen count time (or other possible exposure to allergen such as a new cat), I wouldn't expect a sudden increase in allergy symptoms. 
• Their child is sick. If a child is sick with fever, runny nose, cough, ear infection, or other similar symptoms, it is common for them to share with the parent (and siblings). Parents and older kids often get colds without fever, so no fever doesn't rule out an infection.
• The community is sick. When we're seeing a lot of upper respiratory tract infections in the community, it is at least something to consider.

Why does this all matter anyway?

• Not all treatments for allergies work well for viruses. Treating the symptoms with the proper treatment is important (although there really isn't a wonder treatment for most upper respiratory viruses). When people think they become tolerant to their allergy medicine because it doesn't work for their symptoms, they are likely to not use it when appropriate for allergies. They might switch to a more expensive medicine for the wrong reasons. Bottom line: If the allergy medicine works for allergies, it can be used for allergies, but don't expect it to work for your cold.
• If people presume it's allergies they aren't as careful to wash hands to prevent the spread of infections. This is especially important to infants, young children, immunocompromised, and the elderly. What is a minor cold for you can be a significant illness to others.

So the short of it is, if you think your allergies are flaring, still be careful to not spread germs. It is fine to use allergy medicines, but if they aren't working, consider that you might have a cold. Even if they do help, it doesn't mean that you aren't contagious, so still wash your hands often, especially after blowing your nose!

Flu shots: Who needs them and which type is best?

Flu vaccines are recommended every season for just about everyone over the age of 6 months. There are specifics to age group and risk factors that help determine if they need an injectable vaccine or if they can get the nasal vaccine.

For as common as the flu vaccine is, there is often confusion about who needs what for many reasons:

• it changes yearly 
• recommendations vary by age and history of flu vaccine or not
• there are options for nose sprays and shots. The nose spray (FluMist) and the injectable vaccine (many brands available for different age groups and our office uses Fluzone quadrivalent) both have the same strains as the other each year but they differ in that the spray is a live virus that has been changed so it doesn't cause all the symptoms as the natural virus but still gives the body memory fighter cells (antibodies). The injectable vaccine is an inactivated virus (not live virus) vaccine. It is safer for people with decreased immune function, such as infants and young children or those with compromised immune systems from disease or chemotherapy.
• there is concern that it might be of little value (this is a whole blog in itself and won't be discussed here) 

If you really want to get to the details, this year's trivalent (3 strain) influenza vaccines will contain: 

• hemagglutinin (HA) derived from an A/California/7/2009 (H1N1)-like virus

• A/Switzerland/9715293/2013 (H3N2)-like virus

• B/Phuket/3073/2013-like (Yamagata lineage) virus

Quadrivalent (4 strain) influenza vaccines will contain these vaccine viruses, and a B/Brisbane/60/2008-like (Victoria lineage) virus, which is the same Victoria lineage virus recommended for quadrivalent formulations in 2013–14 and 2014–15

All FluMist last year and this year are quadrivalent. Injectable vaccines vary by manufacturer and the one we will offer is a quadrivalent type.

Last year there was concern that the FluMist didn't work as well as the injectable. In previous years the mist was considered to work better than the shot. We do not have data on the efficacy of the vaccines this year, so I encourage you to pick the one that best suits the needs of your child because any vaccine is better than no vaccine at all, even if the effectiveness isn't 100% (which it will never be).

Here's a breakdown of what is needed by age group to help decide what your child will need. For people with egg allergies, see the bottom of this page. (Quick note: this year there is a delay of shipment of the FluMist again. The flu shot will be available sooner than the mist, and any child over 6 months can do the shot. It is never wrong to give the shot to ensure protection especially if you're in an area that the flu season is starting. The flu season is generally October to May, with peak activity December to February.)

Six months - 2 years

This age group should get the injectable flu vaccine and cannot get the nasal FluMist.

For children under 9 years of age who have not had two flu vaccines, they will need two doses of the same strain. Think of it as the first dose is a primer dose, getting the body primed to make continued antibodies. The second dose boosts that primer. Each season we need a booster to get the antibodies for the strain of virus that is anticipated that year. Talk to your doctor to see if your child will need one or two doses. Each dose must be at least 28 days apart, but can be separated by many months and count as long as they are the same strains of virus. In recent years the same virus strains were in two different seasons, so it even counted if one was given one season and the other the following year. That doesn't often happen and usually two vaccines in the same season must be given. The strains are different this year from last, so if your baby got only one dose last season, he will need two this season.

2 - 4 years

This group can get the FluMist if they have not had wheezing. The reason for this is the nasal vaccine is a live virus and could trigger wheezing in a susceptible child. The injectable vaccine does not carry this risk. If they have had wheezing or if they just have an aversion to things in their nose they can do the injectable vaccine.

These children are still in the age group that might require two doses, see the 6 months - 2 years section for more information on that.

5 - 9 years

This age group is eligible for either the injectable or nasal vaccine. If they have wheezing in the past 12 months you will need to discuss with your doctor or nurse if they should get the nasal FluMist. Since the FluMist is a live virus, it is possible that it can trigger wheezing. My personal recommendation is if the child prefers the nasal spray over the shot and the parent is able to handle any wheezing that might happen, the nasal vaccine is okay. If the child tends to have severe wheezing that is difficult to control or needs oral steroids often, it is not recommended to risk the mist. Most children do not report wheezing after the FluMist, but it is always a possibility.  

Children under 9 years of age who have not had two flu vaccines of the same strain (generally in the same season) will need two doses for full protection. See the 6 months - 2 years section for more information.

10+ years

This age group is also eligible for either the injectable or nasal vaccine. If they have asthma or recent wheezing, you will need to discuss with your doctor or nurse if they should get the nasal FluMist. Since the FluMist is a live virus, it is possible that it can trigger wheezing. My recommendation is usually if the child or teen prefers the nasal spray over the shot and the parent (or older child) is able to handle any wheezing that might happen, the nasal vaccine is okay. If there is a history of severe wheezing I do not recommend the mist. Most people do not report wheezing after the FluMist, but it is always a possibility.  

Only one dose of vaccine is required at this age, regardless of immunization history.

If you're more of a visual person, the following is from the CDC:

For those with egg allergies,  this is helpful guidance from the CDC. People with egg allergy may tolerate egg in baked products but that does not eliminate the risk of vaccine reaction. If children have never eaten egg but previously performed allergy testing shows probable egg allergy talk to your doctor before vaccination. 

Flu Shots: First Update for 2015

Every year I have been a pediatrician there has been something that makes giving flu vaccine difficult. (I've previously written about that here, which also includes similar links.)

In recent years (last year being the exception) we have been able to at least start giving the vaccine over the summer, allowing us to vaccinate at least some of the school aged kids before school even starts. It is especially reassurring to vaccinate the college aged kids before they go back to school, because once they're at school it's hard to ensure that they'll get the vaccine. We missed the opportunity to offer shots at summer physicals last year and it did make a difference. Since schools in our area are starting back up less than a month from now and we haven't heard anything about vaccine shipments, it looks like we'll miss the majority of school aged kids this summer too.

This year we've heard that the FluMist will once again be delayed in shipments. FluMist will not be shipped to distributors until the end of September/beginning of October, and then the distributors will be able to ship the vaccine to everyone nationwide who has ordered it.

Why are the shipments delayed? 

 
There will be three new strains in this year's FluMist, including a more stable version of the type A H1N1. This strain is producing lower yields than expected which is causing the delay.

I have not heard any direct information about when our office should start getting the injectable flu vaccine, but after an online search I did find that Fluzone has been approved for shipment. When we have the vaccine in the office we will start offering it to eligible patients who are in the office. (Eligible means they of the appropriate age and health status for the vaccine.) Once we have enough in stock we will announce flu vaccine clinics. It is too soon to predict exactly when our flu clinics will be available, but hopefully we'll be able to share more soon. I know many of you are asking when they will be, but please be patient and we'll let you know!

Summer Slide...

How do you prevent the summer slide at your house?

By Artaxerxes (http://creativecommons.org/licenses/by-sa/3.0), via Wikimedia Commons

No, not a fun water slide.

You know, the one where all the great information and skills your child learned during the school year dwindles and is forgotten in the months of no brain stimulation?

Some ideas that my family's done or that I wish we would have done...

Read

I am a big believer that kids should read every day. I don't care if it is a comic book or a 1000 page novel. As long as it is age appropriate, kids should read.

• You can have them read signs along the road or the map at the zoo. 
• Kids can read below their reading level to work on speed and just enjoy the story. 
• They can read at their level (or one a little challenging) to work on increasing their reading abilities. 
• Visit the library often. 
• Take turns in the evening with the family reading out loud together - like people did before television. This builds family bonds and is an inexpensive fun activity that can become a fun family tradition.
• Ask about what your kids are reading. Can they summarize what they've read? What do they think will happen next? How would they have ended the story differently?
• Gather a group of friends and start a summer book club. Pick a few good books, and meet once a week to talk about them.
• Check out the many places that offer summer reading rewards, such as your local library, bookstore, or school.

Games

Games and puzzles are another great way to build thinking skills.

• Board games can work on colors and counting for young children, and problem solving and strategy building for older kids. They also work on social skills (such as waiting your turn and being a gracious winner or loser). 
• Computer games can be great learning opportunities, despite all the warnings to limit screen time. Too much of anything is not healthy - we need balance in our lives. Monitor screen use for age appropriate activities and limit times, but allow intellectually stimulating games sometimes. Many computer games allow kids to learn from their mistakes and master skills in fun ways.
• Age appropriate puzzles, sudoku, cards, and word games are a great way to learn critical thinking, build vocabulary, and keep math skills sharp. 

Question

• Throughout the day you can ask your kids questions that require thinking before answering. Instead of letting them give just a simple factual answer, ask how they came up with it or how they feel about something. 
• Let them help you pick out meals for the week, taking into consideration the nutritional components of a healthy meal. Ask how they would like the broccoli to be served.
• If they help cook, you can have them convert a recipe to double it for a neighborhood picnic.
• Describe the weather forecast and plans for the day and ask what clothes would be appropriate with that in mind. 
• Ask kids how they feel in response to things that happen throughout the day. 
• Play a game of what if? How would something that happened have turned out if they did or said something differently at any given moment? (One rule: you can't change what others do or say in real life, so you can only change what you would do or say in the game.) Think about the response other people would have had (such as "What could you have said that would have changed the outcome when Billy cut in line at the slide?" Or "What Sally would have said if you said ___ instead?) or ask about what physical events would have changed (such as if they threw the ball to Bob at first base instead of to the pitcher or if they jumped into the cold pool instead of entering slowly).
• Ask if there's another way to do something, since there are usually many options to get to the same place or conclusion. Maybe there's an alternate route to take to the zoo since there's an accident on the road you usually take. (This also works well if they get the wrong answer, such as on a math problem.)

Play and explore

• Outdoor play is amazing for kids and their development. As they climb, roll down hills, build forts, or do whatever, they are working on motor skills.
• Playing with other children helps develop healthy social skills. When kids are always told what to do (school, sports, other scheduled activities) they never learn how to be independent, which can harm them in the long run.
• Play school. Kids love to be the teacher and teach others!
• Visit a museum, zoo, or historical site.

Music and dance

• Kids love to put on shows for friends and family with acting, singing, dancing and playing instruments. This can be impromptu fun or a more organized neighborhood event where they make posters to announce the show and even make tickets to give out. 
• Older kids will love to shoot videos of themselves and share online. Be sure parents review what is posted and it is appropriate for the type of posting (public vs private). 

Create

• Coloring, chalk art, painting, building with blocks or Legos ... so many options!
• Design a "dream" bedroom and show how even small changes can update the room.
• Make a map of your town of all your favorite spots: home, parks, grocery store, the zoo...
• Have kids make up their own game, complete with game pieces and rules.
• Design new outfits from dress up clothes (or actual sewing for older kids) and put on a fashion show for friends and family.
• Build an art gallery over the summer. Make paintings, paper mache, clay models, whatever suits you! Put it all out for display at the end of summer and invite friends and family to see the art!

Volunteer and give to charities

Volunteering not only helps others and makes our world a better place, but it also fosters a humble heart and can help develop skills we might not know we have. It puts us outside our comfort zone sometimes, which builds us into a better person. By focusing on helping others, we become happier.

• Kids, tweens and teens can find many opportunities to volunteer during the summer months. 
• It can be as simple as playing with young neighbors while their parents do yard work or run to the store, help with a neighbor's pet and newspaper while they are out of town, or pick up trash on a family walk. 
• Teens can find volunteer positions in many places. In my community that may be with their church or synagogue, at Deanna Rose Farmstead, hospitals, animal shelters, Harvester's Food Bank, and many more.
• Kids can write letters to soldiers, make blankets for sick or foster kids, pick up trash at a park, plant a tree, make a care package for a soldier, and many more.
• Anyone with long hair can donate hair to kids in need through ChildrenWithHairLoss or WigsForKids.
• If your family wants to financially help a sponsored child in another country, check out Unbound. Your child can help write letters to that child and learn about that child and his/her life from letters received.
• As a family: go through closets and dressers to find clothes, games, books, and toys that are appropriate to give to your favorite charity. To see how charities rank, check out CharityNavigator and CharityWatch.
• For more ideas, check out DoSomething.org.

Science

The internet makes doing science experiments easy! Check out my Pinterest Science board for ideas.

Make a bucket list of things to do and start doing them!