Win a copy of my lecture series in a TV Theme Trivia Contest!

Posted August 18, 2014 by Dr. Roy
Categories: Pediatric Insider information

The Pediatric Insider

© 2014 Roy Benaroch, MD

My lecture series with The Great Courses is doing really well—so far, all 5-star ratings, and initial sales look great! If you’ve already bought a copy of Medical School for Everyone, thanks! If you haven’t, or if you want a second copy for some reason—here’s your chance to win!

The course is a series of 24, 30-minute lectures, all “medical mystery” cases that I hope will be fun to figure out. I’ll give you the clues, and you’ll try to figure out the diagnosis! Along the way, I’ll teach you about medicine, and about how doctors think. It was fun to write and tape the series, and I think you’ll have fun listening or watching it. You can get audio-only or video versions.

If you don’t want to buy a copy, here’s your chance to win a DVD copy! Below are the names of five TV series that I liked as a kid (I’m not apologizing for The Dukes of Hazzard. I liked the car jumping parts and Roscoe P Coltrane’s dog.) In the comments, give me the NAME of the matching theme song. Hint: these theme songs are NOT named “The Theme From Taxi”—they all have real names. If you’re the first person to name a show’s theme correctly (and you’ve given me an email address that works), I’ll get in touch with you to mail you a copy of the course. Cool!

Please only guess one show in one comment—once you’ve won a copy for yourself, don’t give away any answers for the other shows. The idea here is that 5 different people will each win a copy. If you give multiple answers I’ll delete your post. If you’re not a frequent poster here, your comment will be held in moderation—don’t worry, you’ll still win, I’ll give credit to whomever posted first.

 

What is the name of the theme song of:

1. Sanford and Son

2. Taxi

3. M*A*S*H

4. The Benny Hill Show

5. The Dukes of Hazzard

 

Rules: Only one win per person. I’ll pay to mail these in the USA, but if you live somewhere else you’ll have to pay your own postage. I am the final judge of the winners. If you win and you like the course, please post a review at The Great Courses or Amazon. Thanks for playing!

 

Another win for dogs!

Posted August 14, 2014 by Dr. Roy
Categories: Medical problems

Tags: , ,

The Pediatric Insider

© 2014 Roy Benaroch, MD

Trying to decide whether to get a dog? Here’s more evidence that you should!

A 2012 Finnish study looked at about 400 babies from birth through the first year of life. Families kept diaries to track respiratory infections together with information about both dog and cat contacts.

Author and Misty, 1976

Children who lived with dogs had fewer colds and fewer ear infections; they were also prescribed fewer courses of antibiotics. The effects were dose-related, too—more time with dogs increased the health advantages. Cat exposures were much less beneficial.

Author and Lucky, 2014
Author and Lucky, 2014

Other research has shown that pet ownership decreases stress, increases life satisfaction, and may decrease the incidence of allergies. Dogs are also really fun to have around. Please consider a rescue pup from an organization like Furkids/SmallDog Rescue (they’re in Georgia—many other great non-profit rescues can be found all over the country. Look for your own local rescue via Google.) There are some great dogs out there who really need a home, and they’ll pay you back with love, companionship, and fun.

Cats are nice, too. I suppose.

Getting the most out of your child’s checkup

Posted August 11, 2014 by Dr. Roy
Categories: Pediatric Insider information

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The Pediatric Insider

© 2014 Roy Benaroch, MD

In a recent post, I wrote about the value of a yearly checkup with your child’s doctor—it can be a whole lot more helpful than a quick sports physical at the local quickie-clinic. You can be sure to get the most out of your child’s checkups with these tips.

First, and most important at all, go to the visit. You’d be surprised how often children are brought by a cousin or aunt or sitter. Sometimes they bring a list of questions from mom—but what kind of a way is that to communicate? Even better: if both parents have questions, both of you should try to go to the physical. I like meeting both parents. And we’ll all get more out of the visit together.

Bring records of any visits with other doctors, Emergency Departments, and urgent care centers. If your child has been prescribed medications from other docs, bring those, too. Let’s use this as an opportunity to make sure all of the records and straight and all in one place.

Bring questions! A typed list, scribbled notes on a receipt, or a few words typed in a phone app—I’ve seen it all. Any kind of list is a good idea. You won’t get answers if you don’t remember your questions. Bonus pro-tip: put your questions in order, starting with the one you’re most concerned about.

If possible, don’t bring other children (especially young, distracting siblings). I know it’s not always practical, but if you can possibly set up a time for just the child, parents, and doctor to be in a room together, we can best focus on the star of the show. If you do have to bring siblings (and I understand, sometimes you just have to bring the whole family), try to bring something for them to do. Crayons, iPads, whatever you’ve got.

If for some reason you can’t make it on time, reschedule the visit. You’ll get more out of a rescheduled well check than a rushed well check. If you have to cancel, please call ahead of time—at my office, we always have a waiting list of people hoping to grab a cancelled slot. Do someone else a favor and call ahead of time if you can’t make it to your appointment.

Talk with your child in advance about what to expect. The doctor is going to check “down there”, which is OK for the doctor to do as long as mom or dad is in the room (when kids get older, I’ll ask mom and dad to leave—expect that by the teenage years.) We just want to make sure everything is OK, and that means everything. OK?

There may be some things you don’t want to talk about in front of the child. Maybe school problems, or bullying, or maybe there’s marital problems that are stressing your child out. These are all good questions, and sometimes it can be awkward to bring them up. If it’s a quick question, slip the nurse a note that you need a moment alone with the doc. If you think you need more private time with the physician, call ahead and ask how your doctor’s office likes to handle that. It’s unfair to leave a child alone in the room for a long time while you talk secretly with the doctor—and it makes the kids very, very nervous. It might be best to set up a separate time for parents to come in.

For visits with school-aged or other children, be prepared to let your child talk. I know you’ve got questions, too, and we’ll get to those—but I first want to make sure your child knows this is his visit. He gets to talk first. That drives some parents crazy, but that’s the way it works best.

A yearly checkup with your child’s doctor should be more than a time to get a form signed for soccer. It’s a chance to catch up and make sure someone is looking at “The Big Picture.” Parents and doctors both want to make sure that these checkups are valuable for the children and families. Be prepared, and you’ll get the most out of the visit.

Left your amoxicillin or Augmentin out of the refrigerator? It’s probably OK.

Posted August 7, 2014 by Dr. Roy
Categories: Pediatric Insider information

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The Pediatric Insider

© 2014 Roy Benaroch, MD

We get these calls a few times a month—a family, despite dire warnings that their child’s antibiotic MUST be refrigerated, leaves it out on the counter overnight. Can we call in a new prescription?

Sure we can. But we probably don’t need to.

Many children’s antibiotics come in liquid suspensions. Little ground-up particles of medicine (along with flavorings and colorings and stabilizers and other goodies, collectively called “excipients”) are mixed by the pharmacist with water, and the bottle is shaken. Voila, you’ve got a suspension. But the water can break down some molecules especially if the water gets warm. So some of these suspensions are supposed to be kept in the ‘fridge, especially amoxicillin and amoxicillin/clavulanate (commonly called Augmentin.) That’s in the product insert: “keep refrigerated.” And it’s on a little sticker the pharmacist puts on the bottle. But is it really necessary?

Trust science to find out!

From The Journal of Applied Pharmaceutical Science, 2012, comes a study using state-of-the-art liquid chromotography to determine the potency of amoxicillin/clavulanate stored in three ways: refrigerated, stored in a cupboard at room temperature, and with the bottle submerged in water at room temperature (to minimize fluctuations in temperature.) Both the amoxicillin and clavulanate components of the medication kept all of their potency for at least five days. After that, there was a drop off in potency no matter how the samples were stored, though the refrigerated sample stayed the strongest. The amoxicillin portion of the medication lost about 17% of its potency in the fridge after 10 days, versus 25% of its potency in the cupboard. The clavulanate portion was a little bit more sensitive, losing about half of its potency at room temperature by day 7 to 10.

The study was done in Nigeria, where frequent power outages make consistent refrigeration problematic, and where limited resources make it more difficult to easily replace medications. But the results should be applicable here, too: under ordinary household circumstances, both amoxicillin and Augmentin are stable if left unrefrigerated for 5 days, maybe even longer for amoxicillin alone. They considered up to 84 degrees ordinary room temperature—again, this was in Nigeria. I imagine in typical cooler American homes these medications might last even longer sitting on the counter.

Some factors might further influence unrefrigerated shelf life. Light, especially direct sunlight, could potentially break down medications faster; and if the liquid gets really warm, left in a car, that’s going to ruin the medication pretty quickly. And this study only looked at two penicillin-based antibiotics (amoxicillin and Augmentin.) I can’t vouch for other medicines that are supposed to stay in the fridge. But it’s nice to know that for these common antibiotics, a few days at room temperature probably makes no difference.

Pregnant women should get influenza vaccines to protect their babies and themselves

Posted August 4, 2014 by Dr. Roy
Categories: Medical problems

Tags: , , , ,

The Pediatric Insider

© 2014 Roy Benaroch, MD

The kids are heading back to school, and my zucchini vines are withered—that means summer’s almost over, and we’re heading back into flu season. This year, I’m going to try my best to convince as many of you as possible to get yourselves and your children vaccinated.

Why? Because I don’t like to see people suffer and die. We’ve got a good, safe, effective way to prevent influenza—and the more people vaccinated, the better it works. There are very few medical contraindications, and the CDC recommends that everyone aged 6 months and over get the vaccine each year. That helps protect us all.

Today I’m going to focus at the beginning of the life cycle, with pregnancy. We’ve known for a long time that pregnant women are especially prone to complications and death from influenza infection, and ACOG (The American Congress of Obstetricians and Gynecologists) has recommended since 2010 that women receive a dose of injected influenza vaccine during pregnancy. Uptake has been poor, in part because of lingering safety concerns.

There have been several recent studies that provide solid reassurance about the safety and effectiveness of influenza vaccines during pregnancy. In 2013, the New England Journal published a study from Norway that looked at 117,347 pregnancies—vaccinated moms were less likely to get influenza, and less likely to have their babies die. Another study, BMJ 2012, looked at about 55,000 pregnancies in Denmark, showing no increased risk of birth defects, preterm birth, or fetal growth problems after vaccination. That same Danish group published a second study from their data set showing no increased risk of fetal death. The Danish studies looked rigorously for adverse reactions, finding no support for any significant problems, though these studies were not designed to look at the effectiveness of the vaccines.

The effectiveness of these vaccines has already been demonstrated, both to protect mom and to protect baby. Pregnant women ought to make the safe choice: get vaccinated against influenza. It’s the right thing to do for you, and the right thing to do for your baby.

Your child’s doctor should be doing your child’s checkups

Posted July 29, 2014 by Dr. Roy
Categories: Pediatric Insider information

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The Pediatric Insider

© 2014 Roy Benaroch, MD

Yearly checkups for school-aged and older kids can be a great opportunity to help your child stay healthy. Don’t skimp by relying on a cheapo sports physical at a local drug store. They cannot offer the kinds of important things your own doctor’s office can do for your child at a yearly well check.

We’ll review old issues and problems. Still getting those migraines? Last year, we talked about school problems—how is that going now? Walk-in clinics don’t have access to those old records, and don’t care what happened to last year’s problems. We do.

Speaking of old records: checking a height and weight is a crucial way to know if your child is growing as expected. But you can’t know what those numbers mean if you only check them once. We can look at the trends—is your child growing along an expected path, or has something strange happened this last year? Is puberty progressing as expected?

Following trends isn’t just important for physical growth, but also for cognitive and social development—all of these skills can be followed, to make sure your child is OK. Not everyone has to be able to do the same things at the same ages, but we should be able to see new skills developing at an expected rate. It’s not a one-time check, at least not if you want these things checked correctly.

A lack of prior records also means that the quickie clinic can’t assess your child’s vaccine status. These days, it’s especially important to keep your child protected. We’ve got great, effective, and safe vaccines to prevent cancer, pertussis, and meningitis. Let’s make sure your child has what he needs to stay safe, and also to fulfill what he needs for school.

Medical care is sometimes fragmented. A child might visit the Emergency Department for a broken wrist, and then be referred to an orthopedist. Or maybe your child is taking medications prescribed by an allergist, or an asthma specialist, or a psychiatrist. Maybe your teenager had wisdom tooth surgery, and had a reaction to the anesthetic. Your “main doctor”—your child’s pediatrician or family practice doc—has the one office where all of these records need to be. Your yearly checkup is a great time to review the year’s health issues, and make sure everything is documented clearly in one place. Coordinating care between doctors is a crucial role for your child’s primary care doc, who can help prevent medical errors and duplications of testing. We’ll help make sure nothing falls between the cracks.

An essential component of a yearly well checkup is anticipatory guidance. What challenges can you expect this year? Since all children are different, good anticipatory guidance relies on a knowledge of he child as an individual: what are her strengths, and weaknesses? What sorts of things are likely to go well, and what other things might be more of a stumbling block? For anticipatory guidance, we’ll sometimes talk about school, or diet, or exercise, or relationships. Whatever will help your child the most, and whatever will help mom and dad cope with what’s coming next. It’s not a cookie cutter approach. Guiding a family through the challenges of raising a child is not something that’s done best with checklists and preprinted sheets. Knowing a family is what makes this part of the checkup valuable.

One other thing: yearly checkups help create a bond between child and doctor. We get to know them, they get to know us. If something does go wrong, your child will feel much more comfortable working with a doctor that’s known and trusted. Children do sometimes get rare, serious, or perplexing diagnoses. Believe me, you’ll be glad that your children (and you!) feel comfortable with their doctor when it’s needed most.

Your sports physical at the quick-cheap-clinic might get you a signature on a form—and if that’s all you want, by all means, use them. You can even take advantage of their $5 off coupon. But you will get what you pay for.

Cheap doesn't mean good

Even with a discount, you’re not getting much value

Ironically, all ACA-compliant health care plans cover well checks for children with no cost-sharing—no copays, no deductibles, as long as it’s a current plan that meets federal standards. Most insured families pay nothing out of pocket for these yearly checkups, even without a coupon.

Your children deserve more than a minute at a clinic. They deserve, once a year, a visit with their own doctor, devoted to their own health. Not just a quick physical, but a comprehensive review of where they’ve been, where they are, and where they’re going. That’s what a real checkup is all about.

Drug expiration dates: Do they really matter?

Posted July 24, 2014 by Dr. Roy
Categories: Pediatric Insider information

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The Pediatric Insider

© 2014 Roy Benaroch, MD

Mernga wanted to know about drug expiration dates. Do drugs really “go bad”? Or this is just a scam to get people to buy fresh medicine?

The truth is, they’re a little of both.

There are sometimes two separate “expiration dates” on a prescription medication. The first is the one stamped on the package by the manufacturer. You’ll see that one if what you have is in the original packaging, like a tube of ointment or a small bottle of eye drops, or a bottle of pills if you’ve been given an original bottle straight off the shelf.  Sometimes the manufacturer’s stamp is on a box that the tube or bottle came in (the one you’ve already thrown away.)

exp date on package 1

 

exp date on package 2

The manufacturer’s stamped expiration date is a promise that the medication will keep its potency at least until that date, if it’s been stored correctly. It doesn’t mean that on that date it will actually go bad, but the manufacturer is saying, look, if you use this stuff past the date, we’re not responsible for it any more.

It turns out that many medications will keep at least most of their potency for a while after that date. The best studies that are looking into this are sponsored by the US government through “SLEP”—the Department of Defense Shelf Life Extension Program. This program tests the potency of medications that are kept in long-term strategic stockpiles for the government. It turns out that the feds are keeping big stores of anibiotics, morphine, antihistamines, and many other essential medications for use after The Zombie Apocalypse. To save money, they keep the medicines well-past their expiration dates, while testing selected lots for potency. On average, medications in the program are lasting 5-6 years past their dates—some lasting 15 years or more.

However, the drugs in this program are stored until optimal conditions, in a cool, dark, low humidity facility. They’re all in their original packaging, too. Drugs really can be sensitive to storage, and can rapidly lose their punch if exposed to heat or light, or if they’re moved from bottle to bottle, or removed from foil seals. Also, there’s a lot of variability in the shelf-life of medications, even between lots of the same medication. So though we know that most drugs will last past their dates, it’s hard to know specifically what medications on your shelf will last just a few months longer, or several years longer.

The form of the medication does seem to be important. Hard, dry pills last longer than creams or ointments or liquid drops. Reconstituted suspensions (where the pharmacist adds water and mixes it at their store) last the shortest, and are the most vulnerable to heat and storage conditions.

Though the main issue with older, expired drugs is potency—some get weaker with time—there’s been some concern that at least some medications actually become toxic when they’re old and past their prime. The classic example of this is an older formulation of tetracycline, which was reported in the 1960’s to become toxic to the kidneys if used well past its expiration date. That form of tetracycline is no longer sold in the USA, and it’s not really clear to me if that reaction was ever substantiated. I don’t think there’s much risk of old medicines becoming harmful—it’s more that they might not work as well or as reliably.

There’s a second date that will appear on any prescribed medication, a date typed on by the pharmacist that is usually 12 months after the prescription was filled. This date is added to discourage hoarding of medicines—after all, it may be unlikely that something prescribed a year ago is still needed. It also may be true that my moving pills from the original container (a big bottle) to the new container (a little bottle) they’ll lose some of the manufacturer’s guaranteed protection against aging. Though I don’t want anyone to hoard medicines, especially antibiotics and narcotics, depending on what the medicine is used for it sometimes makes sense to keep a medicine past the pharmacist’s date for occasional use. When in doubt, ask your doctor.

exp date on bottle

The bottom line: these dates are a guide, but for non-critical medications, especially if you’ve been good about storage, it’s probably fine to keep using them past their prime. If the medication is critical, I’d go ahead and keep an eye especially on the stamped manufacturer’s date. Stay safe, and keep important medicines fresh.


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