Penicillin Allergy

Let’s talk a bit about antibiotic allergy. While I have gone on forever about the dangers of overuse, of course antibiotics are one of modern medicine’s most useful tools. It is therefore of benefit to have the option to use any of these agents should the appropriate picture present.

And, naturally, the first among equals in this medicine class are penicillins (and related cephalosporins).  While being able to prescribe is great, seeing a patient develop complications is troubling.  Most know the typical side effects of drug allergy: hives and swelling, as well as coughing or wheezing; also there are more serious ones like “serum sickness” (fever, joint pains, nausea, also rash), and more threatening allergy reaction with thready pulse, shock, throat closing, loss of consciousness.

And reports of penicillin allergy are quite common–10% of patients.  But HOLD ON–careful study demonstrates that the large majority of those reports actually have no medical basis.  Adverse side effects like abdominal discomfort, nausea, vomiting, diarrhea, are common, as well as vaginal itch, discharge, thrush, and mild body rashes.  Many of these problems are inaccurately labelled “allergy” by lay public and even well meaning if uninformed medical providers.  Additionally, some report “penicillin allergy” based on vague personal history from distant past or even because of close family members reporting allergy.  While these problems can be annoying, they have no predictive value of the more dangerous medical allergy reactions listed in the previous paragraph.  Those true allergic reactions are caused by activation of the body’s allergy/immune/IgE system which can progress to dangerous problems and must be taken more seriously.  Therefore, that diagnosis should be made carefully and cautiously. One study from Mayo Clinic demonstrated that of 384 people claiming “penicillin allergy” 94% actually were not when tested scientifically and these people all subsequently tolerated penicillin well.  The incidence of anaphylaxis is only 0.1-0.5%.

Over diagnosis is not a trivial problem.  People diagnosed as penicillin allergic are then given other “broad spectrum” antibiotics that typically have greater risk of side effects like abdominal problems compared to penicillin.  There is also a significant cost factor.  One recent study demonstrated a savings of over $192,000 in one year in one large municipal ER alone by accurately assessing children labelled “penicillin allergic” and avoiding the use of  more expensive alternatives.  Those patients, again, were administered penicillins safely.  Of greater importance and concern is the risk of infection caused by these alternative drugs themselves.  A large study from Massachusetts General Hospital reported its findings that use of these agents increased the risk of MRSA infection by 69% and of Clostridium dificile (“C dif”) infection by 26%.  That is a major concern both individually and as a matter of public health.

So I urge those designated “penicillin allergic” to carry a healthy dose of caution and skepticism regarding that diagnosis for your child.  Please come in to discuss it with me.  Let’s explore it carefully and diagnose it accurately, for your child’s best health and protection.

Thanks for following.

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Slide Safety

As a kid, my generation called it “the sliding pond.”  I have no idea how a “slide” had the characteristics of a “pond” to us–but never mind.  This post has nothing to do with that.  Here’s a very exact recommendation for a very specific injury: broken foot/leg for a child on a child slide. Studies show that from 2002-2015 there were > 350,000 leg injuries from children <6 years old riding slides on the laps of their parent’s/caregiver’s laps. The highest incidence was in children 12-23 months old and 36% involved actual fractures of foot/leg. The mechanism of injury is almost always the child’s lower extremity getting caught between the adult’s body and the slide as they progress downward and the momentum of the ride down against the inertia of the adult’s larger body causing a twisting action of the child’s foot/leg and–yecch! Generally the greater the discrepancy between adult and child size, the greater the risk–but from a practical standpoint the size of the child is mostly irrelevant–bigger adult means greater risk, so fathers cause more injury than moms.

So, its pretty simple, folks–don’t do it!! If you want your child to enjoy a ride on a slide then place the child ALONE on the slide and you stand next to him/her and allow them to slide down themselves with you immediately adjacent, shepherding them down as they go. DO NOT place the child on your lap and ride down that way–EVER!!  If you aren’t comfortable doing it that way, or if you feel that your child is not ready to do it that way, then find something else to do at that playground that day.

Check out this picture that illustrates what can happen:

OUCH!

So please keep this in mind next time at the playground.  Send along questions and comments, and thanks for following.

Burn Prevention

Every parent lives in fear of burn injury to their child.  Here is a good, fairly comprehensive list of safety measures.  How many do you practice?

  1. Do not let cooking appliance electric cords hang off of counter.
  2. Do not leave hot beverages or foods unattended or near the edge of table.
  3. Keep hot beverages away from children and do not have a child sit in your lap if you are drinking a hot beverage.
  4. Teach older children how to safely remove hot food from microwave and stove top.
  5. Minimize use of stove front burners.
  6. When carrying hot food in kitchen make sure young children are not in your path.
  7. Test bath and shower water temp with your hand for 30 seconds before using.
  8. Never leave young children unattended in bath or shower.
  9. Adjust water heater to no higher than 120 degrees.
  10. Avoid leaving unattended pots on stove.
  11. Keep children away form fireplace and wood stove doors.
  12. Install smoke detectors on all floors of your home and test monthly.  Ideally, they should be hard wired with battery back up.
  13. Replace smoke detector batteries at least annually.  Keep a schedule.
  14. Practice home fire drills and make sure children know how to exit the house in the event of a fire and where to meet outdoors.
  15. Keep fire extinguishers in kitchen, furnace room, and by fireplace.
  16. Teach children to exit the house low to floor if their is smoke in the room.
  17. Obtain a safety ladder if your home has a second floor.
  18. Teach children to not use elevators to escape a fire.
  19. Teach children to “stop, drop, and roll” if clothing catches fire.
  20. Avoid smoking indoors.
  21. Minimize storage of flammable liquids, keep them away from child play areas or from potential ignition sources.
  22.  Minimize extension cord use.
  23. Keep matches and lighters out of the reach of children.
  24. Avoid use of fireworks.

Thanks to Robert L Sheridan MD from Shiners Children’s Hospital of Boston Massachusetts who’s article ” Burn Care in Children” is the source of the above list.

Please call with any questions or comments, and thanks for following.

Your Teen’s Cellphone

Remember the “Blockbuster Bowl” on New Year’s Day;  video rental stores?  Where did they go?  An entire industry came and went in only a blink of an eye–a few years, really.  As a still new grandpa I marvel AND fear the rapid evolution of technology and its effects on youth.  This is probably most evident in the proliferation of smart cellphones over the last years.  This was mere science fantasy for my generation as teens, and was mostly in its infancy as my children went through high school.  But its a major part of young families’ worlds now.

Here are a few suggestions to consider:

  1. BE A GOOD ROLE MODEL! Get off the phone yourself.
  2. Set time and place limits for appropriate cell phone use, and stick by them yourself.  No cellphone use AT ALL during homework, family meals.  I think 1 hour/school day and 2 for weekends/vacation days is reasonable.
  3. No phone overnight in child’s room.  This is key.  I cannot tell you how many kids I see complaining of fatigue, headaches, difficulty in school where I find that the likely root cause is poor sleep, as they are up till whenever on line or communicating still with friends (about the usual teen high school social issues and nothing more).  No–not mono, ADHD, or any of those things(at least often not). It’s the darn phone!
  4. Other activities. Read books – take your family to a bookstore or library, especially now that summer is here. Read books yourself. Play sports together – tennis, have a catch, ride a bike, take a walk. No phones during these activities. 
  5. Educate your child about the public nature of online communication.  These devices are NOT private but rather are a combination of billboard and megaphone, I tell young people.  Before posting/sending ANY information–verbal or pictorial–ask yourself this question, I say: do you want everyone, including grandma and/or your worst enemy, to see this?  Because they will.  REMEMBER THAT.
  6. There are good apps out there to help manage your child’s phone use: OurPact, KidsLox and Google Family Link; cost: approximately $50/year. These apps enable you to shut the phone off at a scheduled time, limit the use (internet and text) and can enable you to keep tabs on sites visited. These apps even allow you to add time if YOU feel it’s necessary.
  7. Know your limitations. Again, now into my 7th decade, much of this tech stuff is quite foreign to me. You younger parents mostly grew up in a computer/tech world. But unless you actually do tech for a living, you likely know less here than your kid. So be humble. There are few filters or monitors you can apply that your child cannot at least partially work around. So avoid over-confidence and remain vigilant.

Let’s face it – these tech options aren’t going anywhere, and given the many benefits they bring to society, nobody says they should. But be aware of their disadvantages as well as their advantages.

Thanks for following.

Sports Participation Readiness

With Memorial Day just a week away, what are for me the best 6 weeks of the year–to July 4–are upon us.  Children are now preparing for summer sports and we’ll even begin fall sports physicals soon.  Let’s take a moment to recall some important principles.

30 million US children participate in organized sports annually.  1/3 will sustain injuries serious enough to require formal medical attention at an annual cost of $1.8 billion.  There are important differences regarding youthful athletes that we should keep in mind:

  • Large surface area to body mass ratio
  • Larger head compared to body size
  • Protective gear may be ill fitting
  • Growing cartilage more injury prone
  • Evolving motor skills

A few other considerations:

  • Children are still growing
  • Within competition groups the size, maturity, and ability level between participants can vary considerably
  • Open growth plates (cartilaginous) are more injury susceptible

Adequate nutrition is essential:

  • Calories–good meals before training or competitions
  • Protein–essential for muscle growth and recovery
  • Vitamin D and Calcium–one study of forearm fractures showed that almost 50% of those injured were clinically vitamin D deficient; 1/2 of them required surgery.  Get the kids out in the sun at least a bit, especially Black children in winter months (more melanin means less sunshine metabolized vitamin D conversion in the skin).  Note this is particularly important for girls
  • Hydration–important to drink plenty of fluids before, during and after athletic participation, especially on hot days

Suggestions for  competition readiness:

  • Be in good condition–GET YOUR SPORTS PHYSICAL.
  • Wear all appropriate safety gear
  • Know how to use all equipment and be sure that gear is properly tuned and in working order
  • Warm up beforeheand
  • Proper rest–teens need > 8 hours of sleep/night.
  • Never play through pain. This cliche of “pain is weakness leaving the body” is dangerous nonsense.  Pain is your body telling you something is wrong.  Listen!

It is also essential for responsible adults to create the proper atmosphere:

  • Proper coaching–Coaches should have knowledge of the sports commensurate with the level of competition (college varsity and summer rec league obviously not the same).  It should ALWAYS be fun.  Youth sports can teach a lot about life. But it is NOT life–it is recreation.  I cannot overstate how I abhor the hyper-intense “winning is the only thing” or “failure is not an option” mentality.  It is both physically and psychically destructive.  People fail–it happens all the time; the world doesn’t come to an end and learning to cope with it builds character at least as much as winning.  And losing is a thing too.  Nobody always wins.  Most of us know at least one person who feels that they can, must, or deserve to always win.  Just read the newspapers!  Mostly those are very unlikeable people.  Who wants to cultivate that mentality?
  • Proper officiating and respect for those performing that function to maximize physical safety and a sportsmanlike atmosphere
  • Know the rules

Lastly, a few thoughts on avoiding overuse injury

  • Max training in hours/week should not exceed the athlete’s age in years
  • By middle school only one team and one organized competition/season
  • I strongly urge young athletes to take one season completely off from all organized competition and one season to play a completely different sport
  • If a child misses time due to illness or injury, 1 day of practice for every 2 days missed before return to competition

The percentage of people in a given age cohort who reach Olympic or major professional sports league competition is ridiculously, laughably small.  Turning your family life or financial world upside down in pursuit of such an unlikely achievement is, overwhelmingly, a fool’s errand.  If it happens, it happens.  But mostly take youth sports for what it is.  You and your children will likely be much happier and fulfilled that way.

Thanks for following.

Bugged about bugs (not that one!)

Now that we can finally enjoy spring weather and anticipate summer sunshine, I’m seeing more insect bites of late.  Let’s review a few basic concepts.

First, generally one insect’s bite looks much like the next–red, itchy bumps; there are only a few species who confer a bite with specific appearance.  Often there is swelling initially that usually dissipates within 24 hours or so; swelling in that time frame usually does not suggest infection.  Typically cold compresses and benadryl for itch is all that is needed here.  Keep fingernails trimmed so any scratching is done by blunt fingertips and not sharp nails to limit promoting infection.  Infections are different–firstly, usually, they hurt.  Moreover, if we think about an infection “growing”–somewhat like a plant–then we can understand the GERMS as akin to SEEDS that must GERMINATE.  In other words, like a plant that takes time to grow after the seeds are planted, the infection will take some period of time to “grow”(incubate)–generally 3-4 days–for the infection to develop.  So the usual progression is bite, swelling, improving, then 3-4 days later renewed swelling, redness and pain at the site.  So the former usually does not require any medicine and the latter may well require a course of antibiotics.  Those lesions associated with fever, blisters, pus, or red streak growing towards the body may be more serious and could require IV treatment.

Tick bites are a special case. I have covered them before.  If you find an embedded tick it should be promptly pulled out INCLUDING THE HEAD with a tweezers.  Don’t waste time trying to cover it with vaseline, other caustic agents, or burning it with a match.  Clean the wound off with the best antiseptic in the house(for any open wound)–soap and water.  It is allowable, although not essential in my opinion, to have the live tick tested.  There are limited circumstances under which preventive treatment is indicated and they do not involve identifying lyme in the tick. Note that one does not have to develop the classic “bull’s eye” rash to develop lyme disease, and that the symptoms of lyme infection are specific and well defined–it isn’t just joint aches, headaches, and tired all the time

Finally–prevention.  The best approach is avoidance.  Stay away from standing water (chemically treated pool does not count here)or thick vegetation early or late on summer days when and where insects are most active. Avoid walking in high grass or thickly wooded areas and wear long sleeves and pants if you do; generally better to dress in long sleeves and pants outside anyway if weather permits.  Insect repellent on bare skin is fine; reapply every few hours for prolonged exposure–just wash it off as soon as possible.

But its the spring, so get the heck out there and have fun.  Thanks for following.

Window Blind Cords

Toddlers and cords don’t mix.  That is the message from a recent study published in the journal Pediatrics.  The study examined injuries in children<6 years of age caused by window treatment cords.  This has been a well known hazard among pediatricians, manufacturers, and safety engineers for many years.  Unfortunately, however, and despite numerous product modifications over the years, the rate of occurrence has not changed too much.

Between 1990-2015 there were almost 17,000 cord related injuries treated in US Emergency Departments.  Fortunately, the large majority–93%–were minor injuries that were treated and the patients discharged. Mostly children were just struck by hardware when they pulled too vigorously on the cord.  However, that doesn’t tell the whole story.  12% of all injuries were entanglements, 80% of those involved the neck.  as a result, there were 761 hospitalizations and, worst of all, 271 deaths in that timeframe.  The greatest risk was in 1-4 years but serious injuries were reported up to age 9.

These deaths occurred often during nap time when the child was, obviously, left unsupervised and became entangled in a blind cord close to the crib or bed.  Of course, naturally inquisitive kids often cannot resist experimenting with a newly discovered object, so the fact that that window treatment “has always been there” provides no safety assurance whatsoever.  As, in this scenario, the child’s neck is entangled and she is strangling, the danger is silent.  It is entirely possible that one would not even hear it over a room sound monitor.

Numerous technical innovations have been tried but, as we can see, they have not had much impact.  So what to do?

  1. Examine all window treatments front, side, and back for accessible cords.
  2. Use cordless or inaccessible cord window coverings only.  This goes for grandparents home as well, as seniors often find the old pull cord products to be easier to operate.  Where possible switch to shades.
  3. Use open cord pulls–no loops (cut them if possible)
  4. If you have such products and replacement cost is an issue, at least do so in the child’s bedroom and play area if possible.
  5. If cost is prohibitive or replacement is impractical, keep blinds pulled all the way to the top and wrap up all cords and place out of reach whenever the child is in that room.  Try to never have such products used near the child’s crib or bed.

New safety initiatives under review by the American National Standards Institute should result in >80% of window coverings sold in the US and Canada to be cordless or cord inaccessible by the end of this year.  But there is no substitute for awareness and caution.  As always, the buck stops with us parents.

Thank you for following.