Drug expiration dates: Do they really matter?

Posted July 24, 2014 by Dr. Roy
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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.

MMR litigants’ new target: their own lawyers

Posted July 17, 2014 by Dr. Roy
Categories: In the news, Pediatric Insider information

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The Pediatric Insider

© 2014 Roy Benaroch, MD

This would be funnier if it weren’t so sad.

Back in 1998, British gastroenterologist Andrew Wakefield published The Study That Started It All: 12 children he claimed had developed autism as a result of the MMR vaccine. Since then, that execrable “study” has been shown to have been an “elaborate fraud”, with findings faked to support Dr. Wakefield’s own patent application for a competing vaccine. He was also collecting payoffs from plaintiffs’ attorneys suing vaccine manufacturers. It was, simply, always about money.

Now, a British gentleman who was the first plaintiff in a huge, failed class action lawsuit is suing his own attorneys—really, the attorneys hired by his family—for pursuing a claim based on bad science, bilking the British government out of millions of pounds.

Matthew McCafferty, who developed autism three years (!) after receiving the MMR vaccine, is now suing his attorneys for “unjust enrichment as officers of the court by litigating a hopeless claim funded by legal aid by which you profited.” The class action lawsuit fell apart in 2003, after Wakefield’s research was fully discredited (he later lost his medical license because he lied and took advantage of vulnerable children.)

McCafferty’s attorney said:

“The original MMR vaccine litigation was supposed to be worth billions in compensation, not mere millions, but it cost millions in legal aid,” Shaw told the Times. “There was also a huge personal cost for the families involved – all the raised hopes and expectations, driven by the irresponsible media frenzy based on an unsubstantiated health scare and junk science. Not one penny in compensation was obtained for any child. The families are now just beginning to recover and take stock. They are scrutinising the actions of their former lawyers and medical advisers.”

It was supposed to be worth “billions.” Again, it was always about the money. It was never about the health of children.

And yet, here we are. Vaccine-preventable diseases are roaring back. Parents are fearful of one of the safest, most effective public health interventions ever developed. And, the biggest losers of all, millions of families affected by autism, distracted by false hope, lured into distrust by charlatans taking advantage of their children for profit. Just imagine:  if not for all of this manufactured, fake vaccine-worry, how much more progress we could have made developing a better understanding of the real causes of autism, and the best ways to help identify and treat it.

The evidence for the safety of vaccines and the lack of any connection with autism is overwhelming. I suppose the lawyers will continue to fight over the money. Can the rest of us move along now, and work together towards actually helping children?

Breast milk for eye health

Posted July 14, 2014 by Dr. Roy
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The Pediatric Insider

© 2014 Roy Benaroch, MD


Supermouse wrote: “Several of my online friends have been talking about putting breastmilk in their babies’ eyes, either to cure conjunctivitis or to deal with runny/goopy eyes that result from a cold.  Is there any benefit to doing this?  Is there any risk?  Why would anyone do that?”


A quick Google search shows a whole lot of posts that suggest mother’s milk as an eye drop—and a whole lot of other things, too.  This post claims that breast milk is a “…sterile liquid packed with antibodies giving it countless other uses, some of which you may not be aware of.” Listed uses include not only eye infections, but teething, minor wounds, bug bites, diaper rash, and dry skin. Another site encourages breast milk for the entire family, claiming it helps everything from ear infections to organ transplantation.


Breast milk is certainly a wonderful thing for babies to drink. It is a good source of passive antibodies, especially the earliest milk (colostrum.) Those are infection-fighting molecules made by mother that can transfer into the GI tract of babies, preventing the initial steps of invasion of germs from the environment. That’s different from antibodies made by the baby himself, triggered by disease exposure or vaccinations. Both kinds of antibodies help, and they complement each other.


There’s a lot of other stuff in breast milk, too. Water, mostly; plus fat and protein and carbohydrate (mostly lactose). And: human breast milk is teeming with bacteria, the healthy-good kind that populates the baby’s gut to aid digestion. Breast milk is far from sterile (which for babies, is a good thing)—but maybe it’s not such a good thing for immunocompromised people after an organ transplant, for example. For most of the uses proposed, the idea is to apply breast milk topically into places like the eye or mouth or ear canal, places that aren’t sterile to begin with. So the presence of bacteria in breast milk isn’t really a problem, though the site that called breast milk a sterile liquid isn’t accurate.


Sites that suggest breast milk for eye conditions lump together a few different conditions that can cause a gunky eye. There are three that are common:


Blocked tear ducts are very common, usually presenting in the first several weeks of life with one or both eyes collecting a gunky discharge. The whites of the eyes are white, and there are no symptoms other than goo in the eye. This condition is almost always “self-limited”—it goes away on its own, whatever you do about it one way or the other. My typical advice is it leave these eyes alone.


Gunk can also accumulate in the eyes of a child with a common cold. The nose gets snotty, and some of that snot tracks backwards up the tear duct into the eye. Gross, yes, but it goes away without any specific therapy.

Conjunctivitis means inflammation of the eye, though for practical purposes in babies this usually means an eye infection, typically with bacteria. This is often called “pink eye”, though in truth there are many other reasons for eyes to turn pink. Conjunctivitis causes goo, but also redness to the eye itself. In newborns this can be very serious—some eye infections can lead to permanent vision loss or infection that can spread throughout the body. Bad newborn eye infections are very rarely seen in the United States, in large part because it’s standard care for all newborns to get antibiotic eye drops or ointments shortly after birth. Outside of the newborn period, “pink eye” in an otherwise well-appearing child is rarely anything super-important, and is typically first treated with antibiotic eye drops.


OK, so three causes of gunk eye in a baby. The first two, blocked tear ducts and gunk from a common cold, go away on their own without treatment. The third, bacterial pink eye, is pretty benign in older babies though can be devastating in newborns, especially newborns from the developing world. Keep this in mind when you see what the studies of mother’s milk eye drops have shown.


And, believe it or not, there have been studies:


Verd, in 2007, published an account of his clinic’s switch from treating blocked tear ducts with antibiotic eye drops to mother’s milk drops. The study is retrospective and more descriptive than quantitative, but at least shows that routinely using mother’s milk is probably safe. Blocked tear ducts, we know, get better without any therapy at all. But if you want to do something, instilling mother’s milk seems safe.


In 2012, Baynham and colleagues published a letter in the British Journal of Opthalmology, looking at the in vitro inhibitory effects of donated fresh breast milk against common ocular pathogens. (Translation: they squirted milk into petri dishes of eye germs to see what would happen.) They found that 100% of their donated milk samples contained bacteria (including, in some cases, bacteria that could cause human disease). Though there was some inhibition of bacterial growth against some bacteria, the inhibition wasn’t strong, and the authors concluded that “… human milk is unlikely to be effective against the most common causes of paediatric conjunctivitis.” There was one interesting finding: of all the bacteria tested, human milk was most effective against the bacteria that causes gonorrhea, which is the same bacteria that causes most serious neonatal eye infections, world-wide. Now, it wasn’t as good as an antibiotic, but for resource-poor communities in the developing world, human milk may be much better than nothing.


Ibhanesebhor, in 1996, also did an in vitro (in the lab) study looking at the effects of human milk against bacteria. He found that while colostrum had some inhibitory effects, mature milk did not—presumably because colostrum has a much higher concentration of antibodies. In any case, even colostrum was effective against only some bacteria, and it wasn’t nearly as effective as an antibiotic.


Finally, the oldest study I found: 1982, Singh, in the Journal of Tropical Pediatrics. The study is really quite wonderfully written, and includes a background quote from the 18th century, referring to human breast milk: “It is an emollient and cool, and cureth Red Eye immediately.” From November to December, 1977, the mothers in one wing of the All-India Institute of Medical Sciences were told to instill colostrum into their babies’ eyes three times a day, while babies in the other ward had no such instructions. Then “A careful examination, in good day light, was made twice a day to look for any stickiness of the eyes…” The authors also noted that “We did not encounter any difficulty or resistance in motivating mothers to instil colostrum in their baby’s eyes. In fact, most mothers accepted the suggestion rather enthusiastically.” The incidence of sticky eyes or conjuctivitis was 35% in the control (no colostrum) group, and only 6% in the study group.


Those results look great—but, honestly, I’m not sure they’re very realistic. A 35% rate of conjunctivitis in the control group is oddly high. And the babies were kept in two separate wards—maybe only one ward had an outbreak of conjunctivitis. Also, the observers (who diagnosed “sticky eyes”) couldn’t be blinded. Still, zero ill effects were noted, and the intervention is very low-cost.


To summarize: most conditions that cause gunky eyes in babies (blocked ducts and the common cold) resolve on their own. You can squirt mother’s milk in there, or probably coconut water or contact lens soaking solution—any of these will “work”, because it would have gotten better anyway. For actual bacterial pink eye, what evidence there is shows that mother’s milk is unlikely to be effective for the bacteria that cause this infection. And certainly, in a newborn, genuine pink eyes need to be evaluated by a physician—don’t fool around with home treatments with mother’s milk or anything else.


Apologies, this post got away from me a bit—it came out too long! But the question was good, and I had fun digging up those old studies. I don’t say it often enough, but I really appreciate everyone’s questions and comments. The best posts, I think, come when they’re inspired by you guys. Keep the questions coming, and I’ll keep reading and writing!

The paperwork. It burns.

Posted July 10, 2014 by Dr. Roy
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The Pediatric Insider

© 2014 Roy Benaroch, MD

I love seeing patients, and I love being a doctor—at least when I get a chance to be a doctor, in the short gaps left during the day when I’m done with telephone calls and “paperwork.”  Here’s a few gems from my inbox this week.

From UnitedHealthcare came a letter reminding me that their “members” will incur additional costs if they use an out-of-network lab. This, I knew. We actually have a specific process in our office to steer patients toward their “in-network” labs, so they can save a few bucks. The new development came in this paragraph:

uhc letter cropped

“If the member elects to receive services from a non-network lab, you must complete the Member Advance Notice Form, obtain the member’s signature on the form and retain it for your records.”

Wait—the member (I prefer to call them patients, but I’m old-fashioned) is the one who decided to go to a non-favored lab. So now it’s my job to obtain this form, get it signed, and keep it? I’m supposed to be UnitedHealthcare’s goon enforcer? Maybe I ought to get a truncheon and dimly lit room, you know, to convince them of the error of their ways. Those members, trying to make their own decisions. Fools!

Then this showed up: a subtle thing, but it rubbed me the wrong way.

form nurse clip


A fax, addressed to my “Form Nurse.” I don’t have a “form nurse”! Nurses are there to care for the sick, to teach, to help deliver medical care. They’re part of my essential team. They are not just there to complete forms. If you’ve worked hard and gotten your nursing degree and license, and then someone wants you to be a “form nurse”—no patients, no icky touching people, just filling out forms, day after day—any nurse I know would just poke their own eyeballs out with a fork.

Of course, I’d rather them aim their forks at the UnitedHealthcare goons.

You and I are your child’s drug dealers

Posted July 7, 2014 by Dr. Roy
Categories: In the news, Pediatric Insider information

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The Pediatric Insider

© 2014 Roy Benaroch, MD

Doing drugs no longer requires a dealer on the street corner.

Between the late 1990′s and 2010 sales of narcotic pain medicines quadrupled in the United States. Hydrocodone use increased by 280%, methadone by 1300%, and oxycodone by 900%. As the consumption of these medicines increased, so did ER visits and deaths from overdose– up by about 500%.

A whole lot of these medicines are not going to medical use. And a lot of the abuse is by our children.

And our kids, they know where to get these medicines. 10% of 8th graders and 45% of 12th graders believe they’re easy to obtain. Pain medicines are kept unsecured and unmonitored in about 75% of homes with teenagers. And over 50% of teens who abused narcotic prescription drugs say they got them from their own friends or family, just by opening a pill bottle, usually in their own homes.

Doctors and parents are both to blame. They get the drugs from us. We need to do a better job protecting our own children.

Doctors need to prescribe carefully, and keep track of refills. Pain has to be treated with more than just narcotics (though narcotics have to be part of the treatment of almost all serious pain.) We need to be careful to look for the early signs of dependence, which can develop into addiction and abuse.

Parents, grandparents, and neighbors need to lock up and keep track of these medications. Pain meds, ADHD meds, any kind of meds– they all can be abused. Set a good example by always using medications as directed.

“Leftovers” should be safely discarded, never hoarded. The best way to discard most medications is in your household trash, mixing the pills or liquid into something unpalatable, like coffee grounds or kitty litter. The FDA advises that some medications are best flushed down the toilet, including most narcotics. Alternatively, some pharmacies and doctors are happy to take back unused medicines to put with medical trash for incineration. (We may not legally be allowed to collect “controlled subtances,” including painkillers and ADHD medications.)

Medications, especially narcotics used for pain relief, are a crucial part of the relief of real suffering for many people. But there’s no doubt that a lot of the narcotics prescribed in the US are being abused. You owe it to your kids– don’t become their drug dealer. Keep those medicines safe.

An Emergency Department myth, dispelled: You can say “The Q word”

Posted July 3, 2014 by Dr. Roy
Categories: Pediatric Insider information

The Pediatric Insider

© 2014 Roy Benaroch, MD

When things slow at the Emergency Department, neither the docs nor nurses nor techs are likely to utter the dreaded “Q word”. Because, as everyone knows, once you say it out loud, the magic is gone. And the crowds will swell, and the “Q” will be destroyed.

You can think it, but don’t ever say it out loud.

At least, that was the popular myth. But does it really matter? A British physician put it to the test in his paper, “The Q**** Study – basic randomised evaluation of attendance at a children’s emergency department.”

During the study period, an envelope was opened at the beginning of each shift, randomly containing either the word “Busy” or “Q****.” The physician and nurse on the shift then said sentences containing the word an average of 12 times, and (recklessly!) displayed the word itself for the entire shift.

It turns out that attendance at the ED shift was the same, whichever word was uttered aloud. In the author’s words, “This study has shown that the long-held belief that saying the word ‘Quiet’ has dire consequences is unfounded.”

Like everyone else, doctors cling to superstitions. At least this one doesn’t hurt anyone. Too bad it isn’t so easy to dispel so many other false beliefs!

Mosquito wars: Why do some kids get bitten more than others?

Posted June 30, 2014 by Dr. Roy
Categories: Medical problems

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The Pediatric Insider

© 2014 Roy Benaroch, MD

“I have three children. But it’s only the middle one who gets bitten by mosquitoes! We’re outside for 20 minutes, and he’s covered with big itchy welts. They never bite the rest of us. I’m beginning to wonder what is wrong with him?”

I’ve wondered this myself—why are some people more mosquito-attractive than others? I’ve got some theories:

  1.  Some kids play more in the shade where mosquitoes lurk.
  2. Some kids are less sensitive to mosquitoes on their skin, so they don’t slap them away before being bitten.
  3. Some kids have a bigger reaction than others, so bites are more noticeable. (The welts you see are an allergic reaction to, essentially, mosquito spit. Like any other allergy, some people are more sensitive to others. It’s possible some people get bitten and don’t react at all.)
  4. Some children are just plain tastier. Mmmm, say the mosquitoes.

So what can you do about it? For families who have one or more bite-attracting kids, you need a good mosquito bite prevention and treatment plan for the summer.


Mosquitoes are more than an itchy nuisance. Though uncommon, serious diseases such as West Nile Encephalitis, dengue fever, and now chikungunya fever can be spread by mosquito bites in the USA. The itchy bites can be scratched open by children, leading to scabbing, scarring, and the skin infection impetigo. Prevention is the best strategy.

Try to keep your local mosquito population under control by making it more difficult for the insects to breed. Empty any containers of standing water, including tires, empty flowerpots, or birdbaths. Don’t let gutters or drainage pipes to hold water. Mosquitoes are “home-bodies”—they don’t typically wander far from their place of birth. So reducing the mosquito population in your own yard can really help.

There are yard sprayers either applied professionally or as a home job to reduce the local mosquito population. I have no personal experience with these products, and couldn’t find much in the way to independent assessments on the web. There’s no reason to think they wouldn’t work—but I’m kind of leery about the idea of spraying chemicals all over the place when there are simpler options. Still, for very sensitive people or heavy infestations, this might be a good idea.

There are also devices that act as traps, using chemicals or gas to attract the mosquitoes from your yard. Again, I don’t have much independent confirmation that these work, but they ought to be environmentally friendly and safe. If any of you visitors have used either these traps or the yard/mister sprays, let us know how well they worked in the comments.

Biting mosquitoes are most active at dusk, so that’s the most important time to be vigilant with your prevention techniques. Light colored clothing is less attractive to mosquitoes. Though kids won’t want to wear long pants in the summer, keep in mind that skin covered with clothing is protected from biting insects. A T-shirt is better than a tank top, and a tank top is better than no shirt at all!

Use a good mosquito repellent. The best-studied and most commonly available active ingredient is DEET. This chemical has been used for decades as an insect repellant and is very safe. Though rare allergies are always possible with any product applied to the skin, almost all children do fine with DEET. Use a concentration of about 10%, which provides effective protection for about two hours. It should be reapplied after swimming. Children who have used DEET (or any other insect repellant) should take a bath or shower at the end of the day.

Two other agents that are effective insect repellants are picaridin and oil of lemon eucalyptus. These have no advantage over DEET, but some families prefer them because of their more pleasant smell and feel. (Picaridin, oddly, smells like Fritos.) Other products, including a variety of botanical ingredients, work for only a very short duration, or not at all.


No matter what you do, occasional bites are going to happen. To minimize the reaction to mosquito bites, follow these steps:

  1. Give an oral antihistamine like Benadryl, Zyrtec, or Claritin (do NOT use topical Benadryl. It doesn’t work, and can lead to sensitization and bigger reactions.) For kids who get bitten a lot, it makes sense to just give an oral antihistamine daily, before the bites.
  2. Apply a topical steroid, like OTC hydrocortisone 1%. Your doctor can prescribe a stronger steroid if necessary.
  3. Apply ice or a cool wet washcloth.
  4. Reapply insect repellent so he doesn’t get bitten again.
  5. Have a Popsicle
  6. Repeat all summer!


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