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Black Box Warnings - What do They Mean For My Child?

Catherine Revzon - noemail@kidsmeds.info — Wed, 10 Aug 2011 12:00:00 GMT

A summary of the drug's chemical description, how it works, how it interacts with other drugs, supplements, foods, and beverages, what condition(s) it treats, who should not use the drug, potential serious side effects, commonly occurring side effects, and the effects on children, pregnant women, and the elderly is provided by the pharmacy with your prescription. Complete details of this information, including evidence from clinical trials and other essential data that health care professionals use to determine whether the drug is being prescribed appropriately for your child are found in the prescribing information. This information is also known as product labeling, or the package insert. Biologic products are also dispensed with printed information.

Some drugs and biologic products carry a Black Box Warning, which is the strongest warning issued by the Food and Drug Administration (FDA). The text of the warning is surrounded by a black border and appears on the label of the drug, the package insert, and other literature that describes the medication. The black border is the reason for the name, Black Box Warning.

Just because a drug or biologic product has a Black Box Warning does not mean it cannot be safely used in your child

There are two main reasons for this type of advisory: the medication can cause dangerous side effects as compared to the benefit from the drug and a serious adverse reaction can be prevented or reduced in seriousness if the medication is used properly. Of note, Black Box Warnings may affect a drug that has been designed to be given by mouth and intravenously, but NOT as eye drops. An example of this is found in the antibiotic class, the fluoroquinolones. BlackBoxRx.com is a free website that provides a list of all the drugs that contain a Black Box Warning.

Selected medications with a Black Box Warning may be required by the FDA to distribute a Medication Guide with the prescription to the patient. The Guide contains information approved by the FDA to help avoid serious adverse events and to help the parent make an informed decision about a known serious side effect with the drug. The Guide also urges adherence to directions when using the medication for it to work best. Medication Guides should be provided by the pharmacy when your child's prescription is dispensed and can also be obtained online at the FDA's website.

Be sure to speak to your child's doctor or pharmacist if there is a concern about any drug that your child is taking or is about to take. Just because a drug or biologic product has a Black Box Warning does not mean it cannot be safely used in your child. This medication could be the best option based on your child's current condition and other components of his health history. What IS important is that parents understand the risks and the benefits of the medication and make an informed decision based on this knowledge. Adverse events are encouraged to be reported to the FDA via the MedWatch program.

10-Aug-11 7:00 AM

What is the Meningococcal Vaccine?

Rebecca Pettit - noemail@kidsmeds.info — Tue, 09 Aug 2011 16:00:00 GMT

What is the Meningococcal Vaccine?

The meningococcal vaccine protects against meningitis caused by a bacteria named Neisseria meningitides.

What is meningitis?

Meningitis is a disease that causes swelling of the membranes that cover the brain and spinal cord. Both bacteria and viruses can cause meningitis. Bacterial meningitis, such as meningococcal meningitis, is serious and can result in hearing loss, brain damage, or learning disabilities.

Is meningococcal meningitis contagious?

The bacteria that cause meningococcal meningitis can be spread to others through coughing and sneezing. When the infected person coughs the bacteria into the air a close person can breath in the bacteria and become infected. People in close contact with infected persons should receive antibiotics to help prevent them from becoming sick.

What are some signs and symptoms?

Meningococcal meningitis is a serious disease and should not be taken lightly. It can occur quickly, make you very sick and in some cases may even lead to death. The most common symptoms are fever, headache and neck stiffness. It may also cause sensitivity to light, a stomachache, confusion, and vomiting. Infants with meningitis may be irritable, fussy, not want to eat, vomit, or be less active. If these symptoms are experienced contact your doctor immediately.

What are options for prevention?

The meningococcal vaccine can decrease the risk of getting meningitis from the Neissera meningitides bacteria. It is recommended that everyone get this vaccine at 11-12 years of age and then receive a booster shot at age 16. It is important to receive two meningococcal vaccine shots. The two shots will provide the best protection against meningococcal meningitis. If the first shot in the two shot series is not given until age 13-15 years then the booster shot should be given at age 16 making sure there are 2 months between the two shots. College freshman living in dormitories that have not received the vaccine should receive one dose.

Children at high risk for meningococcal disease including those with immune system problems or those without a spleen should receive 2 doses of the vaccine at least 2 months apart and then receive a booster shot every 5 years there after. Children that travel to some foreign countries where the disease is common should also be vaccinated.

People of any age at high risk include patients with immune system problems including HIV, military personnel, and those living in dormitories should receive the vaccine. Your doctor or pharmacist can help determine if you are at high risk for meningococcal disease. Those people who continue to be at high risk should receive a booster shot every 5 years.

I heard the recommendations for the meningococcal vaccine have changed?

Yes, the 2011 vaccine recommendations have changed. The main change is that a booster shot is now recommended at age 16-18 years after the initial vaccine. This is necessary to protect against meningococcal meningitis.

The FDA also recently approved the use of the meningitis vaccine in children from 9 months to 23 months of age as a 2 dose series. The approval was the result of studies showing that the meningitis vaccine is safe in this younger age group.

What are some known side effects of the meningococcal vaccine?

Possible side effects of the meningococcal vaccine include:

Pain and redness at the injection site
Fever
Rarely a rash and allergic reaction
Rarely neurological disorder

What are some treatment options?

People suspected of having meningococcal meningitis are hospitalized and given antibiotics. Early treatment is important. The antibiotics will help fight the infection but may not prevent all of the damage the disease can cause. Prevention is the best option. All people in close contact with a patient with meningococcal meningitis should receive antibiotics to help prevent the spread of the disease.

Where can I find more information?

http://www.cdc.gov/meningitis
http://www.immunize.org

Additional References:

Committee on Infectious Diseases. Recommended childhood and adolescent immunization schedules united states 2011. Pediatrics 2011;127:387-388.

CDC: http://www.cdc.gov/meningitis/vaccine-info.html
CDC: http://www.cdc.gov/meningitis/about/faq.html
CDC: http://www.cdc.gov/vaccines/pubs/vis/downloads/vis-mening.pdf
Immunization Action Coalition: http://www.immunize.org/catg.d/p4210.pdf

Sanofi gets expanded meningitis vaccine approval. The Associated Press. Apr 25, 2011.

9-Aug-11 11:00 AM

Preparation and Administration of Subcutaneous Injections

Jena Koshaish - noemail@kidsmeds.info — Wed, 13 Jul 2011 16:00:00 GMT

Disclosure: This information is intended to educate parents and caregivers about the techniques of preparing and administering subcutaneous (SQ) injections to children. This information is not meant to replace specific instructions from your healthcare provider. We encourage all parents and caregivers to speak to their healthcare providers about receiving specific hands-on instruction to prepare and administer SQ injections before attempting it at home.

Introduction

There are several reasons why your child might have been prescribed an injectable medication. For instance, there is not a suitable alternative oral medication to treat their condition or the medication is only supplied as an injectable because it cannot be absorbed from the stomach through the oral route. Specific medical conditions that often require SQ medications are diabetes and clotting disorders of the blood. In diabetes, specifically Type 1 Diabetes, insulin is required to maintain normal blood sugar levels. This medication is only available in the SQ form. Although Coumadin, an oral medication, can be used to treat conditions involving clotting disorders of the blood, this medication involves frequent monitoring, special diets, and has an increased risk of bleeding. Therefore, SQ medications, such as Lovenox, Heparin, or Fragmin, can be used to treat clotting disorders, which have a lower incidence of bleeding and no diet restrictions.

Subcutaneous injections can be supplied as prefilled syringes or the pharmacy may provide you with a vial of medication and syringes with which to drawn individual doses from the vial. In the case of prefilled syringes, they can either be administered directly to your child or they may also be dispensed with separate, empty syringes to draw smaller, individual doses. We will discuss how to prepare individual doses from a vial of medication and an empty syringe.

Preparing Your Child’s Subcutaneous Medication

So you’re child was prescribed an injectable medication, what now? Don’t panic, this section is meant to give you step-by-step instructions on how to prepare you child’s medication. Please see the following section for specific instructions on how to administer the subcutaneous injection.

Preparing the medication from a vial and an empty syringe

Supplies you’ll need before you start:

Alcohol swaps
Cotton ball and/or a bandage
Disposable needles (sharps) container
1 ml syringes with needles
Vial of medication

Step 1:

Wash your hands with soap and water for 15 to 30 seconds and dry them thoroughly.

Step 2:

Take off the cap on the top of the vial, and swipe with an alcohol swab in 2 sweeping motions.

Your pharmacy may have given you two sizes of needles, one for drawing medication from the vial and another for administering the injection. The needle used to remove the medication from the vial is thicker (smaller gauge) and sturdier than the needle used to inject your child. The needle used to inject your child is thinner (larger gauge) to reduce pain upon injection, as well as, more flexible which may cause it to bend if used to draw medication from the vial. Therefore, it is important to remember to use the thicker (smaller gauge) needle to remove medication from the vial, and to use the thinner (larger gauge) needle to administer the SQ injection to your child.

Step 3:

Attach the needle to the syringe by twisting it onto the top of the syringe. DO NOT uncap the needle until you are ready to insert it into the vial.

Note: Skip this step if the syringe is supplied with a needle already attached.

Step 4:

Uncap the needle by pulling NOT twisting the cap directly away from the needle in a quick sweeping motion.

Do not let the exposed needle touch anything, as this will spread germs onto the needle, possibly infecting your child. If the needle touches a surface, other than the rubber stopper of the vial, remove the needle and replace it with a new capped needle. Place the old needle in your “sharps” container and begin again with Steps 3 and 4.

Step 5:

Fill the syringe with a small amount of air, usually about three-quarters of the actual dose of the medication (i.e. if the dose is 1 ml, fill the syringe with 0.75 ml of air). This will make it easier to remove fluid from the vial.

Step 6:

Puncture the rubber stopper of the vial with the needle bevel side up at a 45 degree angle. This technique will prevent coring, which is when the needle rips a small piece of the rubber stopper into the vial.

Once the needle is inside the vial, inject the air into the vial by pushing on the plunger of the syringe.

Step 7:

Lift the vial off the table, with the needle still inside, and place your left index finger and thumb around the vial. With your other hand around the syringe, pull back on the plunger of the syringe to fill it to the level of the dose your healthcare provider prescribed.

Note: Make sure that the tip of the needle remains in the fluid to avoid drawing up air into the syringe.

Step 8:

Once the syringe has been filled with the desired dose, pull out the syringe from the vial. If you notice air in the syringe pull back on the plunger and gently tap the side of the syringe, then push the plunger up just until you see the medication fill the inside of the needle hub. This will ensure that no air is injected when the medication is administered.

Step 9:

Carefully change the needles from the smaller gauge to the larger gauge needle. Do not uncap the needle until you are just about to administer the SQ injection. Please see the administration section for more instructions.

Administering Your Child’s Subcutaneous Medication

Your healthcare provider will instruct you on the preferred sites on your child’s body to administer the SQ injection. It may be helpful for another adult to hold your child in a comforting and reassuring position while you administer the medication.

Step 1:

Wipe the area with an alcohol swab where you plan to inject the medication. Allow the area to dry for 10 seconds.

Step 2:

Remove the cap of the needle and grasp the syringe, as if holding a pen.

Step 3:

Lightly pinch your child’s skin with your free hand, about 1 to 1 ½ inches.

Step 4:

Insert the needle of the syringe swiftly and firmly into your child’s skin. Inject the medication by pushing in the plunger of the syringe. Make sure to deliver the entire dose.

Step 5:

Pull out the syringe gently and press a cotton ball over the injection site for 3 to 5 seconds to make sure the medication is absorbed. You can also place a band aid on the injection site.

Step 6:

Throw away all the needles “sharps” into the container provided by your healthcare provider or a hard plastic container, like a milk jug. DO NOT attempt to recap any needles. If the vial of medication is for multiple use, be sure to store it according to the instructions provided by your pharmacist or healthcare provider.

Click here for the original pdf file with pictures.

13-Jul-11 11:00 AM

Low Molecular Weight Heparin Use in Children

Lisa Lubsch, PharmD Bradley McCrory, PharmD - noemail@kidsmeds.info — Sun, 10 Jul 2011 05:00:00 GMT

Low-molecular-weight heparin (LMWH) is a type of medicine known as an anticoagulant. These medicines are used to prevent and treat clot formation in blood vessels, also called thrombosis.

What are the different LMWHs used in children?

enoxaparin (Lovenox®)
dalteparin (Fragmin®)
tinzaparin (Innohep®)

How does LMWH work?

Two important components for forming a clot in the blood are factor Xa and thrombin. LMWH acts by stopping the activity of factor Xa and thrombin and increasing the activity of other proteins in the blood to prevent the formation of clots.

How much LMWH is needed?

The amount of LMWH given is based on the child’s medical problem requiring a LMWH and his weight. LMWH doses are based on different measurements.

enoxaparin (Lovenox®) is based on milligrams (mg)
dalteparin (Fragmin®) is based on units
tinzaparin (Innohep®) is based on units

Normally the dose is given one to two times a day. The dose may be adjusted based on lab tests.

How is LMWH given?

LMWH is given by a subcutaneous injection. A subcutaneous injection is similar to an insulin injection, and is administered into the tissue just below the skin. These injections can be given in the legs, arms or abdomen. Click here to learn how to administer shots in the abdomen. Sometimes a subcutaneous catheter may be used to help with ease of administering the medication. If a subcutaneous catheter is used, you should be taught how to use the subcutaneous catheter for administration of the medication.

What tests are needed when on LMWH?

A laboratory test may be done to monitor for the effects of the LMWH. An anti-factor Xa level in the blood (also called a LMWH level or heparin assay) will be checked after starting the medicine. Then depending on the child’s age and medical problem, the anti-factor Xa level may need to be rechecked as often as once to twice a month.

Special Instructions while receiving LMWH:

Tell your child's dentist, doctor, or surgeon at the beginning of each visit that your child is taking a LMWH
Do not give your child any other medication without first talking to your doctor or pharmacist (for example, avoid products containing ibuprofen or aspirin while on LMWH; avoid warfarin)
Do not use after the expiration date on the bottle or package
Keep this medication out of the reach of children
Monitor your child for excessive bleeding

What are the side-effects of LMWH?

Bruising
Bleeding
Irritation, burning, or pain at the injection site

When to call the doctor?

If any of the following are experienced, contact your physician immediately:

Unusual bruising, prolonged bleeding, or tender swellings without obvious cause
Nose bleeds
Heavy bleeding from the gums
Black, tarry, or bloody stools
Urine that is bloody, dark brown, or cloudy
Vomit that looks like coffee grounds or containing blood
Severe or persistent dizziness, tiredness, or weakness
Suffering a blow to the head, even without losing consciousness
Sever and prolonged headaches
Severe allergic reactions (rash, hives, itching, difficulty breathing, tightness in the chest, swelling of the face)

Where can I get LMWH?

For most children, LMWH may be obtained at your local pharmacy with a prescription. For young children, giving LMWH at home may be a challenge because of the unique dose needed. The amount is smaller than the doses available from the drug company. Below are methods that can be used to help give LMWH’s safely to young children at home.

One way is to use a multiple-dose vial of the LMWH, if available. For example, enoxaparin comes as 300 mg/3 mL vial and the correct dose may be drawn up into an insulin syringe. This product is normally stable for 30 days after opening and may be ordered by your local pharmacy.

Another way is to dilute the LMWH to a desirable concentration with sterile water for injection. For example, if an enoxaparin dose of less than 10mg is needed, a dilution can be done (to make a concentration of 10 mg/ml or 20mg/mL). Then doses can be drawn up into 1ml syringes. This product is stable for a limited time and normally requires the help of a special pharmacy.

How to Administer Subcutaneous Injections

The following list of instructions will help you to properly administer shots to your child in the stomach:

Have your child lie down.
Wash your hands and the area of skin where you will give the shot.
Look at the syringe to be sure the drug is clear and colorless.
Take the cap off the needle. Do not push any air or drug out of the syringe before giving the shot.
Pinch a fold of skin between the fingers and thumb. Push the entire needle into the skin of the stomach area and then press down on the syringe plunger to inject the drug. Hold onto the skin the entire time you give the shot. Do not rub the site after you give the shot to minimize bruising.
Throw away syringe and needle in proper container (sharps container).
Use a different area of the stomach each time you give the shot.

You can also find more detailed step-by-step information on how to prepare and give subcutaneous shots in a related KidsMeds article.

10-Jul-11 0:00 AM

Community-Acquired MRSA Skin Infections

Wed, 23 Mar 2011 13:00:00 GMT

What is MRSA?

Staphylococcus aureus is a germ that is usually found on the skin and nose of healthy people and usually does not cause problems. Staphylococcus most commonly can cause skin infections if the skin is damaged or wounded and can be treated with antibiotics. However, methicillin-resistant Staphylococcus aureus (MRSA) is a type of this bacteria that is commonly seen in the community and does not respond to common antibiotics used for treatment. Staphylococcus (including MRSA) can also cause other types of infections in the lungs or blood as well.

What does MRSA skin infections look like?

Staphylococcus infections of the skin can be red and tender to the touch like a pimple. It can also be mistaken for a spider bite because it can sometimes result in a black area of skin surrounded by redness. MRSA is more likely to cause skin infections that have pus and look like boils than common staphylococcus. The doctor should evaluate any skin infection that causes a child to be tired and have fever.

How is MRSA spread?

MSRA usually is spread from person-to-person, but can also be spread by touching surfaces contaminated with MRSA (towels, razors, etc). Children can get MRSA infections by playing contact sports, sharing sports equipment or towels. It is important to avoid touching the wound of a person with MRSA to prevent further spread.

How are community-acquired MRSA skin infections treated?

Treatment for community-acquired MRSA skin infections depends on the seriousness of the infection. Options may include draining the infection and/or taking an antibiotic. If there is fluid or pus under the skin, it may need to be drained.

Do not attempt to drain the infection yourself. This could cause the infection to worsen or to spread to others. If the child shows no other symptoms of infection, this may be enough for treatment; however, your doctor may also prescribe an antibiotic.

Antibiotics

In addition to drainage, community-acquired MRSA skin infections can be treated with antibiotic medications. Your doctor will prescribe the appropriate medicine for your child based on his/her age, severity of symptoms, other underlying medical conditions, and potential for adverse drug side effects. Intravenous drug therapy may be needed for more serious infections. The following antibiotics may be used to treat community-acquired MRSA skin infections.

Trimethoprim/Sulfamethoxazole

Available as oral (by mouth) and intravenous preparations
May be taken with water or on an empty stomach
If using a suspension, shake well before using
Common side effects may include nausea or rash (If your child develops a rash with this medication, you should tell your doctor immediately)
May be used in combination with another antibiotic if the doctor thinks the infection may be from another type of bacteria.

Clindamycin

Available oral and intravenous
May be taken with or without food
Capsule should be taken with a full glass of water; suspensions should be shaken well before use
Children often complain of bad taste
Commonly associated with diarrhea as a side effect

Doxycycline

Available oral and intravenous
Not for children < 8 years of age
May be taken with food
Capsule should be taken with a full glass of water; suspensions should be shaken well before use
Avoid antacids, infant formula, milk, dairy products and iron for 1 hour before or 2 hours after your child takes doxycycline
May cause upset stomach

Vancomycin

Available intravenous only
Used for moderate-severe infections
Common side effects include rash, flushing of face or neck

Linezolid

Available oral and intravenous
Very expensive; may not be covered by some insurance plans
May be taken with or without food
Gently invert suspension bottle 3-5 times before use
May cause nausea, diarrhea, or headache

Things to remember about antibiotics:

Take all of the doses that your doctor prescribes, even if the infection improves
Never share antibiotics with others
Notify your doctor if infection does not seem to get better, or if symptoms worsen

Topical treatment

Your doctor may also prescribe topical treatment along with antibiotics because MRSA can live on the skin

Mupirocin 2% ointment

Your doctor may instruct you to apply the ointment to the wound or inside the nostrils because Staphylococcus aureus usually is found in the nostrils
It is important to wash your hands before and after applying the ointment
The ointment should not be applied to the eyes

Povidone-iodine, triclosan, or chlorhexidine gluconate body wash

Your doctor may instruct you to bathe/shower with one of these medications
Apply body wash to wet body and/or hair and rinse with water
Do not irritate the wound while bathing
The body wash should not be swallowed and if it gets in the eyes, rinse the eyes immediately with water
This body wash should only be used during the length of treatment and is not a substitute for everyday soap/body wash

How does one avoid getting or spreading MRSA infections?

Maintain good personal hygiene

Wash your hands often with soap and water or use hand sanitizers. More importantly, wash your hands after touching wounds or bandages
Do not share personal items such as towels, toothbrushes, bar soaps, razors, or sports equipment with others
Children should shower/bathe after participating in athletic activities
If MRSA skin infections are recurrent, bathing in a bleach bath (1 teaspoon of bleach per gallon of water or ¼ cup in ¼ full bathtub) twice a week may be helpful, but you should ask your doctor before beginning this regimen

Properly care for wounds

If wounds become red, swollen, warm, or painful, contact your doctor immediately
Keep wounds clean and dry and covered with a bandage if there is drainage
Change bandages often and always use new bandages. Be sure to throw away used bandages and wash your hands after handling bandages
Avoid touching other people's wounds or bandages
Always follow your doctor's instructions on how to take care of your wound

Do laundry and clean up

If your child gets an MRSA infection, it is important to clean all linens and clothes he/she uses. Wash clothes, bedding, and towels using hot water, laundry detergent, and bleach if it is possible
Disinfect your house by cleaning areas or items that are used often such as bathrooms, kitchens, telephones, TV remotes, and doorknobs. Using diluted bleach or other cleaning products is recommended

Can my child attend school with MRSA skin infection?

Infected children do not need to stay home from school if their infection was properly treated. Some schools may require children to stay home for at least 24 hours after starting antibiotics
If your child returns to school or athletic activity with a bandaged wound, advise him/her to keep it covered and avoid touching it
Children may be excluded from school or other activities if they have wound drainage that cannot be covered with a bandage

Things to remember:

Draining wounds should be kept covered
Follow your doctor's recommendations for wound care
Always wash hands and use gloves to care for your child's infection
Avoid contact activities until the wound has completely healed

Notify your doctor if infection does not seem to resolve, or if symptoms worsen.

References

Cohen PR. The skin in the gym: a comprehensive review of the cutaneous manifestations of community-acquired methicillin-resistant Staphylococcus aureus infection in athletes. Clinics in Dermatology 26:1 (2008), 16-26.

Klevens RM, Morrison MA, Nadle J, et al. Invasive Methicillin-Resistant Staphylococcus aureus Infections in the United States. JAMA 298:15 (2007 Oct); 1763-1771.

Kaplan, SL. Evaluation and management of suspected methicillin-resistant Staphylococcus aureus skin and soft tissue infections in children. In: UpTo Date, Torchio, MM (Ed), UpToDate, Waltham, MA, 2010.

Stevens, DL, Bisno, AL, Chamber, HF, et al. Practice Guidelines for the Diagnosis and Management of Skin and Soft-Tissue Infections. Clin Infect Dis 2005;41:1174-8.

"Information for schools/parents/students on community-acquired methicillin-resistant staphylococcus aureus (CA-MRSA).” American Academy of Pediatrics. Available at URL: http://www.aap.org/NEW/MRSA.HTM. Accessed March 23, 2011.

23-Mar-11 8:00 AM

Pinkeye in Children

Fri, 18 Mar 2011 08:00:00 GMT

What is conjunctivitis?

Conjunctivitis is inflammation of the tissue that covers the white part of the eye and lines the inside of the eyelid. It is the most likely diagnosis in someone with a red eye and discharge. It is often called “pinkeye”.

What are the types of conjunctivitis?

There are 3 main types of pinkeye: Bacterial, Viral, and Allergic pinkeye. WebMd has a complete slideshow of the different types of pinkeye.

Bacterial pinkeye is commonly caused by germs that are spread by coming in contact with the secretions of someone who has the infection or with contaminated objects and surfaces. It is highly contagious. The affected eye often is crusted in the morning. The discharge is thick and may be yellow, white, or green in color.

Viral pinkeye is typically caused by a virus that can also cause the common cold. Viral pinkeye is highly contagious. It is spread by direct contact with the secretions of someone who has the infection or with contaminated objects and surfaces. The eye may produce watery or thick discharge. Patients often complain of a burning, sandy, or gritty feeling in one eye. The eye may also be more sensitive to light.

Allergic pinkeye is caused by exposure to an allergy-causing substance, such as pollen or dander. Symptoms include itchy, puffy, red, watery eyes. This type of pinkeye is not contagious

What are some treatment options?

Bacterial: Your child’s doctor may prescribe ointments or eye drops , which contain antibiotics for the treatment of bacterial conjunctivitis. These medicines are commonly used for 7 days. For more information regarding the best way to place eye drops or ointment in your child’s eye, check out the following link from KidsMeds: http://www.kidsmeds.info/en/art/22/

Viral: There is no treatment for viral pinkeye. However, your child may get some relief from itchy eyes by using a topical antihistamine or decongestant, which are available over-the-counter. Warm or cool compresses may be comforting. Medicines used to treat pain, such as acetaminophen (Tylenol®) provide additional relief for symptoms. You can also clean the affected eye with warm water and cotton balls to help remove the crusts that cause the eye(s) to stick together in the morning. When using cotton balls or napkins, it is important to wipe from the inside corner of the eye to the outside. It’s also important to wash your hands and the washcloth immediately after to prevent spreading germs.

Allergic: Avoiding exposure to the allergen is the best treatment. Applying a cool compress over the eye may also help alleviate symptoms. Consult your child’s doctor before starting an antihistamine, since these are not recommended in children under the age of 2 years. Saline eye drops, such as Artificial Tears®, may also help relieve eye discomfort. If over-the-counter medications do not improve your child’s symptoms, you should call your child’s doctor.

When can my child go back to school or day care?

Your doctor will advise you when it is safe for you or your child to return to work or school. Since bacterial and viral pinkeye are highly contagious, your doctor may suggest staying home until there is no discharge from the eye(s) or until symptoms improve. This can take 3-5 days. For many children, most schools require that students should be receiving 24 hours of antibiotics before returning to school for bacterial pinkeye.

How can you avoid getting conjunctivitis?

Adults or children with bacterial or viral pinkeye should not share handkerchiefs, tissues, towels, cosmetics, silverware, or bed sheets/pillows with uninfected family or friends. In the summertime, pinkeye can be avoided by not allowing kids to swim in contaminated water or to share contaminated towels.

Hand washing is an important way to prevent the spread of infection. Hands should be wet with water and soap, then rubbed together for 15 to 30 seconds. Teach children to wash their hands before and after eating and after touching their eyes, coughing, or sneezing.

The best way to avoid allergic pink eye is to avoid exposure to the allergen, such as pollen or pet hair.

References:

Jacobs DS. Patient information: conjunctivitis (pinkeye). Available at URL: http://www.uptodate.com/online/content/topic.do?topicKey=eye_heal/2971&selectedTitle=3%7E150&source=search_result Accessed March 18, 2011.

American Academy of Ophthalmology. Viral conjunctivitis. Available at URL: http://www.aao.org/theeyeshaveit/red-eye/viral-conjunctivitis.cfm. Accessed March 18, 2011.

American Academy of Ophthalmology. Allergic conjunctivitis. Available at URL: http://www.aao.org/theeyeshaveit/red-eye/allergic-conjunctivitis.cfm. Accessed March 18, 2011.

American Academy of Ophthalmology. Bacterial conjunctivitis. Available at URL: http://www.aao.org/theeyeshaveit/red-eye/bacterial-conjunctivitis.cfm. Accessed March 17, 2011.

American Optometric Association. Conjunctivitis. Available at URL: http://www.aoa.org/conjunctivitis.xml. Accessed March 18, 2011.

Mayo Clinic. Pink eye. Available at URL: http://www.mayoclinic.com/health/pink-eye/DS00258. Accessed March 17, 2011.

18-Mar-11 3:00 AM

What Parents Should Know About Prevnar 13

Thu, 17 Mar 2011 13:00:00 GMT

What is Prevnar 13?

Prevnar 13 (Pneumococcal Conjugate Vaccine 13) is a new vaccine that has been approved by the Food and Drug Administration (FDA). The vaccine prevents infections caused by 13 of the most common types of bacteria called Streptococcus pneumoniae that can cause serious infections in children. Children 2 months to 5 years-old should get this vaccine during their well-child visits.

What is so special about S. pneumoniae?

There are over 90 types of S. pneumoniae. This bacteria can cause serious childhood infections, including blood infection (bacteremia), lung infection (pneumonia), and infections around the brain (meningitis). S. pneumoniae infections can be spread by direct contact or air particles. Young children under the age of 5 are more likely to get serious infections from this bacteria than healthy adults. Some infections can lead to deafness, brain damage, and, in rare cases, death. The Centers for Disease Control (CDC) recommends that all children between between 2 and 59 months of age receive this new vaccine, Prevnar 13, in order to protect them against this bacteria. Older children with certain underlying health conditions are also recommended to receive Prevnar 13.

Prevnar 13 vs. Prevnar 7 - what's the difference?

The number after the name Prevnar indicates the number of types of S. pneumoniae contained in the particular vaccine. Prevnar 7 was the first pneumococcal vaccine that became available in the year 2000. Children who have received the Prevnar 7 vaccine are protected against 7 types of S. pneumoniae that are included in the vaccine. In fact, the number of cases of serious infections caused by S. pneumoniae has dropped by almost 80% in children under 5. Prevnar 13 now replaces Prevnar 7. It has six additional types of S. pneumoniae than Prevnar 7. While it does not protect against all types of S. pneumoniae, Prevnar 13 will work against the 13 types contained in the vaccine.

Who should be vaccinated with Prevnar 13?

Prevnar 13 is recommended for all infants at ages 2 months, 4 months, 6 months, and between 12 and 15 months. A complete series is made up of 4 doses of Prevnar 13. If your child is over 12 months old and has not received the doses of Prevnar 13 during the recommended time frame, your child's doctor will help your child get caught up. Since children are frequently exposed to this bacteria, it is important to make sure your child is fully vaccinated. The total number of doses depends on the child's current age. The updated immunization schedule for children is available from the CDC. Table 1 explains the number of doses of Prevnar 13 children should receive if they started on Prevnar 7 and have not completed the series, yet.

When is Prevnar 13 appropriate for older children?

Is Prevnar 13 safe?

Yes, Prevnar 13 is as safe as Prevnar 7. Prevnar 7 has been given to children since it was available in 2000. The vaccine's side effects are well known. The most common side effects are mild and will go away on their own with time. They include: pain, swelling, tenderness, and/or redness where the shot was given. Decreased appetite, fever, irritability, and increased or decreased amount of sleep may be seen. Make sure you report other side effects to your child's doctor.

Where can I find more information?

For more information about the Prevnar vaccine, download the CDC's vaccine information sheet on Prevnar 13.

References:

CDC. Prevnar 13 (Pneumococcal conjugate vaccine 13) Vaccine Information Sheet (VIS). Accessed March 17, 2011.

CDC. Licensure of a 13-Valent Pneumococcal Conjugate Vaccine (PCV13) and Recommendations for Use Among Children --- Advisory Committee on Immunization Practices (ACIP), 2010, Morbidity and Mortality Weekly Report (MMWR); 59(09): 258-261. March 12, 2010. Accessed March 17, 20011.

CDC. PCV13 (Pneumococcal Conjugate Vaccine) for parents. Accessed March 17, 2011.

17-Mar-11 8:00 AM

Respiratory Syncytial Virus - Not Always Just a Cold

Mon, 21 Feb 2011 22:00:00 GMT

What is respiratory syncytial virus (RSV)?

RSV is a virus that causes colds in people of all ages. However, RSV can cause a serious lung infection in infants and young children. Most children will get RSV by the age of three. RSV is most common during the winter months.

How can my child get RSV?

RSV, like other cold viruses, is easy to spread to other people by touching, kissing, and shaking hands. Sometimes it can be spread by close contact with a person who is sneezing or coughing or touching things that have RSV on them. The most common way to spread RSV is by hand contact. People “catch” RSV from other people who have colds caused by RSV.

Who is at risk?

Premature infants born more than 4 weeks early
Low birth weight babies
Babies with chronic lung disease
Babies with serious heart disease
Babies with severe neuromuscular disease
Infants who attend daycare
Infants exposed to smoke
Family history of asthma
Infants who live with school age siblings
Infants who cannot fight infections well

What are the Symptoms of RSV?

Runny nose
Cough
Fussiness
Your child may seem very tired, less active
Your child may not want to eat
Loud or fast breathing
Wheezing (a tight whistling or musical sound heard when your child breathes)
Your child’s chest sinks in with each breath
Low grade fever (in some children)
Difficulty breathing, gasping for breath

Why is respiratory syncytial virus (RSV) a concern?

Worsening symptoms can lead to severe lung infections, and may become life threatening.

How can I prevent my child from getting RSV?

There are two ways to help prevent your child from getting RSV:

1. Take everyday steps to prevent the spread of RSV, especially good hand washing;

Wash your hands before touching your baby
Ask other people to wash their hands before touching your baby
Wash hands with soap and water or alcohol-based rub
Keep your baby away from crowds
Keep your baby away from people with colds
Wash your baby’s toys and bedding often
Keep your baby away from cigarette smoke

2. A medication called palivizumab (Synagis®) is recommended for babies at high risk for RSV. It is usually given monthly during the RSV season (late fall through spring). It is not a vaccine, but it can help your baby’s immune system fight against the virus.

What is palivizumab (Synagis®)?

Some high-risk children under the age of 24 months may benefit from palivizumab, which is a medicine to help prevent RSV infections and is given as a shot into the baby’s thigh muscle. Each dose helps build the body’s immune system to fight viral infections caused by RSV for about one month. It is usually given in 1-5 monthly shots, depending on your child’s age during the RSV season. It is important that your child gets all the required doses.

How do I know my child has RSV?

It is sometimes hard to know whether your child has RSV because it can look like other infections. Illness in other family members or the time of the year may provide clues. Symptoms also differ with age. Babies under one have the most trouble breathing. If you notice a bluish skin color (not enough oxygen), difficulty breathing or labored breathing, coughing, fever, nasal flaring, fast breathing, shortness of breath, stuffy nose, or wheezing in a baby, contact the doctor. Your doctor may examine your child and also test your baby’s nose drainage to see if RSV is present. Older children may just look like they have a mild cold.

What do I do if my child gets RSV?

Make sure your baby gets enough fluids to drink
Keep your baby’s nose clean using a bulb syringe
If you are concerned, call your doctor

How is RSV Treated?

Most children get better without medical treatment. Some children, especially newborns, premature infants or infants with heart or lung problems can be sicker and may need to be hospitalized. In the hospital, your child will be watched closely. Because a virus causes the illness, antibiotics will not be useful. Some children may need oxygen, breathing treatments, medicine for fever, or fluids by IV.

Can my child get RSV again?

Yes, your child can get RSV again, but most likely it will be milder than the first time.

References:

Redbook Online. Respiratory syncytial virus. Accessed on 10/13/10
American Academy of Pediatrics. Diagnosis and management of bronchiolitis. Pediatrics 2006; 118(4): 1774-1793.
A.D.A.M. Respiratory syncytial virus. http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0002531. Accessed on 02/21/11.

21-Feb-11 4:00 PM

FAQ About the Flu and Flu Vaccine

Tara Smith - noemail@kidsmeds.info — Wed, 02 Feb 2011 12:00:00 GMT

Why is it important to get a flu vaccine every year?

The flu illness is caused by a virus. The flu vaccine contains three types of influenza viruses. It is updated every year to match the specific types of the flu virus that people are getting sick with. It is important to get the current vaccine each year to protect you and your child against the type of virus that is most likely to cause the flu illness this year.

Why do some children need 2 flu vaccines and others only need vaccine?

Children ages 6 months to 8 years will need 2 doses of the flu vaccine if they are getting the flu vaccine for the first time. The first dose will help the body’s immune system get ready to fight the flu. The second dose provides the full protection against the flu viruses. Only one dose is needed every year after. Children over the age of 8 have a stronger immune defense system and only need one dose of flu vaccine every year.

Do we need to get a separate vaccine for the H1N1 flu this year?

No. The flu vaccine for 2010-2011 protects against the seasonal and H1N1 strain of the flu virus because it is included in the vaccine.

Can the nasal spray flu vaccine cause someone to get the flu?

No. The flu vaccine in the form of a nasal spray is a weakened virus even though it is a live vaccine. The weakened virus cannot live long enough to make someone sick. The nasal spray flu vaccine will provide the same protection against the flu as the flu shot.

Is it every too early or too late to get the flu vaccine?

You should try to get the vaccine each fall as soon as it is available. The vaccine should not wear off before the end of flu season. Getting the vaccine as early as September or October is okay.

If you do not get the vaccine before the end of December, it is not too late. You should try to get it when you can. It is better to have protection against the flu, even late in the season.

Do you have a question about the flu virus or flu vaccines? Please leave a comment below or contact us via the form on the left of this web page.

2-Feb-11 6:00 AM

A Closer Look at Pertussis (Whooping Cough)

Swarupa Pisupati - noemail@kidsmeds.info — Tue, 18 Jan 2011 15:00:00 GMT

What is Pertussis (whooping cough)?

Pertussis is also known as whooping cough. It is an infection affecting the respiratory system. The respiratory tract includes the parts of the body that help you breathe.

What causes the Pertussis infection?
Pertussis is caused by the bacteria, Bordetella pertussis.

How is it transmitted?
Pertussis is spread when the pertussis bacteria is sneezed or coughed into the air and a close contact breathes it in. Most babies and unvaccinated children get pertussis from infected teenagers and adults.

Is it contagious?
Yes. Pertussis is extremely contagious. People who have the infection will be very contagious for about 21 days after the onset of symptoms. If you or your child is suspected of having pertussis, seek medical care promptly to get started on antibiotics. Close contacts should also be treated with antibiotics as a precaution.

What are some signs/symptoms?
Pertussis is a serious disease that should not be taken lightly. It can make you very sick, and in rare cases may even lead to death, especially in babies. The incubation period is commonly 7-10 days. This means that signs and symptoms may take a week to begin. There are three stages of pertussis infection. Here is a list of signs and symptoms that a person with pertussis may experience:

The First Stage (Catarrhal Stage) can last about 1-2 weeks. Presentation includes:
    •    Slow onset of runny nose
    •    Sneezing
    •    Mild fever
    •    Occasional cough that becomes more severe

The Second Stage (Paroxysmal Stage) can last 1-6 weeks, but may continue up to 10 weeks. Signs and symptoms include:
    •    Bursts of numerous, rapid coughs that may or may not sound like a high-pitched "whoop"
    •    Take a listen to what pertussis (whooping cough) sounds like: http://health.utah.gov/epi/diseases/pertussis/pertussis_sounds.htm
    •    Vomiting
    •    Exhaustion

The Third Stage (Convalescent or Recovery Stage)
    •    Fewer bursts of coughing that gradually disappears in 2-3 weeks

What are some treatment options?
Most young infants will need to be hospitalized if they are suspected of having pertussis. All patients will receive antibiotics (azithromycin, erythromycin, sulfamethoxazole/trimethoprim) that may decrease duration of symptoms and limit the spread of pertussis. Additionally, appropriate rest and fluids are recommended. Since many of the signs and symptoms of pertussis are similar to other diseases like the common cold, it is very easy for the disease to be overlooked. It’s always important to remember that prevention is the best option. All persons in close contact with the patient with pertussis should also receive antibiotics to prevent disease. When in doubt, be sure to call the doctor to check it out.

What are options for prevention?
Immunization is the best option available for prevention. Depending on age, several vaccines are available for use based on the person's age. See Table 1. DTaP (combination of diphtheria, tetanus, and acellular pertussis toxoids) and Tdap (tetanus, diphtheria, and acellular pertussis toxoids). DTaP is given as a routine childhood vaccination, while Tdap is given as a booster shot for adolescents and adults. In cases of outbreaks, these vaccines may be suggested for older or younger persons. By giving Tdap, the patient gets a full dose of tetanus, and a smaller dose of diphtheria and pertussis than that given to younger children to help protect your body from getting pertussis or diphtheria.

Table 1: Available Pertussis Vaccines


DTaP	for children 6 weeks through 6 years of age
Tdap	for adolescents and adults
Boostrix®	minimum age 10 years
Adacel®	minimum age is 11 year

Why is it important for adults to get a booster shot for pertussis?
Vaccinations have always played a major role in the prevention of many infections diseases, including pertussis. This has led to a dramatic decrease in the number of annual cases of pertussis reported. In recent years, however, there has been a rise in the amount of pertussis outbreaks in daycare, school, and hospital settings - making vaccinations a must. Between January - August 2010, over 3,000 cases have been reported in California alone. See Table 2. This is a huge increase from the 434 cases reported during the same time period in 2009. Other states, including Michigan, have reported similar trends.

Table 2: Impact of Pertussis Vaccination
Time Period	Incidence of Pertussis
Pre-Vaccination Era	200, 000 cases/year
Post-Vaccination Era	1, 010 cases/year
2005	25, 000 cases/year

Additionally, according to the Centers for Disease Control (CDC), the number of pertussis cases involving adolescents and adults has jumped from 24% to a staggering 56%. This jump points toward the overwhelming need for vaccination among adults and adolescents. See Figure 1. In 2005, the Tdap vaccine (Tetanus, Diphtheria, and Acellular Pertussis Vaccine) was introduced to help in the fight against pertussis. Unlike the previous pertussis vaccines, the Tdap vaccine is approved for use in those greater than 7 years of age – allowing for vaccination among adults and adolescents. Talk to your doctor or pharmacist today about Tdap to help protect you and your family from pertussis.

Figure 1: Data from the CDC

Table 3: CDC Recommendations for Tdap
Age	Recommendations
*Children (7-10 years)	Those not fully vaccinated against pertussis and have no contraindication to pertussis vaccine should receive a single dose of Tdap. Children who have never been vaccinated against tetanus, diphtheria, or pertussis or who have unknown vaccination status should receive a series of three vaccinations containing tetanus and diphtheria toxoids. The first 3 doses should be Tdap. A fully vaccinated child has had 5 doses of DTaP or 4 doses of DTaP if the fourth dose was given on or after the 4th birthday.
Adolescents (11-18 years)	Adolescents who received DTaP as kids and need a booster dose of Td (For those individuals, one booster dose of Td should be substituted with one dose of Tdap.) Adolescents should receive Tdap at the 11-12 year-old well-child visit. Adolescents who received their booster dose of Td should still get vaccinated with Tdap. In most cases, it is suggested to wait five years from his/her last Td to get a dose of Tdap, but can be administered regardless of interval since the last tetanus- or diphtheria-toxoid containing vaccine.* Adolescents who did not complete the DTaP series should finish the series with Tdap and Td.
Adults (19-64 years)	New mothers who have never been administered Tdap should get a dose of Tdap soon after giving birth. It is not contraindicated in pregnancy, and in areas where pertussis is known to be prevalent, it may be recommended during pregnancy. It is important to remember that although there has been a rise in pertussis cases among adolescents and adults, the CDC reports that 38 out of 39 pertussis-related deaths in 2005 occurred in infants. Vaccinating new mothers and direct caregivers of infants will help reduce the risk of passing on the infection. Any adult less than 65 years of age who cares for an infant under 12 months of age should get vaccinated with Tdap Health care employees less than 65 years of age involved in direct patient care Any adult who has never received Tdap and requires a booster of Td. Remember that booster doses with Td are required every 10 years. These individuals can substitute one Td booster with one dose of Tdap. For adult patients requiring Tdap, a minimum separation of 2 years between Td and Tdap is suggested, but not required.
Other Ages	Although not currently approved by the Food and Drug Administration (FDA), during times of outbreaks (such as the case in California in 2010), local Departments of Health may suggest administering a pertussis-containing vaccine to older or younger aged patients than stated on the vaccine label.

*new recommendations from the CDC

What are some known side effects of the pertussis vaccines?

Possible side effects of the Tdap vaccine include:

Pain and redness at the injection site
Fever
Headache
Nausea
Vomiting
Diarrhea
Stomachache
Tiredness
Body aches, chills, rash, and swollen glands

Where can I find more information?

http://www.cdc.gov/pertussis/outbreaks-faqs.html
http://www.immunize.org/pertussis/
http://www.soundsofpertussis.com/
Listen to a pertussis cough: http://health.utah.gov/epi/diseases/pertussis/pertussis_sounds.htm

Additional References:

Brown K. The Centers for Disease Control. www.cdc.gov/pertussis. Updated August 10, 2009. Accessed August 20, 2010.
Immunization Action Coalition. http://www.vaccineinformation.org/pertuss/qandadis.asp. Updated February 2009. Accessed August 20, 2010.
The Centers for Disease Control. http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5104a1.htm#fig1. Updated February 2002. Accessed August 20, 2010.
Appendix A: Summary of Recommendations for Tetanus Toxoid, Reduced Diphtheria Toxoid and Acellular Pertussis. http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5517a2.htm
MMWR. Updated Recommendations for Use of Tetanus Toxoid, Reduced Diphtheria Toxoid and Acellular Pertussis (Tdap) Vaccine from the Advisory Committee on Immunization Practices, 2010. January 14, 2011/60(01);13-15.

18-Jan-11 9:00 AM

Controlling Your Child's Asthma

Ruth Kurland - noemail@kidsmeds.info — Mon, 11 Oct 2010 04:00:00 GMT

What is asthma?

Asthma is a chronic inflammatory condition of the airways. Inflammation, or swelling, of the airways causes repeated episodes of wheezing, breathlessness, chest tightness, and coughing. The swelling causes the airways to react too much in response to various irritants, such as exercise and cold air. When the airways react to the irritants, they can narrow and tighten up suddenly, which is otherwise known as an “asthma attack”. An asthma attack is usually reversible by itself or with medicine.

http://www.nhlbi.nih.gov/health/dci/Diseases/Asthma/Asthma_WhatIs.html

What causes asthma?

The exact cause of asthma is unknown. However, asthma is understood to be a combination of genetics and the environment. Environmental factors include allergens, pollution, and infection.

Who is affected by asthma?

Asthma affects both children and adults, but it usually starts during childhood. Among children, asthma is more common among males, and by puberty it is more common among females.

When should I take my child to the doctor?

If your child is experiencing symptoms of asthma, such as wheezing, breathlessness, chest tightness or coughing, bring your child to the doctor. If your doctor suspects that your child has asthma, a spirometry test will be performed, which tests lung function. Spirometry testing is only performed in children five years and older. The diagnosis of asthma will be based on a physical exam, medical history, and results of spirometry testing, and is classified by severity, ranging from “intermittent asthma” to “severe persistent asthma”. “Intermittent asthma” is the least severe level of asthma and “severe persistent asthma” is the most severe level of asthma.

How is asthma treated?

Treatment of asthma is based on how severe the symptoms are and how often they occur. There are two parts to asthma treatment. The first part, which applies to all levels of asthma severity, is to control environmental factors that may affect asthma. This includes avoidance of allergen exposure and avoidance of cigarette smoke and wood smoke, such as the fireplace.

The second part of asthma treatment, which varies based on severity and frequency of symptoms, is medicine. There are two main categories of asthma medicines: those that are used daily for long-term control and those that are used on an as needed basis for quick relief.

Medicines that are usually used for long-term control include inhaled corticosteroids, such as fluticasone (Flovent^®), budesonide (Pulmicort^®), and mometasone (Asmanex^®). If your child requires more medicine to control his or her symptoms, a combination of an inhaled corticosteroid with another inhaled medicine, called a “long acting beta agonist”, will be given for long term therapy. Products that combine the two inhaled medicines are available, such as fluticasone/salmeterol (Advair^®) and budesonide/formoterol (Symbicort^®). Another long-term medicine that may be given with an inhaled corticosteroid is montelukast (Singular^®). Montelukast is an oral medicine and is available in a chewable form that makes it easier for children to take.

Medicines that are used only during an asthma attack are inhaled albuterol (Proventil^®), pirbuterol (Maxair^®) and levalbuterol (Xopenex^®).

An action plan between you and your child’s doctor should be created to tell you exactly how to treat your child’s asthma with the methods above in a long term plan and what to do during an asthma attack.

About inhaled asthma medicines:

Inhaled medicines that are used for asthma come in three forms: metered dose inhalers (MDI) with spacers, dry powder inhalers (DPI), and nebulizers. There are different methods for properly using each form. For photos of inhalers, click here.

Metered Dose Inhalers (MDI):

Medicines that are available as an MDI consist of the rescue medicine, albuterol (Proventil^®), several inhaled corticosteroids, including fluticasone (Flovent^®), flunisolide (Aerobid^®), and triamcinolone (Azmacort®), and the combination product budesonide/formoterol (Symbicort^®). Inhaled corticosteroids can cause oral fungal infections and hoarse voice. Therefore, your child should rinse out his or her mouth after taking the medicine. Using a spacer, a device that is attached to the mouthpiece of the MDI, can decrease the risk of these side effects. A spacer is also helpful if your child has difficulty breathing properly while pressing down on the inhaler.

How to use an MDI:

1. Remove the cap from the mouthpiece

2. Shake inhaler while holding it upright

3. Breathe out all the way

4. Place mouth on mouthpiece of the spacer

5. While inhaling slowly, press down on the inhaler, and continue inhaling slowly

6. Hold breath for ten seconds

7. Breath out slowly and breath at a normal pace

More about spacers:

Spacers, also called holding chambers, will make it easier for your child to breathe the medicine in when using an MDI. Spacers should be used with inhalers containing steroids. After your child presses down on the inhaler, the medicine stays in the spacer, giving your child more time to breathe in the dose. The spacer is prescribed by your child’s physician together with the MDI your child will be using. The Aerochamber^® is a spacer that is commonly used and is available in three sizes. Like other spacers, the Aerochamber^® is available with a mask attached to the mouthpiece which makes it even easier for your child to breathe in the medicine. To attach the spacer to the MDI, remove the cap of the MDI and insert it into the back of the spacer. For pictures of spacers with MDI's attached, click here .

Dry Powder Inhalers (DPI):

Medicines that are available as a DPI include inhaled corticosteroids and combination products of inhaled corticosteroids and long acting beta agonists, such as budesonide (Pulmicort Flexhaler^®), mometasone (Asmanex Twisthaler^®), fluticasone (Flovent Diskus^®) and fluticasone/salmeterol (Advair Diskus^®). Spacers and holding chambers cannot be used with a DPI so it may be difficult for children to use. Do not shake or tilt the DPI after activating a dose. After using a DPI that contains a corticosteroid, rinse your child's mouth out to decrease the risk of local side effects, including developing thrush.

How to use a DPI:

Pulmicort Flexhaler^®

1. Hold the inhaler upright and twist off the cover

2. Turn the brown piece as far as it will go in one direction and then as far as it will go in the other direction (it does not matter which direction you turn it first)

3. Breathe out

4. Place mouth on mouthpiece and inhale deeply and quickly

6. Remove inhaler from mouth and breathe out

Asmanex Twisthaler^®

1. Hold inhaler upright

2. Twist cap open and remove cap

3. Breathe out

4. Place mouth on mouthpiece and inhale deeply and quickly

5. Remove inhaler from mouth, hold breath for ten seconds, and breathe out

6. Replace cap and twist it closed until you hear it click

Advair Diskus®

1. Place thumb on thumb grip and push your thumb away from you so that you can uncover the lever

2. Slide the lever until you hear it click

3. Breathe out while holding the inhaler away from the mouth

4. Place mouth on mouthpiece and inhale deeply and quickly

5. Remove inhaler from the mouth, hold breath for ten seconds and breathe out

Nebulizers:

The most common medicines that will be used as a nebulizer are albuterol (Proventil®) and levalbuterol (Xopenex^®) for rescue treatment, and budesonide (Pulmicort Respules®) for daily treatment. Nebulizers are easy for children to use because they do not require coordinated breathing techniques. Children may have difficulty keeping the mouthpiece in for several minutes, so a mask can be attached to the mouthpiece for easier use. The medicine does not reach your child's lungs if the tube is just held near the child's face. The mouthpiece or mask must be used properly in order for your child to receive the full treatment delivered by the nebulizer.

How to use a nebulizer:

1. Connect the hose to the nebulizer machine

2. Fill the medicine cup with medicine

3. Attach the hose and mouthpiece to the medicine cup

4. Place the mouthpiece in your mouth and breathe through your mouth until you no longer see medicine in the cup (about fifteen minutes)

Peak Flow Meters:

In addition to controlling environmental factors and using medicines, continuously measuring your child’s asthma severity is an important factor in asthma management. Peak flow meters assign a number that measures how well your child’s asthma is controlled. When your child’s asthma is well controlled, use a peak flow meter to find your child’s “personal best”. To find your child’s personal best, take his or her peak flow daily for two to three weeks anytime between noon and 2:00 pm. The highest number that you get during those two to three weeks is your child’s personal best. This value will be different from person to person. Once you know your child’s personal best, your child should use the peak flow meter every morning before asthma medicine is taken. In your child’s asthma action plan, recommendations will be based on the peak flow reading you get compared to your child’s personal best.

How to use a peak flow meter:

1. Move the red marker to the bottom of the meter

2. Stand up and take a deep breath.

3. Hold breath while you place the mouthpiece in between the teeth

4. Seal lips around the mouth piece

5. Blow out as hard and as fast as possible

6. Record the number you see

7. Repeat two more times

8. The highest number of the three is your child's peak flow number

Important Tips to Remember:

· Inhaled corticosteroids and long acting beta agonists are for daily use

· Albuterol, pirbuterol and levalbuterol are rescue medicines and should not be used daily

· If you child consistently needs to use rescue medicines, their primary care provider should be notified

· Rinse your child’s mouth out after using an inhaled corticosteroid

· Breathe slowly when using an MDI and breathe quickly when using a DPI

References:

Expert Panel Report 3: Guidelines for the Diagnosis and Treatment of Asthma. National Asthma Education and Prevention Program: National Institute of Health. August 2007. Available at http://www.nhlbi.nih.gov/guidelines/asthma/index.htm. Accessed July 30, 2010.

National Heart Lung and Blood Institute Diseases and Conditions Index: Asthma. National Institute of Health. September 2008. Available at http://www.nhlbi.nih.gov/health/dci/Diseases/Asthma/Asthma_WhatIs.html. Accessed 2010 July 30.

Using Your Inhaler: Demo. Schering-Plough. Available at http://www.proventilhfa.com/phfa/application?namespace=main&event=content_display&event_input=using_your_inhaler. Accessed 2010 July 30.

How to Get Started Using Your Pulmicort Flexhaler®. AstraZeneca. January 2008. Available at http://www.pulmicortflexhaler.com/flexhaler/resources/PULMICORTFLEXHALER.pdf. Accessed 2010 July 30.

Instructions for Using Asmanex®. Schering-Plough. Available at http://www.asmanex.com/asmanex/application?namespace=main&event=content_display&event_input=how_to_use_asmanex. Accessed 2010 July 30.

Using Advair Diskus®. GlaxoSmithKline. Available at http://www.advair.com/copd/If-you-are-taking-advair/using-the-advair-diskus.html. Accessed 2010 Jan 29 (site currently being updated as of July 30, 2010.

How to Use a Nebulizer. MedlinePlus Encyclopedia. October 2008. Available at http://www.nlm.nih.gov/medlineplus/ency/patientinstructions/000006.htm. Accessed 2010 July 30.

How to Use Your Peak Flow Meter. MedlinePlus Encyclopedia. October 2008. Available at http://www.nlm.nih.gov/medlineplus/ency/patientinstructions/000043.htm. Accessed 2010 July 30.

10-Oct-10 11:00 PM

What is Swimmer's Ear (Otitis Externa)?

Jenny Boucher - noemail@kidsmeds.info — Fri, 30 Jul 2010 05:00:00 GMT

What is Swimmer's Ear?

"Swimmer's Ear" refers to an infection of the canal that connects the outside of the ear with the inside of the ear. Normally this passageway is dry and slightly acidic so germs do not grow there. Swimmer's Ear happens when bacteria (Pseudomonas aeruginosa) or fungi have a chance to grow in the canal. This causes pain and swelling of the ear. Cleaning the ear and applying ear drops is usually needed to treat Swimmer’s Ear.

Figure 1. Anatomy of the ear.

Who is affected by Swimmer's Ear?

Swimmer's Ear can occur at any age, but is most common in school-aged children. In fact children get Swimmer's Ear most frequently between 7-12 years of age. This infection is nicknamed Swimmer’s Ear because swimmers get this ear infection much more often than non-swimmers.

What causes Swimmer's Ear?

When contaminated water stays inside the ear canal after swimming, several things can happen that can lead to an infection. The water can wash away the earwax that is usually in the canal to help keep out objects. The water changes the normally dry, acidic skin in the area. The ear canal is also warm and dark. All of these things allow for bacteria to grow in the ear canal.

What increases the risk of Swimmer's Ear?

Conditions that may break down the natural defenses in the ear include:

- When the ear stays moist or wet or keeps getting wet repeatedly - The presence of moisture or water can change the acidity that would help keep bacteria from growing. This happens in swimmers when the inside of the ear stays wet for long periods of time. The surface of the skin becomes irritated, allowing bacteria to grow rapidly in the ear canal.

- When cleaning or scratching the inside of the ear causes breaks or cuts in the skin - This lets bacteria get into the skin and cause an infection.

- Overuse of devices for the ear – Using earphones or hearing aids that do not fit properly and rub the skin can cause irritation.

- Certain skin conditions, like eczema, psoriasis, or even acne - These conditions can cause cuts in the skin.

How can I tell if my child has Swimmer's Ear?

Initial symptoms may be mild to severe. These usually include:

- Itching in and around the ear

- Pain or discomfort in and around the ear

- Small amounts of clear liquid is in or draining from the ear

As the infection gets worse, the symptoms may include:

- Pain when touching or pulling on the ear

- Large amounts of fluid (white or yellow) draining from the ear

- Temporary hearing loss as the ear canal swells up

- A feeling of pressure in the ear

If the infection is severe, other possible symptoms include:

- Severe pain

- Redness around the ear, face, or neck

- Dizziness

- Fever

How is Swimmer's Ear treated?

Treatment starts with cleansing of the ear canal by the doctor. Debris is usually removed with a small device. The ear canal is then rinsed with a cleaning solution like hydrogen peroxide diluted with water. One or more kinds of topical ear drops may be placed in the ear canal as part of the treatment. Try to have your child stay away from water sports for at least 7 to 10 days. If your child is a competitive swimmer, she may be allowed to return after two-three days of antibiotic treatment. Check with the doctor first. Well-fitted earplugs may also be needed.

If Swimmer’s Ear is caused by bacteria, the doctor will prescribe an antibiotic ear drop to kill the bacteria causing the infection. Examples are tobramycin or ofloxacin. Sometimes other drops may also be included in your child’s treatment, such as a steroid to help with the pain and swelling. Dexamethasone, hydrocortisone, and prednisolone are examples of steroid ear drops. The doctor may also prescribe an ear drop with acetic acid to restore the acidity of the canal. Products that combine one or more of these ingredients are available to make treatment less of a hassle.

If there is a lot of swelling in the ear canal, the doctor may use something known as a "wick". A wick is a small cotton sponge filled with medicine that is put inside the ear canal so that the antibiotic can reach the skin.

An antibiotic to take by mouth may be required if your child has a serious infection or is at risk for more severe infections. Sometimes the infection takes longer than usual to heal. This is another reason to start an antibiotic by mouth. Make sure your child finishes the course of antibiotics.

Acetaminophen (Tylenol^®) or ibuprofen (Motrin^® or Advil^®) can help with the initial pain. The condition(s) that led to the infection should be avoided to allow for healing and preventing the infection from coming back.

When should I take my child to the doctor?

If a Swimmer's Ear infection is suspected, consult a doctor for treatment. Some people are at a higher risk of having a more severe form of Swimmer's Ear infection. People who have diabetes or any other condition that causes them to have a lower immune response are at risk for getting Swimmer’s Ear. These conditions delay the speed and process of healing. These children may need additional treatment. Also, some infections may spread into deeper tissues, even to the bone. Serious infections like these will also require more treatment than the topical ear drops.

If you suspect that any of these conditions exist, contact your child’s doctor immediately. Sometimes a concentrated infected area, also called an abscess, may form. The abscess may need to be opened and drained, Doing this will help to relieve the pain and allow for faster healing. For complicated infections, a long course of antibiotics either taken by mouth or through an I.V. (intravenous) may be necessary.

A child under 2 years old with a respiratory infection and a fever should also be brought to the doctor to make sure it is not a middle ear infection (otitis media).

How can I prevent Swimmer's Ear in my child?

Some great tips to avoid getting Swimmer’s Ear again or for the first time can be found at the CDC’s website and other resources. Here are KidsMeds’ favorites:

· Avoid getting water in the ears when bathing or swimming.

· Use cotton with petroleum jelly, earplugs, or tight-fitting bathing caps when swimming.

· Dry the ear canal after bathing or swimming by wiping the outside of the ear thoroughly.

· Tipping the head can help drain water from the ear.

· Using a hair dryer on the lowest heat setting can also work.

· Alcohol-based ear drops or other drops, such as aluminum acetate drops (Burow's Solution), may also be used to dry the ears after bathing or swimming. Check with your child’s doctor first, since these may be irritating to the infected ear. Ask the pharmacist to help you find these products.

· Acetic acid drops may be used to try to return the ear canal to the normal acidic environment there.

· Avoid using hairpins, fingernails, or cotton swabs. These may scratch the inside of the ear.

- Beware of polluted locations; do not swim in those areas.

References:

Otitis Externa, Swimmer's Ear. URL: http://www.fpnotebook.com/ENT/Ear/ActOtsExtrn.htm (Accessed July 29, 2010)

http://www.uptodate.com/online/content/topic.do?topicKey=pc_id/2947 (Accessed April 2009)

Waltzman AA. Otitis Externa. URL: http://www.medscape.com/article/994550-overview (Accessed July 29, 2010)

Mayo Clinic Staff. Swimmer's ear. URL: http://www.mayoclinic.com/health/swimmers-ear/DS00473/METHOD=print (Accessed July 29, 2010)

Swimmer's Ear - Otitis Externa. URL: http://www.cdc.gov/healthyswimming/swimmers_ear.htm (Accessed July 29, 2010)

Swimmer’s ear. (Figure 1 URL: http://www.mdconsult.com/das/patient/body/157391184-2/0/10041/35116.html (Accessed July 29, 2010)

30-Jul-10 0:00 AM

Allergies Can Be Serious

Catherine Revzon - noemail@kidsmeds.info — Wed, 14 Jul 2010 15:00:00 GMT

What are allergies?

An allergy is a reaction of the protective immune system of your child’s body in response to something that does not usually bother other people. Certain substances, situations, or physical situations can cause this reaction. These irritants can be found indoors or outdoors. An allergy is also called hypersensitivity. Some allergic reactions need immediate attention.

What do I look for to see if my child has allergies?

Each child can show different signs and symptoms of allergies. However, common signs are itchy, watery eyes, itchy nose, sneezing, runny nose, itchy throat, congestion, rashes, or even trouble breathing. Congestion can lead to “allergic shiners” (which are dark circles under the eyes). The “allergic salute” (rubbing the nose upward because it is itchy) is also common in children. This leaves a small crease in the skin of the lower part of the nose. These signs and symptoms may occur during certain times of the year (seasonal allergies), may be constant (perennial allergies), or may show up after your child eats certain foods or is exposed to certain physical situations

How did my child get these allergies?

Allergies may be passed from parent to child through genetics. They may also be caused by exposure to certain substances that your child’s body thinks is a germ. The immune system normally fights germs. However, the defense system is responding to a false alarm in most allergic reactions. Common triggers include: pollen, mold, pet dander, dust mites, cockroaches, cigarette smoke, viruses, bacteria, insect stings, certain foods, medicines, chemicals, and plants.

What is considered a serious allergic reaction?

Although it is not common in the general population, children with severe allergies to insect bites and stings, foods, or certain medications or vaccines can be at risk for anaphylaxis. Anaphylaxis is a sudden, potentially life-threatening allergic reaction. This is a serious reaction that may affect the skin, gastrointestinal system, respiratory system, and / or cardiovascular system. It is considered a medical emergency if two or more of the systems are affected. Common signs and symptoms of anaphylaxis include difficulty breathing, tightness in the throat (feels like airways are closing up on themselves), hoarseness or trouble speaking, wheezing, nasal stuffiness and coughing, nausea, abdominal pain or vomiting, fast heartbeat or pulse, skin itching, tingling, redness, or swelling,

How do I manage my child’s allergies?

To prevent or treat these reactions, make a dedicated effort to avoid the triggers, using allergy medications, or take your child to an allergist. Your child may benefit from allergy shots. For anaphylaxic reactions, use an epinephrine pen (Epi-pen® or Epi-pen Jr®, prescribed by your primary care provider) and call 911.

First, try keeping your child away from things that cause him/her to have allergic reactions. Allergy-proof your house. Here are some tips:

A completely smoke-free environment is best for your child. Even smoking outside or in one particular room is not enough as smoke residue clings to EVERYTHING, including clothing, skin, hair, etc.
Wear a pollen mask when mowing the lawn or cleaning the house—to avoid pollen exposure
Stay indoors in the morning time because this is when the pollen in the air is high—to avoid pollen exposure
Keep windows and doors closed during pollination season—to avoid pollen exposure.

Listen to the local weather report, usually it will tell you when a pollen count outside will be high. You can also check www.pollen.comfor daily reports in your area

Don’t allow animals in the house—Animal dander can cause these reactions.

Change feather pillows, wool blankets and clothing to cotton or synthetic materials

Wash sheets, mattress pad, and blankets weekly in hot water (if possible, wash the curtains on a regular basis)

Remove carpeting, if possible.

Use air filters

Use a dehumidifier to keep indoor humidity low. Dust mites and mold increase in high humidity.

Keep a list of things that trigger an allergic reaction.

Teach everyone caring for your child how to use epinephrine pens and have two epinephrine pens available if your child is at risk for anaphylaxis to certain foods, medicines, vaccines, and other exposures.

In addition to these methods, over-the-counter medications are available that might give your child some relief. To get the maximum benefit from the allergy medicines, your child should be using these medicines everyday. Taking it only as needed will not work as well as taking it everyday. Continue giving the allergy medicines until the allergy season is over for your child or until the doctor tells you to stop giving it.

Antihistamines, such as children’s loratidine (Claritin®) or cetirizine (Zyrtec®)—help with itch, watery eyes and runny nose.
Nasal sprays such as nasal saline—help clear out the nose
Oral nasal decongestants—help the stuffy nose
Table 1. Antihistamines, nasal sprays, and decongestants for kids

Antihistamines	Approved Ages
Benadryl® (diphenhydramine)	Ages 6 and older
Claritin® (loratadine)	Ages 2 and older
Zyrtec® (cetirizine)	Ages 6 and older

Nasal Sprays	Approved Ages
Little Noses Saline Spray/Drops	All ages
Baby Simply Saline Nasal Drops	All ages
*Little Noses Decongestant Drops	Ages 2 and older

*Oral Decongestants	Approved Ages
*Children’s PediaCare Decongestant	Ages 2 and older
*Children’s Sudafed	Ages 2 and older

*Speak with your child’s pharmacist or pediatrician to make sure your child will benefit from the decongestants before using any of these products.

Check with your child’s pharmacist or pediatrician before giving any of these

medications to your child to make sure you give the right dose

Table 2. Common over-the-counter and prescription medicines used to treat allergies.

Antihistamine (Oral Formulations)	Approved Ages	Dosage Forms	Drowsiness
Allegra^® (fexofenadine)	Seasonal Allergic Rhinitis: ≥ 2 yrs	Generic Tablets: 30mg, 60 mg, 180 mg Allegra ODT: 30 mg (only approved for ≥ 6 yrs of age) Allegra Capsule: 60 mg Allegra Suspension: 30 mg/5 mL Allegra Tablets: 60 mg, 180 mg	1.3%^a
Benadryl^® (diphenhydramine) *many other generic forms available	Allergic Rhinitis: ≥ 6 yrs	Generic Capsules and Liquid Benadryl Liquid and Perfect Measure: 12.5 mg / 5 mL Benadryl Fastmelt Tablets: 12.5 mg Benadryl Tablets, Liquid Gels, Quick Dissolve Strips, Kapgels: 25 mg	Most Sedating; May also potentially cause opposite effects, i.e. excitation^b
Clarinex^® (desloratadine)	Perennial Allergic Rhinitis: ≥ 6 months Seasonal Allergic Rhinitis: ≥ 2 yrs	No Generic Available Clarinex ODT: 2.5 mg, 5 mg (safety and efficacy have not been established for ≤6 yr old) Clarinex Syrup: 0.5 mg/mL (safety and efficacy have not been established for ≤6 months old) Clarinex Tablet: 5 mg	9.1%^c
Claritin^®/Alavert^® (loratadine) *many other generic forms available	Seasonal allergic rhinitis: ≥ 2 yrs	Generic Tablets and Syrup Claritin Syrup*: 5 mg/ 5 ml Claritin Chewables: 5 mg Claritin Tablets, Liquid Gels, Reditabs: 10 mg (only approved for ≥ 6 yrs of age) Alavert Tablets: 10 mg (only approved for ≥ 6 yrs of age) Alavert Orally Disintegrating Tabetls: 10 mg (only approved for ≥ 6 yrs of age)	8%^d
Xyzal^® (levocetirizine)	Perennial Allergic Rhinitis: ≥ 6 months Seasonal Allergic Rhinitis: ≥ 2 yrs	No Generic Available Xyzal Solution: 0.5 mg/mL Xyzal Tablet: 5 mg	3%^e
Zyrtec^® (cetirizⁱne) *many other generic forms available	Perennial Allergic Rhinitis: ≥ 6 months Seasonal Allergic Rhinitis: ≥ 2 yrs	Generic Tablets, Syrup, Chewables Zyrtec Tablets, Liquid Gels: 10 mg (only approved for ≥ 6 yrs of age) Zyrtec Chewables: 5mg, 10 mg (10 mg only approved for ≥ 6 yrs of age) Zyrtec Perfect Measure: 10 mg (only approved for ≥ 6 yrs of age) Zyrtec Syrup*: 5 mg/ 5 mg	5 mg = 1.9%^f 10 mg = 4.2%^f
Antihistamine (Nasal Sprays)	Approved Ages	Dosage Forms	Drowsiness
Astelin^® (Azelastine)	Perennial Allergic Rhinitis: ≥ 12 yrs Seasonal Allergic Rhinitis: ≥ 5 yrs	No Generic Available Astelin Ready Nasal Spray: 137 mcg/actuation	11.5%^g
Astepro^® (Azelastine)	Perennial Allergic Rhinitis: ≥ 12 yrs Seasonal Allergic Rhinitis: ≥ 12 yrs	No Generic Available Astepro Nasal Spray: 205.5 mcg/actuation
Patanase^® (Olopatadine)	Seasonal Allergic Rhinitis: ≥ 12 yrs	No Generic Available Patanase Nasal Spray: 0.6%	in poisoning^h
Antihistamine (Opthalmic Solutions)	Approved Ages	Dosage Forms	Drowsiness
Optivar^® (Azelastine)	Allergic Conjunctivitis: ≥ 3 yrs	Generic Opthalmic Solution: 0.05% Optivar Opthalmic Solution: 0.05%
Pataday, Patanol^® (Olopatadine)	Allergic Conjunctivitis: ≥ 3 yrs	No Generic Available Pataday Opthalmic Solution: 0.2% Patanol Opthalmic Solution: 0.1%
Leukotriene Modifier	Approved Ages	Dosage Forms	Drowsiness
Singulair^® (Montelukast)	Perennial Allergic Rhinitis: ≥ 6 months Seasonal Allergic Rhinitis: ≥ 2 yrs	No Generic Available Singulair Granule Packets: 4 mg/packet Singulair Chewable Tablets: 4 mg, 5 mg Singulair Tablet: 10 mg	in overdoseⁱ

*May be marked as a solution

a: In patients 6 months to 5 years of age.¹

b: Most sedating antihistamine but it may cause excitation in children²

c: In patients 6-11 months old with syrup vs placebo (9.1%, 8.1%).³

d: In clinical trials versus placebo (6%) (no specific information regarding pediatrics); effect was dose-related⁴

e: In children.⁵

f: Somnolence rates in patients 6-11 years of age vs placebo (1.3%); patients 6-24 months, somnolence rate was about the same as placebo. ⁶

g: Up to 11.5% somnolence.⁷

h: Somnolence in mild to moderate poisoning.⁸

i: Drowsiness reported with overdose.⁹

References for Table 2:

sanofi-aventis U.S. LLC. Allegra (fexorendadine) tablets, ODT (orally disintegrating tablets) and oral suspension [product information]. Bridgewater, NJ: sanofi-aventis U.S. LLC; 2007.
Diphenhydramine. In: DRUGDEX® System [Internet database]. Greenwood Village, Colo: Thomson Reuters (Healthcare) Inc. Updated periodically.
Schering Corporation. Clarinex (desloratadine) tablets, syrup, Reditabs [product information]. Eden Prairie, MN: Schering Corporation; 2005.
Loratadine. In: DRUGDEX® System [Internet database]. Greenwood Village, Colo: Thomson Reuters (Healthcare) Inc. Updated periodically.
Levocetirizine. In: DRUGDEX® System [Internet database]. Greenwood Village, Colo: Thomson Reuters (Healthcare) Inc. Updated periodically.
McEvoy GK, ed. AHFS Drug Information 2009. Bethesda, MD: American Society of Health-System Pharmacists, Inc; 2009.
MedPointe Healthcare Inc. Astelin (azelastine) nasal spray [product information]. Somerset, NJ: MedPointe Pharmaceuticals; 2006.
Olopatadine. In: DRUGDEX® System [Internet database]. Greenwood Village, Colo: Thomson Reuters (Healthcare) Inc. Updated periodically.
Merck Sharp and Dohme Corp. Singular (montelukast) tablets, chewable tablets, and oral granules [product information]. Whitehous Station, NJ; Merck & Co., INC; 2010.

Table 2 Constructed by Amanda Jensen, Christina Christopher, and Michelle Eykamp (PharmD Candidates at time of development) and Lynnette Sever, PharmD, PGY1 Pharmacy Resident at time of development.

General References:

Tietze KJ. Disorders Related to Cold and Allergy. In: Berardi RR, McDermott JH, Newton GD, et al. eds. Handbook of Nonprescription Drugs: An Interactive Approach to Self-Care. 14th ed. Washington, DC: APhA; 2004: 240-245.

Allergy. National Institute of Allergy and Infectious Diseases. URL: http://www.nlm.nih.gov/medlineplus/allergy.html. Accessed: July 14, 2010.

Serious allergic reactions (Anaphylaxis). KidsHealth. URL: http://kidshealth.org/parent/medical/allergies/anaphylaxis.html. Acccessed July 14, 2010.

Allergy-proof your house. URL: http://www.mayoclinic.com/print/allergy/HQ01514/METHOD=print. Accessed: July 14, 2010.

All about allergies. KidsHealth. URL: http://kidshealth.org/parent/medical/allergies/allergy.html. Accessed: July 14, 2010.

Allergy treatment guide. Keeping Kids Healthy. URL: http://www.keepkids.healthy.com/welcome/treatmentguides/allergy.html. Accessed: July 14, 2010.

14-Jul-10 10:00 AM

Understanding Pain and Fever Medicine

Lubsch Lisa - noemail@kidsmeds.info — Wed, 05 May 2010 11:00:00 GMT

With so many different pain and fever medicines in the pharmacy, it can be confusing. There are infant drops, children’s liquid suspensions and chewable tablets. Each one of them contains different medicines and different doses. To add to the confusion, since November of 2008 infants’ and children’s TYLENOL^® (acetaminophen) packaging no longer gives dosing information for children less than two years old. The Food and Drug Administration (FDA) was concerned about reports of accidental acetaminophen overdoses in children caused by parents’ dosing mistakes. In some cases, parents had failed to either read or understand the label instructions, which led them to use an incorrect measuring device or formulation (for example, drops instead of suspension). Acetaminophen is not unsafe to give to your infant, just always talk to your doctor before you do so.

If your child is sick, you should give them lots of liquids to drink and make them rest.

Fever

If your child has a FEVER - See the Mayo Clinic Fever Guide below for recommendations on how to treat it. Although there are many thermometers on the market that measure temperature in different areas, parents should use rectal thermometers with their babies for the most accurate reading. “The ‘gold standard’ measurement is still the rectal temperature. For more information on how to take a temperature, click here for the Mayo Clinic's recommendations.

How high is it?

Pain

If your child is in PAIN: Pain may be treated for five days in children when using acetaminophen. Ibuprofen may be used instead, but for no more than three days. Take your child to the doctor if the pain doesn’t go away by that time. However, if the pain is due to a sore throat, make sure to you take them to a doctor if it lasts more than two days.

*Do not give ASPIRIN to anyone age 18 years or younger*

Aspirin has been linked with Reye's syndrome, a rare but serious condition that can affect children and teenagers recovering from a viral infection. Aspirin and products that contain aspirin should not be given to children less than 18 years old unless prescribed by your doctor. Some medical conditions require treatment with aspirin.

KidsMeds Tips:

Know your child's weight in pounds and kilograms.
Always check with your pharmacist or child's doctor first if you're not sure about the dosing of acetaminophen or ibuprofen.
Store brand products work the same way as the main brand (Tylenol, Motrin, Advil) products. Dosing is the same.
Use the dropper, medicinal cup, or oral syringe provided with the product for that product only! Do not use the measuring tool for other medicines.

Children's Tylenol and Motrin Liquid Product Recall:

What does the recent recall of Tylenol and Motrin products mean for you? Read more about it here.
Which lots of Tylenol and Motrin were recalled? Here is the complete list. Please note that the store brand equivalents were not recalled and can still be used.

5-May-10 6:00 AM

Taming Itchy Skin in Children

Catherine Tom-Revzon - noemail@kidsmeds.info — Tue, 27 Apr 2010 15:00:00 GMT

There are many reasons why children have itchy skin. During the winter months, excessive dryness is the most common cause of itchy skin. Another common cause is a harmless skin condition called keratosis pilaris. Scratching the skin too much can lead to more serious skin conditions, including infections. Seriously dry skin can also lead to other skin conditions, such as [CT1] eczema (atopic dermatitis). Using a simple moisturizer can relieve itchiness and prevent dry skin.

Dry Skin and the Itch Sensation

Water is the main "softener" of skin. Cold air and dry air from artificial heat act like a sponge to pull water from the skin. When the skin becomes overly dry, it becomes rough and scaly, then red, inflamed and itchy. Children with eczema may have flaky skin. Those with keratosis pilaris will have a sandpaper like feel to their skin from the flesh-colored to slightly red bumps.

The itch sensation occurs when nerve signals from the receptors at the free nerve endings at the outer layer of the skin (epidermis) and derma go through the spinal cord to the thalamus. There the itching sensation is picked up in the somatosensory cortex. The somatosensory cortex is the area of the brain that receives information from the general sensory receptors in the skin and from the skeletal muscles. After the information is processed, the part of the body being affected is identified and the data is interpreted. Then the motor areas (fingers, for example) are signaled to initiate the scratching. Without treatment, a vicious cycle of itching and scratching can interrupt your child’s daily activities.

Treating Dry Skin

Here are some tips on how to keep the winter itch (or just dry skin in general) under control:

Use a humidifier. When the relative humidity of air is low, artificial heat can dry out the skin.
What’s the problem? Identify other factors that worsen the problem of dry skin and minimize them. These factors include taking many baths and using harsh soaps. Products with alcohol will also dry out the natural oils from the skin.
Avoid hot water. Hot water removes the skin’s natural oils more quickly. Use warm water to bathe your child. Shorter baths or showers (5-10 minutes) add moisture to the skin. The skin is less hydrated after the bath the longer your child stays in the water.
Don’t forget to add the “softener.” Moisturize the skin with lotions, creams, or ointments. Keep it simple. Use products without perfume. Apply right after a bath or shower to retain moisture.
Which product? For severely dry skin and keratosis pilaris, try an over-the-counter moisturizer that contains urea or lactic acid. These ingredients help the skin retain water. Some prescription moisturizers also contain these ingredients. Children with eczema should avoid these ingredients because it may irritate the skin. Speak with the pharmacist about the different available products. Table 1 lists some common over-the-counter and prescription products. (Click here for PDF of Table 1) If the condition worsens, bring your child to the doctor.

What if it’s “angry”? If the skin is red and inflamed, your child may need a mild topical corticosteroid or an immunomodulator (tacrolimus, pimecrolimus). Apply sparingly. Check with the doctor first before using any products for this condition.
Prevention is key. Prevent dry skin by using a moisturizer every day. Keeping the skin moisturized will also prevent eczema flares.

References:

Bernhard JD. Pruritus and Xerosis. The Academy of Dermatology. 2010. URL: http://www.aad.org/education/students/pruritusxerosis.htm. Accessed: March 3, 2010.

The Academy of Dermatology. Dry Skin & Keratosis Pilaris. 2009. URL: http://www.aad.org/public/publications/pamphlets/skin_dry.html Accessed: March 3, 2010.

27-Apr-10 10:00 AM

Don't Let the Ticks Bite

Catherine Tom - noemail@kidsmeds.info — Wed, 17 Mar 2010 17:00:00 GMT

I. QUICK SUMMARY OF TICKS AND TICKBORNE DISEASES

What are ticks?

Ticks (Ixodidae) are six-legged insects responsible for transmitting diseases caused by bacteria and parasites. Ticks have four stages in their life cycle: egg, larva, nymph, and adult. Nymphs must feed once to develop into an adult tick. When they feed on blood from an animal infected with rickettsia, they become infected. After ticks develop into adults, the infection may be spread to humans or other animals during their feeding process. Humans may be bitten by either the male ticks or female ticks, but females are responsible for spreading most of the infections.

What do ticks look like and what diseases do they transmit to humans?

Ticks are hard to spot at a glance. In fact, nymphs are the size of poppy seeds. The following table describes the different kinds of ticks, their reservoirs, places where they are commonly found, and infections they can cause.

What ticks look like	Animal Reservoirs	Where transmission has occurred	Disease Transmitted
Blacklegged Tick, also known as deer tick	White-footed mice, squirrels, and other small mammals	Parts of New England, New York State, New Jersey, Wisconsin, and Minnesota	Lyme Disease
Western Blacklegged Tick	White-footed mice, squirrels, and other small mammals	Pacific coastal US	Lyme Disease
Rocky Mountain Wood Tick	Small rodents	South-Atlantic region of the US (Delaware, Maryland, Washington D.C., Virginia, West Virginia, North Carolina, South Carolina, Georgia, and Florida) Southern Canada	Rocky Mountain Spotted Fever
Dog Tick	Small rodents	South-Atlantic region of the US (Delaware, Maryland, Washington D.C., Virginia, West Virginia, North Carolina, South Carolina, Georgia, and Florida Southern Canada	Rocky Mountain Spotted Fever

In the United States, common infections caused by tick bites include: Lyme disease and Rocky Mountain spotted fever.

How did my child get a tick bite?

Your child may have gotten exposed to ticks by playing outdoors in areas with woods, brush, or grass where infected ticks may be found during warm months. The toxins from tick bites can lead to Lyme Disease or Rocky Mountain Spotted Fever.

Lyme Disease

Lyme Disease is the most common tickborne illness. The number of reported cases of Lyme Disease has been rising in the last several years. In 2007, about 27, 000 cases were reported to the CDC. Lyme Disease is caused by bacteria called Borrelia burgdorferi. It is transmitted to humans by bites of infected blacklegged tick (Ixodes scapularis) in the northeastern and north-central regions of the United States and by infected western blacklegged ticks (Ixodes pacificus) in the west coast. In general, ticks need to be attached for 36 to 48 hours before the bacterium gets transmitted. Thus, it is important to check for ticks and remove them promptly. Most infections in humans are caused by the bites of nymphs in the late spring and early summer, but adult ticks can also transmit the bacterium in the fall and early spring. They can attach to any part of the body, but are often found in the thigh, armpits, groin, trunk, and scalp.

The diagnosis of Lyme disease is based on symptoms, physical findings (rash), and the possibility of being exposed to infected ticks. In later stages of the disease, laboratory testing to look for antibodies may be helpful. There are two stages of Lyme Disease: Early Lyme Disease (ELD) and Late Lyme Disease (LLD). Signs and symptoms to look for in ELD are chills and fever, headache, fatigue, muscle and joint pain, swollen lymph nodes, and a characteristic skin rash that looks like a bull’s eye (erythema migrans). The red circular patch appears where the tick bite has occurred within 3 days to 1 month, and it will grow larger (up to 30 cm) across. If Lyme disease is not treated, the infection can spread to the large joints, the heart, and the nervous system within a few days to weeks. This is known as Late Lyme Disease. Problems with memory or cognition, fatigue, headache, and sleep disturbance sometimes continue even after treatment. Not all signs and symptoms are present in infected patients.

Rocky Mountain Spotted Fever

Rocky Mountain spotted fever (RMSF) is the most severe tick-borne illness in the US. It is caused by the bacteria Rickettsia ricketsii. It can be transmitted to humans by the bite of an infected tick, the American dog tick (Dermacentor variabilis) and Rocky Mountain wood tick (Dermacentor andersoni). It usually occurs during April through September in the south-Atlantic region of the US (Delaware, Maryland, Washington D.C., Virginia, West Virginia, North Carolina, South Carolina, Georgia, and Florida). The three most important parts of how a person with the illness presents are fever, rash, and a previous tick bite. The initial symptoms of RMSF may include fever, nausea, vomiting, muscle pain, lack of appetite, and severe headache. Later signs and symptoms include rash, abdominal pain, joint pain, and diarrhea. RMSF is a severe illness that requires hospitalization. The diagnosis is based on the clinical signs and symptoms and special laboratory tests to confirm the presence of the bacteria. Other blood tests will check the platelets, sodium, and liver enzyme levels.

II. HOW ARE TICKBORNE DISEASES USUALLY TREATED?

LYME DISEASE

The treatment of Lyme Disease usually depends upon a few factors: the symptoms that the child displays, diagnostic tests, age of the child, and if the child has any allergies to any medications. Based upon these factors antibiotic therapy will be given either orally (by mouth) or intravenously (through a vein) for more severe disease.

Lyme Disease and Body Systems Affected

The most common type of Lyme Disease, that which has some flu like symptoms and usual rash is generally treated with 2 to 3 weeks of oral antibiotics.

If children have any signs that the disease may be affecting the nervous system the physician will often need to rule out meningitis. If meningitis is ruled out, the child may be able to receive oral antibiotics but if not intravenous antibiotics (or sometime oral doxycycline) are generally needed. The duration of therapy for this is usually 2 to 4 weeks.

Although rare, Lyme Disease affecting the heart can occur, and is treated with 2 to 3 weeks of antibiotics. In children with less severe disease oral therapy may be okay. Most recommend intravenous antibiotics for children with more severe disease that requires hospitalization.

If a child has Lyme Disease affecting the joints (i.e. arthritis), they will usually need 4 weeks of oral antibiotics. Lyme arthritis is one of the few conditions that sometimes will require a repeat course of oral therapy or a trial of a few weeks of intravenous antibiotics. This second course is generally used if the child does not respond to the initial 4 oral therapy.

Antibiotic Therapies Recommended for Treatment of Lyme Disease:

Oral Therapy

For children at least 8 years old, doxycycline is the preferred oral therapy. Because the bacteria that causes Lyme Disease also responds to other antibiotics, doxycycline is not generally recommended for children less than 8 years old. The oral antibiotics recommended for young children include amoxicillin and cefuroxime. If a child cannot receive doxycycline, amoxicillin or cefuroxime a macrolide (azithromycin, clarithromycin, or erythromycin) may be considered. The reason that the macrolide is only used if they cannot receive the other agents is because it may be less likely to work.

Intravenous Therapy

Ceftriaxone is usually the preferred intravenous therapy for the treatment of Lyme Disease. Other antibiotics that are also efficacious, but need to be administered more frequently are cefotaxime and penicillin G.

ROCKY MOUNTAIN SPOTTED FEVER

The CDC suggests that because these diseases are often severe, doxycycline is the preferred drug in children of all ages. Treatments can be either oral or intravenous depending on the severity. Duration of therapy is usually between 5 to 14 days. Longer therapies are sometimes needed for more severe disease.

MEDICATION SUMMARY

For all of medications you should give your child all of the doses prescribed.
If your child has any concerning reactions (rash, throat swelling, severe or bloody diarrhea, etc) contact your physician right away.
If your child is given the medication as a liquid – shake well before giving each dose and ask your pharmacist for a measuring device.
If there is any drug remaining after the course is done, throw it away.
Many of these drugs may have interact with other medications, please let your pharmacist know if your child takes any prescription, over the counter medication, or herbal supplements.

Penicillins

Amoxicillin (oral)

Amoxicillin should not be used in children that have an allergy to penicillins.
You should talk to your child’s doctor if your child has an allergy to cephalosporins it is possible that your child will also be allergic to amoxicillin.
Could cause tooth discoloration that is lessened by brushing your child’s teeth well.

Penicillin G (intravenous)

Penicillin should not be used in children that have an allergy to penicillins.
You should talk to your child’s doctor if your child has an allergy to cephalosporins your child may also be allergic to penicillin.

Cephalosporins
Cefuroxime axetil (oral)

Cefuroxime should not be used in children that have an allergy to cephalosporins.
You should talk to your child’s doctor if your child has an allergy to penicillins as there is a chance that your child will also be allergic to cefuroxime.
Cefuroxime axetil liquid should be taken with food.
Cefuroxime axetil tablets can be taken with food to make it less likely to cause upset stomach.

Ceftriaxone or cefotaxime (intravenous)

Ceftriaxone or cefotaxime should not be used in children that have an allergy to cephalosporins.
You should talk to your child’s doctor if your child has an allergy to penicillins as there is a chance that your child will also be allergic to either ceftriaxone or cefotaxime.

Tetracyclines
Doxycycline (oral)

Your child should try to avoid prolonged exposure to sunlight and tanning because this can lead to a bad reaction.
This medication can cause tooth discoloration in young children.
This drug can discolor skin and/or fingernails.
This drug should be spaced at least 2 hours from iron, calcium, antacids, or dairy products.
If tolerated this medication should be taken on an empty stomach.
If your child is taking a tablet or capsule it should be swallowed whole with a full glass of water.

Macrolides

Azithromycin, clarithromycin, or erythromycin (oral)

· Space antacids at least two-hours from taking the medication.

· If your child is taking a tablet or capsule it should be taken whole.

· Clarithromycin and azithromycin should be stored at room-temperature, not in the refrigerator.

· Some types of erythromycin are stored in the refrigerator while others can be kept at room-temperature.

· Erythromycin is best taken, if it does not cause stomach upset, on an empty stomach.

· Clarithromycin extended-release tablets should be taken with food.

Others
Atovaquone (oral)

· The drug should be administered with a high fat meal.

· Let your child’s doctor know if your child has diarrhea.

Clindamycin (oral)

· Do not refrigerate solution.

· Take capsules with a full glass of water.

Quinine (oral)

Let your child’s doctor know if you child has a heart condition.
Do not crush capsules.

III. Prevention of Tick Borne Illnesses in Children

How do I protect my child from a tick borne illness?

· The best way to protect your child from a tick borne illness is to keep your child away from areas where ticks may be found (for example: wooded areas, fields, infested animals).

· If you can’t keep your child away from a tick infested area, then protective clothing should be worn.

Your child should wear light colored clothing (so ticks can be seen on the clothing and removed before they attach to the child’s skin).
Your child should also wear long sleeve shirts, long pants and a hat to limit a tick’s access to your child’s skin.
Pants should be tucked in to your child’s boots or socks and shirts should be tucked in to your child’s pants.

· Products that contain DEET (like Cutter’s® and Deep Woods Off®) or permethrin (like Sawyer®) can be sprayed onto your child’s clothing to repel and/or kill ticks.

· DEET and permethrin should not be used in infants less than 2 months of age.

· Products that contain DEET may also be applied to exposed skin. Avoid spraying or applying DEET to your child’s face to avoid getting DEET in your child’s mouth or eyes. For younger children, you may want to apply DEET to your hands then rub your hands on any exposed areas of your child’s skin. Do not apply DEET to the hands of young children since they may rub their eyes or stick their hands in their mouths.

· Permethrin should never be applied to the skin.

· After your child has returned from an area that may be infested with ticks, check his/her body and clothing for any ticks. Be sure to check your child’s hair and behind his/her ears. Remove any ticks you find on your child.

· If you have pets in your household, they should also be kept free of ticks. Your veterinarian can help you pick a product that will keep your pets tick-free.

If I find a tick on my child, how do I safely remove the tick?

To remove a tick:

Use a pair of tweezers (not your bare hands) to grasp the tick as close to your child’s body as possible.
Steadily pull the tick straight out from the body without twisting your hand. Do not crush or squeeze the tick. If you cannot remove the entire tick, do not panic. Simply clean and disinfect the area as noted below.
After removing the tick, clean and disinfect the area with soap and water, a chlorhexidine wash, an iodine wash or rubbing alcohol.
Be sure to wash your hands thoroughly after you remove the tick from your child.
The CDC recommends that you save the tick in a sealed plastic bag (like a Ziplock® baggie) stored in your freezer in case your child later becomes sick. You should write the date of the tick bite on a piece of paper placed inside the plastic bag.

If my child is bitten by a tick, will he/she need antibiotics?

· In general, antibiotics are not recommended for most people who are bitten by a tick. Usually, your doctor will ask you to watch your child closely for signs of a tick borne infection, like a skin rash or flu-like symptoms, for one month after the tick bite happened. In states where tickborne illnesses are most common, your doctor may give your child a single dose of doxycycline.

· If your child does develop a skin rash or flu-like symptoms (low fever, tired, achy joints/muscles), then your child should be seen by his/her doctor as soon as possible.

References

1. American Academy of Pediatrics. Prevention of Mosquitoborne Infections. In: Pickering LK, ed. Red Book: 2009 Report of the Committee on Infectious Diseases. 28th ed. Elk Grove Village, IL: American Academy of Pediatrics; 2009:193-195. Available at: http://aapredbook.aappublications.org/cgi/content/full/2009/1/2.14. Accessed September 30, 2009.

2. American Academy of Pediatrics. Prevention Of Tickborne Infections. In: Pickering LK, ed. Red Book: 2009 Report of the Committee on Infectious Diseases. 28th ed. Elk Grove Village, IL: American Academy of Pediatrics; 2009:191-193. Available at: http://aapredbook.aappublications.org/cgi/content/full/2009/1/2.13. Accessed September 30, 2009.

3. Center for Disease Control and Prevention. Department of Health and Human Services. Lyme Disease: A Public Information Guide. May 2007.

4. Centers for Disease Control and Prevention. Learn About Lyme Disease. http://www.cdc.gov/ncidod/dvbid/Lyme/. Accessed September 30, 2009.

5. Centers for Disease Control and Prevention. Prevention and control. http://www.cdc.gov/ticks/prevention.html. Accessed June 17, 2009.

6. Centers for Disease Control and Prevention. Removing ticks. http://www.cdc.gov/ticks/tick_removal.html. Accessed June 17, 2009.

7. Centers for Disease Control and Prevention. Rickettsial Diseases. Questions and Answers. What is Rocky Mountain spotted fever? http://www.cdc.gov/ticks/diseases/rocky_mountain_spotted_fever/faq.html. Accessed September 30, 2009.

8. Centers for Disease Control and Prevention. Tickborne Rickettsial Diseases. http://www.cdc.gov/ticks/transmission.html. Accessed September 30, 2009.

9. Chen LF, Sexton DJ. What’s new in rocky mountain spotted fever? Infect Dis Clin North Am 2008;22:415-432.

10. Feder HM Jr. Lyme disease in children. Infect Dis Clin North Am 2008;22:315-326.

11. Nelson’s Pocket Book of Pediatric Antimicrobial Therapy. 16^th Ed. J Bradley and J Nelson, eds. Alliance for World Wide Editing, Buenos Aires, Argentina.

12. Pediatric Dosage Handbook. 15^th Ed. C Taketoma, J Hodding and D Kraus, eds. Lesi-Comp. Hudson, OH.

13. Treatment of Lyme disease. The Medical Letter 2007;49:49–51.

14. Wormser GP, Dattwyler RJ, Shapiro ED, et al. The clinical assessment, treatment, and prevention of lyme disease, human granulocytic anaplasmosis, and babesiosis: clinical practice guidelines by the Infectious Diseases Society of America. Clin Infect Dis 2006:43;1089-134.

17-Mar-10 12:00 PM

How Insect Repellents Work and What to Look For Before Buying

Bernard Lee, PharmD - noemail@kidsmeds.info — Sat, 06 Feb 2010 06:00:00 GMT

1. How do repellents work?

Mosquitoes are attracted to moisture, carbon dioxide, warmth, odor, and estrogen on skin. Insect repellents work by producing a vapor layer that has an unpleasant taste or smell to insects.

2. Why should insect repellents be used?

Mosquitoes can transmit fatal diseases worldwide (i.e. West Nile virus, malaria and yellow fever).

3. When should insect repellents be used?

Anytime you or your child are going to be outside. In many areas of the country, mosquitos not only bite at night, but also during the day.

4. Who should use insect repellents, or take precautions against insects?

Anyone who is at risk for exposure to insects (i.e. mosquito bites) that may cause local skin or allergic reactions. If you or your child is exposed to insects that can cause serious illness or death by spreading bacteria or viruses (such as the West Nile virus).

5. Who should NOT use insect repellents?

-Anyone who has a history of a skin irritation or an allergic reaction to insect repellents should not use repellents with known ingredients (active or inactive) that caused these reactions. Read the labels carefully to find out what ingredients are in a product.

-The American Academy of Pediatrics (AAP) generally recommends that infants under 2 months old should not use insect repellents containing N,N-Diethyl-meta-toluamide (DEET).

6. What makes a product an ideal insect repellent?

•   Long lasting or works long enough against a wide variety of insects
•   Nonirritating to the skin when it is put on
•   Odorless or has pleasant odor
•    No effect on clothing after application (i.e. staining, bleaching, weakening of fibers)
•    No oily residue on skin and resists removal by wiping, washing, or sweating
•   Inert to commonly used plastics
•   Chemically stable
•   Economical for broad use by all
•   Non-toxic

7. What is(are) the safest and most effective product(s)?

• The Environmental Protection Agency (EPA) and Centers for Disease Control and Prevention (CDC) recommend products that contain either DEET (N,N-diethyl-m-toluamide) or Picaridin (KBR 3023) as the active ingredients of insect repellents. These have been shown to have the best efficacy in clinical trials. Products with these active ingredients typically offer longer-lasting protection than others.

• Oil of lemon eucalyptus [active ingredient: p-menthane 3,8-diol (PMD)] and oil of citronella are plant-based repellents. When used against mosquitoes in the US, scientific trials have found that they provide protection similar to insect repellents containing low DEET concentrations.

• The amount, or percentage (%), of the active ingredient makes all the difference in an insect repellent product. When comparing two products, make sure you are looking at the same active ingredient. Typically, the higher the percentage of the active ingredient a product contains, the longer the protection from mosquitoes. However, the concentration of different active ingredients cannot be directly compared (for example, 10% concentration of one ingredient doesn’t mean it works exactly the same as 10% concentration of another ingredient).

8. What are the different kinds of insect repellents available over-the-counter (OTC)?

There are MANY different brands of products available in the pharmacy. Read the label carefully for instructions on how to properly use the insect repellent. Find out what the active ingredient is and how much of it the product has. See Tables 1 and 2.

Table 1. Main ingredients and products names

Main ingredient Products

DEET Cutter, Cutter Backwoods, Cutter Backyard, Cutter Deep Woods,

Skedaddle, Skinastic, OFF!, Muskol, Outdoorsman, Sawyer, Ultrathon

Picaridin Repel, Off Skintastic
Lemon eucalyptus oil Cutter Advanced, Cutter Advanced Sport
Citronella oil Buzz Away, Green Ban, Herbal Armor, Natrapel

9. What are the differences between the products, brand vs. generic/store brands?

There are no known significant differences between brand, generic, or store brand insect repellents. The active ingredients of and past experiences with the most effective products should determine what you should buy and use.

10. Why are there so many different products?
Different products contain different concentrations of the main ingredient. A product should be chosen based on the duration of protection needed (from 20 minutes – 8 hours). See Table 2 for more information. Additionally, certain characteristics such as odor, sticky/greasiness, irritation, and potential damage to clothing and plastics differ between the products.

Table 2. Main ingredients with concentrations and their duration of action

Main ingredient              Concentration           Duration of Action
DEET 5 - 7%                     Up to 2 hours
DEET                                    10 - 30%                  Up to 6 hours
Picaridin                                 5 – 7 %                     Up to 4 hours
Picaridin                                    15%                         Up to 8 hours
Lemon eucalyptus oil 10 – 30%                    Up to 4 hours
Lemon eucalyptus oil 40%                         Up to 6 hours
Citronella oil 5 – 15%              About 20 – 30 minutes

11. Where is the best place to find insect repellents?

Repellents are found at retail, discount, and drug stores. Larger selections may be found at "outdoor" stores.

12. Where should insect repellents be applied?

Insect repellents should be applied to clothing, especially if the material is thin enough for insects to penetrate through. They should be applied to any exposed areas of skin, but avoid sensitive places like the face. Avoid breathing in the repellent through the nose or mouth. Do not let it contact the eyes. This can cause painful irritation.

13. What should be done if a side effect or reaction happens?

• If the reaction is local (limited only to the skin) and is not severe (no skin breaking, blisters, or hives), the area can be washed thoroughly with plain water. Do not use soaps or other harsh to remove any excess repellent chemicals as they could worsen the irritation.

• If the reaction is more severe, skin breakdown, spreading skin reactions, or anything happens beyond the skin (difficultly breathing, fast heart beats, “feeling very sick”), call 911 emergency services or your local Poison Control Center at 1-800-222-1222.

14. What are some alternatives to chemical insect repellents?

• Children and adults can wear protective clothing with long pants and long sleeves while outdoors. Be sure to apply insect repellent on the clothing and not directly contact the skin. Mosquitoes may bite through thin fabric.

• Mosquito netting can be used over infant carriers. Make sure there are no holes in the netting or large openings/gaps in the carrier.

• Dispose of containers or clear areas with standing water (bird baths, outdoor waterproof tarps, etc.), that provide breeding places for mosquitoes. Avoid stagnant bodies of fresh water, i.e. marshes, wetlands, farm ponds, shallow lakes, retaining/drainage ponds, etc.

15. What medications, or other products, can interact with insect repellents?

There are currently no known prescription medications taken that interact with common insect repellents. When using other topical products with insect repellents, the insect repellent should be the LAST thing applied to offer the best protection against insects.

16. Can sunscreen be used with insect repellents?

• Yes. People can, and should, use both a sunscreen and an insect repellent when they are outdoors. It is recommended NOT to use a single product that combines insect repellent containing DEET and sunscreen. The instructions for use of insect repellents and use of sunscreen are different. In most situations, insect repellent does not need to be reapplied as frequently as sunscreen. While no recommendations are available at this time regarding products that combine other active ingredients and sunscreen, it is important to always follow the label on whatever product you are using.

• To protect from sun exposure and insect bites, you can also wear long sleeves and long pants and apply insect repellent to your clothing, rather than directly to your skin.

17. When should insect repellents be reapplied?

• A product should be chosen with the concentration of insect repellent that will allow you to stay outside for the desired time. Use Table 2 to serve as a guide for the expected duration.

• Insect repellent should only be reapplied if mosquitoes have started biting. Products state that frequent reapplication and saturation are unnecessary. Repellent should not be applied more than 3 times per day.

• Combination sunscreen/insect repellent products should be avoided since sunscreen needs to be reapplied every two hours and the insect repellent does not need to be applied this often.

18. How do I read an insect repellent product label?

The active ingredient and concentration is listed on the label. Additionally, important directions and precautions are listed on the label. The pharmacist is available to help understand the label.

19. How can I find more information?

• Environmental Protection Agency (EPA) Web site

• Center for Disease Control (CDC) Web site

• National Pesticide Information Center (NPIC) through their toll-free number, 1-800-858-7378 or their web site

References:

1.   Brown M, Hebert AA. Insect repellents: an overview. J Am Acad Dermatol. 1997 Feb;36(2 Pt 1):243-9.
2.   Elston DM. Insect repellents: an overview. J Am Acad Dermatol. 1998 Apr;38(4):644-5.
3.   Combemale P, Dupin M. Insect repellents. J Am Acad Dermatol. 1998 Apr;38(4):645.
4.   Roberts JR, Reigart JR. Does anything beat DEET? Pediatr Ann. 2004 Jul;33(7):443-53.
5.   Buka RL. Sunscreens and insect repellents. Curr Opin Pediatr. 2004 Aug;16(4):378-84.
6.   Flake ZA, Hinojosa JR, Brown M, Crawford P. Clinical inquiries. Is DEET safe for children? J Fam Pract. 2005 May;54(5):468-9.
7.   Katz TM, Miller JH, Hebert AA. Insect repellents: historical perspectives and new developments. J Am Acad Dermatol. 2008 May;58(5):865-71.

8. CDC web site for “Insect Repellant Use and Safety”: URL: http://www.cdc.gov/ncidod/dvbid/westnile/qa/insect_repellent.htm Accessed 7/9/2009

6-Feb-10 0:00 AM

The Flu at a Glance

Tara Smith, PharmD - noemail@kidsmeds.info — Wed, 03 Feb 2010 05:00:00 GMT

What is influenza?

Influenza, or the flu, is a contagious infection of the respiratory tract caused by influenza viruses that can make people very sick. People with the flu might have a cough, sore throat, fever, chills, or a runny nose. They may also have a headache, muscle aches, weakness, diarrhea, loss of appetite, nausea, and vomiting. http://www.flu.gov/individualfamily/about/index.html

What is the difference between seasonal influenza and H1N1 influenza?

Seasonal influenza virus usually makes people sick in the fall and winter months. It can be mild or serious. http://www.flu.gov/individualfamily/about/seasonalflu/index.html
H1N1 influenza virus (or "Swine flu") is a different flu virus than the seasonal flu virus. H1N1 flu will occur in the fall and winter, but it can also make people sick in the spring and summer. It can be very serious. http://www.flu.gov/individualfamily/about/h1n1/index.html
Antiviral medicines work against both the season flu and H1N1 viruses.
There are two different vaccines (seasonal flu vaccine and H1N1 flu vaccine) being offered. http://www.flu.gov/individualfamily/vaccination/index.html#seasonal

How do I recognize if my child has the flu?

Call your child's doctor if your child gets sick with a runny nose, sore throat, or cough along with muscle aches, fever (often high), chills, nausea/vomiting, and loss of appetite. It is important to treat the flu early with antiviral medicines. Call the doctor as soon as you think your child has more than just a common cold. http://www.flu.gov/individualfamily/prevention/medicine/index.html

What can I do to prevent my child and myself from getting the flu?

Wash hands often with soap and water.
Cover coughs and sneezes with an elbow. Turn away from other people.
Get both the seasonal flu vaccine and the H1N1 flu vaccine as soon as possible, especially if you or your child are at high risk for getting sick with the flu. Children and pregnant women are at high risk. Children as young as 6 months old can get the vaccines.
Avoid being around others who are sick. If a child you care for has the flu or flu symptoms, keep him home away from other children until he is well again. http://www.flu.gov/individualfamily/caregivers/index.html
Check with your child's school or daycare for rules about when a child can return to school after being sick.

How can I find out where the flu vaccines are being offered?

Call the local health department or your child's doctor to check their supply of the vaccines. They may offer clinic times to give the vaccines. You can also visit http://www.flu.gov/whereyoulive/index.html to locate a clinic near you.

If I get sick, how do I keep my child and those around me from getting sick?

Call your doctor to see if you need antiviral medicines or if you need to go to the hospital. Antiviral medicines can make the illness milder and help you feel better faster. The medicines must be taken as soon as you start feeling sick. http://www.flu.gov/individualfamily/prevention/medicine/index.html
If you must be around other people, wear a mask to cover your nose and mouth. http://www.flu.gov/individualfamily/prevention/facemasks/index.html
Stay in a separate room of the house as much as possible while you have flu symptoms.
There are some over-the-counter medicines that can help relieve flu symptoms. Ask your pharmacist about them.

Where can I get up-to-date information on the flu, vaccines, and treatments?

The Centers for Disease Prevention and Control (CDC) offers helpful information on their websites: www.flu.gov and www.cdc.gov/flu.

Specific information for your state can be found at http://www.flu.gov/whereyoulive/index.html.

2-Feb-10 11:00 PM

Cough and Cold Medicine

Leslie Briars, PharmD - noemail@kidsmeds.info — Thu, 22 Jan 2009 17:00:00 GMT

As a parent, you may be confused by cough and cold medicines in the pharmacy. There are over a hundred of these products. Each one of them contains different medicines and different doses. If your child is sick, you should give them lots of liquids to drink and make them rest. Here are some tips to help you if your child has a cough or cold.

Non-medicine remedies: Non-medicine remedies may be helpful for some children. Here are some examples:
1. Cool mist vaporizers: These will add moisture to the air. They can also thin secretions.
2. Nasal bulb syringe: These can stop congestion in infants with stuffy noses.
3. Saline drops or spray: These can stop secretions in the nose for older infants and children. Use these four times a day. Follow the directions carefully.
Children less than four years of age: Ask your child’s pharmacist or physician before giving them medicines. These medicines can cause side effects in children less than four years of age. The Consumer Healthcare Products Association (CHPA) has recommended that manufacturers modify the product labels of OTC cough and cold medicines to state "do not use" in children under 4 years of age. The Food and Drug Administration supports this effort. Products will continue to be available during this transition time, so it is very important that parents ask their pharmacist or physician before giving these medications and follow the instructions on the label carefully. For older children, look at the label on the medicine. This label should give a dose for your child. Ask your child’s pharmacist or physician if you have questions.
Single product medicines: It is best to use single medicine product if your child is sick. These medicines will treat just the symptom that your child has. Here are some examples: Pseudoephedrine (Sudafed^®), (Dimetapp^®) and phenylephrine (Vicks^®, Neo-Synephrine^®) are used to stop stuffy noses. Diphenhydramine (Benadryl^®) and chlorpheneramine (Chlor-Trimeton^®) are used to stop runny eyes or noses. Guaifenesin (Robitussin^®) is to break up chest congestion. Dextromethorphan (Delsym^®, Vicks 44^®, Robitussin Pediatric Cough^®) is used to stop a cough.
Combination medicines: Medicines used to stop cough and congestion are not the same. Your child may not need a combination medicine if they are sick. Combination medicines may cause side effects. Many combination medicines have the same main ingredients. Ask yourself these questions to pick the best medicine. Does my child’s cough stop him/her from sleeping? Does the congestion make it hard for my child to eat? These questions will help you choose the best medicine for your child.
Medicines with acetaminophen (Tylenol^®): Do not choose combination medicines with acetaminophen (Tylenol^®). Read the label carefully. Give this only if your child has fever or pain.
Medicine measurement devices: You can use the measuring device that comes with your child's medicine or you can also use an oral syringe. These are sold at most pharmacies and are not expensive. Do not use tablespoons or teaspoons for medicines.
Vitamin C and Zinc: Do not buy vitamin C and zinc medicines. These medicines are not helpful. They can cause side effects in large doses.
Chicken soup: Chicken soup is a home remedy. It can help your child if they have a sore throat. It also helps with getting your child to drink fluids. It does not cure the flu or common cold.
Cold weather: Cold weather does not cause colds. The flu and colds are more common in the winter. This is when there are more viruses in the community. Your child can get a cold any time of the year. Make sure your child gets a flu shot every year. Hand washing is also very important to avoid catching colds from other people who are sick.

****You can find more information on the internet at the Food and Drug Administration

http://www.fda.gov/drugs/drugsafety/publichealthadvisories/ucm051137.html

22-Jan-09 11:00 AM