What’s in a teaspoon?

medication-teaspoonWhen I was growing up, no one used syringes or measuring cups to dole out medication. As a result, a child could easily be over or under dosed. Why? Because the spoons used for ice cream and yogurt can vary a lot in terms of what they hold. Nowadays, doctors and parents need to be more precise in the way they give medicine to kids.

If a doctor tells you to give your child a teaspoon of Motrin for fever, he means you should administer 5 ml, not what fits in the spoons you use at mealtime.

Modern parents know this, but I thought it was worth blogging about. A measured teaspoon is 5ml. It can be given with a syringe, a measuring cup like in the picture above or in measuring teaspoon.

Is it OK to give kids fever (or other) medicine before a doctor’s visit?

kid's tylonol before doctor visitLots of parents think that giving a child acetaminophen or ibuprofen prior to seeing the doctor will compromise the visit. This is not true. Fever reducing medicine won’t make it harder for the doctor to figure out what’s wrong. In fact, reducing a child’s fever usually makes it easier for the doctor because the child is more likely to cooperate if her temperature is lower during the visit.

The same thing is true for asthma medicine or any other drug your child is taking. Unless the doctor or nurse specifically tells you not to give a medicine before a visit, you should do what you can to control your child’s symptoms.

Why do kids have to be fever-free for 24 hours before returning to school?

Why do kids have to be fever free for 24 hoursBody temperature varies throughout the day whether you’re sick or healthy. If you take your daughter’s temperature three times a day for a number of days, you will see that the highest readings come in the evening. Similarly, if she is sick, you are more likely to find high temperature at 9pm rather than 9am. This diurnal variation in body temperature causes two problems for parents. First, it’s harder to manage high fevers at night when everyone is trying to get some sleep. Second, if your feverish child wakes up cool, you may think all is well until the fever returns in the afternoon or evening. Although it’s not always clear when a child isn’t contagious, most schools have adopted a 24-hour fever free policy because they know temperatures can come back as the day progresses. That’s why you shouldn’t take your kids to school the morning after a feverish night.

Are spider bites dangerous?

Spider BiteAlthough a fear of spiders is on everyone’s top ten list of phobias, most spider bites are (a) not dangerous and (b) occur without the victim even knowing it happened.

Because I’m a pediatrician, most of the spider bites I see happen to children. I have also noted that the ear is the most common place where these bites occur. (The above picture is one of my patients.) I’m not sure why this happens, but I’ve often wondered if it’s because the ear has a large, convoluted surface area that attracts the spider or gives it a place to hide. It’s also possible that the warmth of the ear attracts spiders.

Spider bites usually occur when kids are outside playing or at night while they’re asleep. However, don’t worry that Aragog is stalking your children at night. (Aragog is the name of Hagrid’s spider friend from the Harry Potter books.) The spiders that bite people are tiny ones that are easy to miss even in the daytime.

The typical spider bite presents as a red, swollen area that is warm or hot to the touch, but doesn’t hurt much. In fact, most of the time, they itch more than they hurt.

The bites from black widow spiders and brown recluse spider scan be very dangerous, but in 30 years, I have never had a patient in this region of the country bitten by one of these species.

Parents often give children Benadryl for spider bites assuming the child is having an allergic reaction to the bite. Benadryl doesn’t usually work because the swelling that accompanies spider bites is a local inflammatory reaction to venom rather than an allergy. However, Benadryl may help if the bite itches. The main first aid treatment is to put something cold on the area to reduce the swelling. My favorite remedy is a bag of frozen peas because it conforms to the swollen area.

Kids who get spider bites are often treated with antibiotics because of a concern that the area is infected. Although this is possible, “garden variety” spider bites rarely get infected, possibly because the venom kills any bacteria in the area.

If a spider bite is very swollen, oral steroids may help because they are anti-inflammatory medication.

Swallowing capsules versus pills

PillsThis is a simple tip, but one that makes a big difference when you have to take a medication for 10 days. The basic difference between capsules and pills is that capsules float and pills sink. If you put a capsule in your mouth, take a sip of water and throw your head back to swallow the capsule, it will be hard because the capsule will float on the water and move away from the back of your throat. The best way to take capsules, therefore, is to take a mouthful of water, put the capsule in your mouth and then lean your head forward as you swallow. When you do this, the pill will still float on the water, but now it will be at the back of your mouth and go down more easily.

Because tablets sink, the best way to swallow them is with the opposite maneuver. Take a mouthful of water, put the pill in your mouth and lean your head back when you swallow.

If you have trouble swallowing pills and capsules, I discussed a trick for doing this in an earlier blog.

When does medication really expire?

when-do-medications-expireMost medicine cabinets contain a variety of prescription and nonprescription medication. Some drugs, like allergy medicine, are used intermittently or for long periods of time. Other drugs, like antibiotics, are generally used short-term for an infection. If a doctor prescribes medicine for intermittent use, you’re supposed to keep the pills or liquid on hand for whenever you need it. If a doctor prescribes a drug for acute use, such as a strep throat, you’re supposed to throw away any remaining medicine so you’re not tempted to use it in the future without the doctor’s advice.

All drugs have expiration dates. With nonprescription drugs, the expiration date is printed somewhere on the bottle or tube. With prescription drugs, the expiration date is printed on the instruction label that tells you how to take the medicine.

If the medicine has a short lifespan, the pharmacist will put the appropriate expiration date on the bottle. This is common with antibiotic suspensions that are used with children for ear or sinus infections. However, even if the medicine has a long shelf life, like most pills, the pharmacist is required by law to indicate that the prescription expires one year after it was filled. The reason for this is to reduce the risk that a patient will use the drug inappropriately.

In some cases, it’s okay to use the true expiration date instead of the one listed by the pharmacist. The best example of this situation involves medicine that comes in a tube. In addition to the one-year expiration date provided by the pharmacist, all tubes have the “real” expiration date stamped on the crimp, which is the folded metal part at the bottom of the tube. That being said, it’s always a good idea to check with your doctor before using a prescription medicine.

Why creams sting

CreamI get lots of calls that children complain when parents use either prescription or non-prescription creams to treat eczema and other rashes. In many cases, parents think their kids are just being difficult, and there is no way a cream can sting. Your kids are not making this up.

Most creams contain a substance called propylene glycol. Although propylene glycol is not dangerous, it can sting if a child has tiny cuts or cracks in his skin. The best way to deal with this is to use ointments instead of creams.

I prefer ointments not only because they don’t sting, but also because they do a better job moisturizing the skin. Parents are often hesitant to use ointments because they are greasy. You can manage the greasy quality of ointments by being careful to only apply a thin layer to the skin. The best way to do this is to rub some ointment onto your palms before applying it to your child’s skin.

Fever management for children who can’t (or won’t) take oral medication

In a recent article, I stated that fever does not always need to be treated. In many cases, however, it’s worthwhile to treat fever to help children sleep or prevent them from becoming dehydrated.

There are two situations when parents will have difficulty managing their child’s fever with oral medication. First, if the child is unable to keep the medication down because he is vomiting. Second, if he is being uncooperative and won’t take the medication in the first place.

In general, I don’t use my blog to endorse products. However, parents should know about an over-the-counter medication called FeverAll that will come in handy if their child can’t take acetaminophen by mouth. FeverAll is acetaminophen in suppository form. It’s safe to use and works as well as oral acetaminophen. It is worth having FeverAll in your medicine cabinet in case your child gets sick at night or when it would be difficult to buy the medication on an urgent basis.

FeverAll comes in three doses: 80mg, 120mg and 325 mg. You use the same dose as you would with oral acetaminophen. Directions for inserting suppositories into the rectum are included with the packaging.

Teaching children to swallow pills

Learning to swallow pills is difficult for many children. One technique I find helpful is to “hide” the pill in another food before attempting to swallow it. Bread is an excellent choice because it’s sticky and easily encases the pill. Before you suggest the technique to your child, remind her that she swallows large chunks of food all the time. The reason this trick works is because the bread “fakes out” her throat so it doesn’t know a pill is coming. This is how it works.

  • Have your child chew a small piece of bread.
  • Once the bread is gooey, ask him to push the pill into the center of the bread.
  • Next, ask him to move the bread/pill mixture to the back of his mouth and swallow it with a sip of water.
  • Have your child practice with small pieces of candy like tic-tacs. Once this has been mastered, she can graduate to M&Ms and capsule-shaped candy like Mike and Ike.
  • Once your child has done this a few times, swallowing a pill is usually easy.

I use a variation of this technique for children who take time-release capsules, but can’t learn to swallow the pill. Time-release capsules can be opened and their contents can be mixed into pudding or applesauce. To ensure that children don’t chew the beads, I have them practice with candy sprinkles. Once they have done this a few times, they can accomplish the same thing without crushing the granules of their medication.

Be careful if your child is taking an antibiotic you are allergic to

Before prescribing antibiotics for children, doctors ask if the child has any known drug allergies. It is not uncommon in this situation for parents to mention their own history of drug allergy. A doctor’s standard response is to reassure parents that their child is unlikely to be allergic to a medication just because they are.

I have had two experiences that illustrate an important twist to this scenario. In each case, I put a child on amoxicillin despite the parent’s history of amoxicillin allergy. Both parents inadvertently licked their fingers after giving the medicine to their children. One parent developed an itchy rash that responded to Benadryl. The other parent developed hives that required a trip to the emergency room.

The lesson here is obvious—while it is routine practice to administer medications to children regardless of their parent’s allergy history, be sure that you do not inadvertently ingest the drug yourself.

How to prevent prescription medication from running out too soon

One of the most common complaints I hear from patients is that liquid antibiotic prescriptions never last as long as they’re supposed to. The reason this happens is because most antibiotics come in set amounts and pharmacists are not allowed to add extra to make sure patients do not run out early. To get around this policy, I calculate how much a child needs for a full-course of treatment and then prescribe the next larger size bottle. For example, if a child is taking 1 tsp of amoxicillin twice a day for ten days, he needs a 100 ml bottle. When I fill out the area on the prescription that says how much the pharmacist should dispense, I write 150 ml instead of “ten-day supply.” You can ask your doctor to do the same thing.

An uncommon, but serious side effect of acne medication

Tetracycline and its derivatives (doxycycline, minocycline) are commonly used to treat acne. I have noticed that dermatologists sometimes forget to warn patients that a severe sore throat may occur if these medications dissolve in the esophagus. This can occur if the capsule “gets stuck” on the way down or if a teenager has an episode of stomach reflux while lying down and the capsule washes back into the esophagus. Although there is a warning label on the bottle that instructs patients to take the medication with lots of water, people do not always read these labels. 

To avoid this situation, I always tell teenagers why it is important that the capsule makes it into the stomach. I also prefer derivatives such as doxycycline because they can be taken with food. This reduces the chance that the pill will lodge in the esophagus and circumvents the need to take the medication on an empty stomach before bed. If one of my patients remembers to take his acne pill within an hour of bedtime, I tell him to skip the dose that night. 

Make it easier for young children to use asthma inhalers

When children with asthma get to be two or three years of age, most doctors switch from nebulizers to handheld devices called metered dose inhalers (MDIs). There are two advantages to MDIs. First, they deliver inhaled medication faster than nebulizers. Instead of taking five or more minutes to complete the treatment, MDIs get the job done in less than a minute. Second, the size of the particles coming out of MDIs is smaller than nebulizers and therefore can penetrate deeper into a child’s bronchial tubes. Spacers comes with or without a mask that covers the nose and mouth. Younger children use the mask version.

Despite these advantages, some children do not like the aftertaste of the medications used with MDIs. A great way to reduce this unpleasant taste is to tell your child you are going to give him two treats with his medicine. The first treat consists of a couple of chips that he can eat before he uses the inhaler. The chips coat the mouth with a salty/oily flavor that reduces the unpleasant taste. The second treat can be a small piece of candy or something else he can have once he’s finished. If you are opposed to giving your child candy as a reward for taking medication, a piece of cheese and a glass of juice may work as well.

Don’t diagnose drug allergies over the phone

The parent of a 12-month-old patient called my office recently and talked to one of my nurses. I had put the infant on antibiotics the previous day for an ear infection, and the baby woke up with a rash. The parent asked if we should diagnose the baby with an amoxicillin allergy and switch her to a different antibiotic. The answer was no. Instead, I saw the baby and determined she had a heat rash from the fever that had accompanied the ear infection.

It is difficult to diagnose drug allergies for a number of reasons. First, children commonly get rashes from viral infections and other causes (fever, insect bites, etc). Second, allergic reactions can manifest themselves with a variety of skin findings, some of which are hard to “pin down” as being allergic in nature. Third, most drug allergies can not be diagnosed by skin testing.

Over the years, I have seen a number of patients who were diagnosed with a drug allergy based on a phone conversation. This is not a good idea for two reasons. First, it is difficult to describe a rash over the phone. Second, given the importance of labeling a child as being allergic to a medication, doctors should have all the facts before making this determination.

Unfortunately, real life can complicate this process. Unless a child is having a severe reaction, it is problematic to send the family to an emergency room in the middle of the night to be assessed for a possible drug reaction. When you see the child the following morning, the rash may have disappeared or faded so much that it is impossible to make a diagnosis. However, because most people have cell phones days, taking pictures of the rash when it was at its worst may help in this situation.

If your child develops a rash while taking an antibiotic (or other medication), she should be seen to confirm or “rule-out” an allergic reaction. If your healthcare provider attempts to make a phone diagnosis, you should insist that the child be seen.

Putting drops in children’s eyes

The most common reason children need eye drops is to treat conjunctivitis due to infection (pink eye) or allergy. The proper way to instill eyes drops involves the following steps:

  • Have your child lean back on a couch or comfortable chair. It helps if there are no bright lights in the room.
  • Ask your child to look to the side rather than directly at you or the bottle.
  • Gently pull down the lower eyelid and hold the bottle ½ to 1 inch above the eyelid.
  • Squeeze the bottle so one drop falls onto the inner part of the lower eyelid nearest the nose.
  • Ask your child to close his eyes for a few seconds so the drop coats the inner aspect of the eyelids.

Infants and young children are usually uncooperative when it comes to having drops put in their eyes. With infants, parents can usually accomplish the task if one person opens both the upper and lower eyelids while the other instills the drops. Toddlers and preschoolers are impossible to coerce so the technique that works best with this group is to ask them to lie back with their eyes closed. You then place two drops on the closed eyelids nearest the nose. Once the drops are in place, ask your child to blink, which allows some of the medicine to enter the eye. If you’re not opposed to giving your child a treat, you can increase the odds of success by promising him something tasty if he cooperates.

Should you give your child fever medicine before a doctor’s visit?

Parents frequently avoid giving their children fever medicine before a sick visit because they are afraid it will compromise the doctor’s medical evaluation. In reality, giving a child something to lower her fever before a visit usually makes it easier for doctors to determine what is going on. Fever medicine is not strong enough to mask symptoms, but has the potential to make a young child more cooperative during the visit. There is one caveat to this recommendation, however. NEVER give fever medicine to an infant less than 2 months of age because in this age group, doctors need to assess the baby before the fever is treated.

Some tips about food allergies

• Most serious reactions to foods happen away from home two reasons: (1) you don’t ask if a food item contains the substance your child is allergic to and/or (2) you don’t have epinephrine with you. If you have a child with food allergies, never leave home without your Epi-Pen or Twinject.

• Since manufacturers can change ingredients at any time, read product labels every time you go to the grocery store.

• Epinephrine loses its effectiveness if it’s kept in an environment that is either too hot or too cold. Never leave an epinephrine auto-injector in your car during the day.

• Not all ambulances are equipped with epinephrine. Therefore, if you call 911 for an allergic emergency, make sure they send a life-support unit.

• When your child’s Epi-Pen or Twinject expires, practice using the device on an orange or grapefruit. Although these devices come with trainers, it may make you more confident if you practice with the real thing.

• Bring expired epinephrine autoinjectors to your doctor’s office so they can be disposed of with medical waste.

• Buy (and read) a copy of Food Allergies for Dummies by Dr. Robert Wood, a national authority on food allergies.

• Become a member of the Food Allergy and Anaphylaxis Network


Discolored nasal mucus does not necessarily need antibiotics

In the first few days of a cold, the mucus coming out of your child’s nose will usually be clear. By the third or fourth day, it’s common for nasal mucus to turn yellow or green. Parents may misinterpret this to mean the child has a bacterial infection. The reason your child’s mucus turns color is because her body’s defenses begin to kill the virus. As white blood cells “ingest” viral particles, they die and mix in with the clear mucus creating the yellow or green color. This process will go on for three or more days until the viral infection is eliminated. Doctors become concerned about sinus infections if a child is very sick or if the infection goes on too long (usually more than 10 days) regardless of the color of the nasal mucus. In addition, recent evidence has shown that most sinus infections resolve on their own without antibiotics. However, some children will need antibiotics so you should discuss the pros and cons of medication with your doctor.

Strep throats always need to be treated

Most parents are aware of the problem created when doctors overprescribe antibiotics. This practice not only encourages bacterial resistance to antibiotics, but it also increases the odds that your child will become allergic to antibiotics. Because of this trend, the doctor may recommend deferring antibiotics if your child has a mild sinusitis or ear infection. It’s important to know, however, that strep throats are different. Because there is a risk of developing rheumatic fever with an untreated strep infection, doctors always treat strep throats. Therefore, if your child has symptoms of a strep throat or is acting sick and has been exposed to someone with strep, it is important to make an appointment to see your doctor.

Prescription Creams Have Instructions On the Box, Not the Tube

If you take your child to the doctor because of a rash or skin condition, the doctor will often prescribe a cream or ointment. The instructions will state how often and how long you should apply the medication. Because we are a “throw-away” society, most parents toss the box when they get home and put the tube in a convenient location. If you do this, you will not only be throwing away the doctor’s instructions, but the box also contains the phone number for the pharmacy and whether the doctor gave you any refills. So the next time you get a tube of cream, remember to keep the box it came in.