Safe sleep for baby is flat — not inclined

The Pediatric Insider

© 2019 Roy Benaroch, MD

In June, 2019, Fisher-Price recalled almost 5 million of their “Rock ‘n Play Sleepers”, after publicity surrounding dozens of deaths. Pediatricians and other advocates had been saying these things were unsafe for years – at least one blogger even tried to warn the company directly, six years before the recall — but a lack of oversight and formal safety testing kept them on the market for far too long.

It was clear that the device prevented parents from being able to put their babies to sleep in a safe way, following the guidelines of the AAP. Babies, for safest sleep, should always be put down flat on their backs on a firm, flat surface.

Now, a new study (summarized here, details here under “Tab B”) has added even more weight to the evidence. It turns out that even a small inclined angle, raising the head even slightly, dramatically changes the way a baby can breathe, potentially causing death. The bottom line: these researchers showed that an incline of greater than 10 degrees makes sleeping less safe. So what’s ten degrees? Less than you’d think.

I’ll use an ordinary cookbook and my fingers to demonstrate. Here’s a firm, flat surface, at zero degrees – completely flat, which is the recommended way for babies to be put down to sleep:

If I put one finger under the edge, the book is at 5 degrees. This is just a tiny little angle, and the new study shows this slight incline is probably still safe:

But just two fingers reaches 12 degrees, above the unsafe threshold:

Three fingers gets you to 17 degrees:

And if I stick my whole hand under one edge, the book is at 30 degrees – the angle the recalled Rock n Play sleeper was designed for:

From the photos you can see that anything beyond the slightest angle is unsafe. And these “inclined sleepers”, like the recalled Rock n Play, went way beyond that. They were unsafe for other reasons, too – their sleep surfaces were not firm, and they surrounded the baby with soft cushy material. No wonder babies died.

Please, put your babies down to sleep on a firm, flat, not-inclined surface. If you’ve still got an “inclined sleeper”, return it or destroy it (don’t give it away or donate it!) Be safe!

Cell phones are not causing teens to grow horns: WaPo blows it

The Pediatric Insider

© 2019 Roy Benaroch, MD

Last week the Washington Post (“Democracy Dies in Darkness”) ran this headline: “’Horns’ are growing on young people’s skulls. Phone use is to blame, research suggests.”

The headline is entirely correct except for a few minor points:

• They’re not horns, which point up from the forehead. They’re more like little ½ inch nubs protruding downwards from the back of the skull.
• They’re not new. There’s no comparison group to show that these are more or less common than they used to be.
• They’re not “growing” on people’s skulls. There was no follow-up to show that they’re getting larger. They’re just “there”, and may always have been there.
• Phone use isn’t to blame. Phone use habits weren’t even recorded, and no comparison between phone users and non-users was possible.
• No research has suggested that any of the headline is accurate.

The article stems from two studies performed in 2018 by a chiropractor and a specialist in biomechanics, both from Australia. One study was on four teenagers whose parents brought them into a chiropractor to address their poor posture. Lumps were noted on their skull x-rays (Why were skull x-rays are needed to assess posture? Who knows. At least there wasn’t something important like a brain being irradiated for no reason. But I digress.) The authors speculated that perhaps the bony lumps appeared as a result of biomechanical stress from the teens’ leaning forward to look at their phones. It’s not an entirely outlandish idea – bones can and do remodel in response to mechanical stress. But it was only an idea, and an entirely untested idea at that. No one had asked the teens if they had used cell phones, or for how many hours; and there was no mention of any symptoms or problems the teens had (other than that their posture was upsetting to their parents.) And there was no comparison between phone users and non-users to help establish that phone use could be correlated with those bone lumps.

Later in 2018, the same authors reviewed 1200 x-rays from patients seen at chiropractic clinics. They found that 33% had these prominent boney lumps on the back of their heads—prominent meaning more than 10 mm, or about ½ an inch. There was no mention of cell phone use; there was no comparison group; and there was no correlation with any symptoms whatsoever. And certainly – I can’t stress this enough – the boney lump nub things did not look like horns.

I think the WaPo editor just like the idea of a headline including the words Horns, Growing, Skulls, Phone, and Blame. That’s a magical combination. Really: put those words in any order, and it’s a winner. But that doesn’t make it an accurate headline.

Don’t get me wrong: when you look around, you do see people hunching forward, clutching their phones. That can’t be good for posture. And I could see that contributing to neck and back pain. But to go from there to “Phones are to blame for head horns” is, well, ridiculous. WaPo, you really should have done better.

Hey! D’ya looking critically at media stories of health issues, maybe poking a little fun, and sometimes finding real gems of good reporting? Learn how to read studies and media reports with a skeptic’s eye, and how to find good, reliable health info in the news. Check out my 5-star course, A Skeptic’s Guide to Health, Medicine, and the Media. You can buy it or stream it, or get the audio-only from Audible. It’s fabulous!

BONUS mix -n- match headline section! Combine the words Horns, Growing, Skulls, Phone, and Blame to make your own Washington Post Style Headline! Put your favorites in the comments! I’ll start:

• Blame Phone Skulls for Horn Growing
• Horny Teen Blames Growing Phone Skull
• Skull Growing? Blame Phone Horn

 

Pertussis is making a comeback – what’s the best protection?

The Pediatric Insider

© 2019 Roy Benaroch, MD

Pertussis is also known as “whooping cough”, or sometimes “the 100 day cough”, or sometimes “DAMMIT WHY CAN’T I STOP COUGHING?!”. It is truly miserable. In adults and teens, three months of coughing – and I mean serious, loud, hard coughing, sometimes until you break a rib, vomit, or pass out – is not fun. Young babies, instead of coughing their little heads off, sometimes just stop breathing.

Unfortunately, it’s making a comeback. Both national statistics and our experience at my offices are showing increasing numbers of pertussis cases. Pertussis had become very uncommon with widespread vaccination by the 1980s. Why is it back?

(Aside: about 25 years ago, in my very first month of training as a pediatrician, I was taking care of a newborn in the emergency department who stopped breathing. Completely. Just stopped. Turned blue and floppy. I was terrified, but kept my cool and performed mouth-to-mouth resuscitation. The baby did fine. Later, my attending told me to never use my mouth on a baby – there was resuscitation equipment literally hanging on the wall behind me that I didn’t think to use. Oops. Later, I found out the baby had pertussis.)

The first pertussis vaccine was developed in the 1930s, and in the 1940s it was combined with tetanus and diphtheria vaccines to create the “DTP” vaccine. This was very effective at preventing pertussis, but it was quite “reactogenic”. DTP commonly causing fevers and sometimes febrile seizures (which, by themselves, are harmless – but really scary.) There were cases of encephalitis and dramatic developmental regression seen, too, though it’s become clear since then that these were cases of the genetic condition Dravet Syndrome, which unfortunately starts showing symptoms around the time DTP was given. The quest was on for a pertussis vaccine that caused fewer fevers, and a newer, more purified “acellular” DTaP was developed.

After extensive studies showed that the DTaP was effective and caused fewer fevers, the acellular vaccine replaced the older, “whole cell” vaccine in the US and many other developed countries in the 1990s. And, at least at first, things seemed to go well. Pertussis cases remained low.

But we’ve seen a steady increase in cases over the last 10-15 years. Part of that could be ascertainment bias – there are newer, better, and faster tests for pertussis that have come into wider use, and doctors think about testing more kids for pertussis now that’s clear there are more cases. That doesn’t explain all of the increase.

A study published this week in Pediatrics has helped clarify what’s going on. About a half million children managed at the huge Kaiser Permanente system in Northern California were studied, looking at their pertussis vaccine status and the rates of proven cases of pertussis in the group. Almost 750 cases of pertussis were documented in these children from 2006-2017, revealing some important conclusions:

• Pertussis risk, overall, was 13 times higher in unvaccinated versus fully-vaccinated children. The vaccine is protective.
• Still, 80% of the cases occurred in children who had received the full set of doses. Pertussis immunity dropped off over time – and the longer since the most-recent dose, the more at-risk a vaccinated child became.

So what should we do?

First: widespread, continued universal DTaP vaccinations in infancy and Tdap boosters for preadolescents is still a good idea. It is far better than not vaccinating. The Kaiser data clearly shows vaccinated individuals are at lower risk. Since one of the highest risk groups for severe disease is newborns, vaccinating pregnant women is a key strategy. Though maternal pertussis immunity after Tdap doesn’t last long, it does last long enough to transfer protective antibody to the unborn baby, providing crucial protection during the first few months of life.

But we clearly need a better vaccine and other strategies to provide better, more-lasting protection. Alternatives are being studied, including a nasal-spray pertussis booster and new, adjuvanted vaccines that can hopefully provide more-lasting protection safely. New vaccines take many years to study, so don’t expect anything on the market soon.

In the meantime, we need to do the best we can. Make sure you and your children are fully vaccinated against pertussis, and follow the recommendations for all vaccines. We need to be a better job developing better tools, but in the meantime we could be doing a better job using the tools we’ve already got.

Chicken pox vaccine prevents shingles, too

The Pediatric Insider

© 2019 Roy Benaroch, MD

A study published today in Pediatrics confirms good news about routine chicken pox vaccination in children: it also prevents shingles. Smaller studies had seemed to show this was likely, and this huge new study of over 6 million children nails it down. And: the benefit seems to apply to all of our children, even those unable to be vaccinated.

A little background: chicken pox and shingles are both caused by the same virus, named “Varicella Zoster Virus”, or VZV. When people first catch this very contagious illness, they get a painful and itchy rash accompanied by fever – that’s chicken pox. It’s a miserable experience – I remember when I had it, a summer long ago – that can also lead to complications like pneumonia, life threatening skin infections, and encephalitis. Even when you’ve recovered from chicken pox, the sneaky devil-virus hides in your nerve cells, waiting for an opportunity to swing back into action. And that recurrence of symptoms is what’s known as shingles, or “zoster” – a very uncomfortable rash that can leave lasting pain that can very difficult to control. Zoster especially likes to pop back up when you’re already sick or having other health problems, just to give you an extra poke in the eye.

“Remember me?” VZV says. “Have some pain!”

A vaccine to prevent VZV infections was developed in Japan in the 1970’s. It was specifically targeted at first for children undergoing chemo for leukemia, because so many of them were dying of overwhelming VZV infections (in people with suppressed immune systems, primary or recurrent VZV infections can be devastating.) The vaccine was very successful in saving lives and preventing misery in these children, which led to more-widespread testing in healthy kids and the adoption of widespread chicken pox vaccinations in the 1990’s. Later, it was shown that two doses worked better than one, and the current guidelines in the US recommend two doses be given routinely to all children starting at 12 months of life. This protects not only the children who get the vaccine, but their families and their communities, including people who can’t be vaccinated and children and adults on chemo or other medicines that suppress their immune systems (By the way: there are a lot of these people around. Including some of your friends and their children. Immune-suppressing “biologic” agents are now used routinely to improve the lives of people with psoriasis, Crohn, rheumatoid arthritis, and many other diseases. You’ve got friends, neighbors, and coworkers on these medicines. You can help protect them.)

A fair question to ask: do routine chicken pox vaccines also prevent VZV from recurring – that is, do they prevent shingles? Those studies in immunocompromised children showed it definitely did, but we needed years of data to prove that it was also effective in the broader population, because shingles may occur many years after chicken pox. And now, we’ve got solid data.

This study was done at six sites in the US, mostly in California, following the medical records of 6,372,067 children for 12 years. The results are impressive. First: rates of zoster/shingles dropped dramatically in the whole population, by about 50%, over the 12 years. Even in children who weren’t vaccinated, zoster is boing prevented by the use of this vaccine. But the effect was much larger children who did get the vaccine, and larger still among children who got the full course of two doses rather than one.

Vaccine science is always evolving, and important studies continue – there is always more to learn. All of the good evidence so far had shown that this vaccine was preventing both chicken pox and shingles, and this long-term, huge study adds to the evidence. Make sure your children and your family are up to date on their vaccines, including this chicken pox vaccine, to best protect yourself and your community. We’re all in this together, folks. Do the right thing. Vaccinate.

 

Measles update: Which adults need a dose of MMR vaccine?

The Pediatric Insider

© 2019 Roy Benaroch, MD

While the vast majority of measles cases in the US and worldwide are occurring in unvaccinated children, a fair percentage is also occurring in adults.  With more-widespread transmission of measles, it’s becoming more important for all of us – yes, that includes parents – to make sure we’re well-protected.

Measles is probably the single most contagious infection that humans face. The key to preventing the return of widespread measles is in keeping vaccination rates high, so even if there is a case it cannot spread or cause an outbreak. Once there’s a neighborhood, school, or community with a concentration of unvaccinated individuals, it’s only a matter of time before measles returns and spreads widely.

Though we’re used to our children getting vaccinated on well-established schedules that ensure vaccines are safe and effective, many adults have fallen through the cracks.

People born before 1957 are presumed to be immune, because measles was so widespread in the past that almost all children contracted the infection.

Adults considered at “high risk” include healthcare workers, international travelers, those who are living in communities with outbreaks, and university students (I would also include all adults who teach and work in universities, though that’s not part of the official CDC high risk group). If you’re in these groups, you should have had TWO doses of MMR to ensure immunity. If you’ve only had one, get another; if you’re not sure if you’ve had any, get two doses. The second dose should be 4 weeks or more after the first.

Other adults (those born after 1957 and who do not live in a community with measles transmission) are considered immune and protected if they’ve had one dose of MMR.

For people born between 1957 and 1968, there’s a catch. Some of the measles vaccine used then was an inactivated vaccine that didn’t confer good immunity. If you have documentation that your vaccine was the “live” vaccine, that’s the good one. If you’re not sure which you received, get one dose of the current MMR to make sure you’re protected.

An alternative to receiving the vaccine, if you’re unsure of your vaccine status, is a blood test for measles titers (IgG antibodies.) If your titers are high, you’re protected; if they’re low, you need another dose of MMR.

The MMR vaccine shouldn’t be given to people with compromised immune systems or pregnant women, though it is fine for nursing moms.

Bottom line: if you’re an adult and you’re not sure if you’re adequately protected, you should receive at least one dose of MMR.

 

From the CDC:

Current outbreaks

More info about measles

 

What’s the best timing for my child’s measles vaccine doses? Should we give them early?

The Pediatric Insider

© 2019 Roy Benaroch, MD

As the US endures its largest measles outbreak in 25 years – one that’s almost certainly going to get worse before it gets better – we’re getting a lot of calls and questions at my office. What’s measles, what’s the best way to prevent it, when should the vaccine be given to adults and children? I’m going to do a series of mini-posts, just focusing on one question at a time. We’ll see how this format works out – let me know if you like it!

The measles vaccine is given as “MMR”, which teaches the immune system to fight off measles, mumps, and rubella. It’s a very effective vaccine that confers lifelong immunity. A single dose is about 93% effective, and two doses get that up to 97%. There aren’t many other preventive interventions in medicine that are even close to that good.

The first dose should be given between 12 and 15 months of age, though at this point I’d say 12 months is better. Why wait until 12 months? Earlier than that, babies may still have enough antibodies from their mother to partially block the effectiveness of the vaccine.

But in some circumstances, you should get that first dose early, as early as six months. If there’s a high risk of exposure, an early dose (though imperfect) will give at least some protection. That dose should then be repeated at 12 months. Who’s at high risk of exposure? Anyone who’s living in a community with cases of measles – that includes, as I’m writing this, areas of New York, Michigan, and California. Plus the Philippines, Israel, and Ukraine. And, really, most of Europe. If you’re traveling with your baby under 12 months out of the US (or even within the US), you should look at the news and talk with your child’s doctor about getting an early dose of MMR.

The second dose of MMR is traditionally given at age 4-6 years, prior to school entry. But that timing was chosen for purely administrative reasons –kids almost always come in for a preschool physical, and they also need doses of polio and DTaP vaccines, which must be given after the fourth birthday. But that second dose of MMR can be given much earlier. It will be just as safe and effective if given any time 4 weeks or more after the first dose. So if the first dose is given right at 12 months, the second dose could be given at 13 months (or, more likely, at 15 months, since that’s when the next check-up age falls.)

Again, if you’re living in or traveling to an area experiencing a measles outbreak, you should get that second dose early. There is no downside. Honestly, there’s no reason why any of our young babies should wait until age 4 to get it – it’s just a bit of history and convenience that placed the second dose at age 4. If your children do get the second dose early, keep in mind that they do not ALSO need a dose at age 4 (though a third dose will not be harmful, it’s just not necessary.)

 

More info:

The nitty gritty details about the history of the MMR vaccine and its timing

Measles from the CDC

Telehealth leads the way in antibiotic overprescribing

The Pediatric Insider

© 2019 Roy Benaroch, MD

You’ve seen the ads, and you may have even gotten a flyer in the mail directly from your insurance company. Use an app to make a quick video call to get the medical care you need. No waiting rooms, no appointments, no having to be touched or even sit in a room with a physician – just the magic of the internet, and you’ll get what you want.

But will you get what you need?

Today a study was published in Pediatrics showing that pediatric remote telehealth visits are far more likely to result in an antibiotic prescription than an in-person visit with a doctor. Researchers looked at a total of about 500,000 visits for acute respiratory symptoms (typically common colds) from 2015-2016, matching visits by things like age, medical complexity, location, and the diagnosis. They then looked to see how many of the encounters resulted in an antibiotic prescription, separating out telehealth, urgent care, and primary physician visits. By telemedicine, here, they looked only at direct-to-consumer telemed visits, the kind you’ve seen advertised by private companies and promoted by your insurance.

Before we look at the numbers, let’s ask:  how many of these visits should have resulted in an antibiotic prescription? Among respiratory diagnoses, infections that typically “need” antibiotics include strep pharyngitis, otitis media (ear infections), sinusitis, and pneumonia. By the way, even these infections don’t necessarily always need an antibiotic – in many cases, they’ll improve just fine and just as quickly without a prescription. But for a generous benefit of the doubt, let’s assume all visits with these diagnoses should have ended with an antibiotic prescription, and that visits for diagnosis with a viral cause should not have resulted in an antibiotic.

The study found that among all of the visits examined that had a clear-cut diagnostic code, 27% were for a diagnosis that should typically result in an antibiotic prescription. Keep that figure in mind – 27% of these encounters, to fit within well-established, evidence-based guidelines, should have had an antibiotic prescribed. The other 73% were for viral infections (almost all of these were for common colds.)

So how did the groups do in this study? Primary care physicians prescribed antibiotics 31% of the time/ That’s pretty darn close to 27%, so good on them. Urgent care centers didn’t do quite as well in meeting the guidelines, prescribing antibiotics at 42% of visits. And the telemed visits did the worst, prescribing antibiotics 52% of the time, about twice as often as they should.

Why should anyone care? Antibiotic overuse is a huge problem. On a community level, we’re creating legions of superbugs becoming resistant to ordinary antibiotics. We’re also risking c difficile colitis, allergic reactions, and other health problems. But worst of all, to me, is that these antibiotic prescriptions create a creepy, self-fulfilling over-reliance on prescription medications. In a way, overprescribing is a good business model – it leads to repeat business, as your patients grow to expect to need a prescription for every cough. But it’s certainly not helping anyone become healthier.

Telemedicine is here. I get flyers directly from my insurance company, encouraging me to try it out instead of visiting my doctor. It’s quick, it’s easy, and it’s cheaper for the insurance company. They love it. And I think telemed does have a role for diagnosing and treating some health problems (especially mental health issues or follow-ups that don’t require a physical exam.) But the way it’s commonly done now isn’t delivering good care. We need to figure out the best way to deliver quality medicine via telehealth platforms – not medicine that’s cheap, quick, and harmful.

Recurrent vomiting in a baby – could it be FPIES?

The Pediatric Insider

© 2019 Roy Benaroch, MD

Not every diagnosis is easy, and not every diagnosis can be made correctly from a first impression. FPIES is one of those tricky ones, and parents and docs can get it right by paying attention to clues and keeping an open mind. Let’s start with a story, and then we’ll talk about FPIES (hint: these are not the kind of PIES you want to eat!)

5 month old Sally has had two trips to the emergency department and one to her pediatrician for vomiting episodes. Each time, she has a sudden onset of vomiting, diarrhea, and lethargy, and gets sick quickly – twice she ended up needing IV fluids. She recovers in a few days and seems to feel better. Overall she’s usually a happy baby, but her weight has been concerning. She’s not growing as fast as she should. Sally attends day care and has two older siblings.

What do you think? Vomiting illnesses are very common, and they’re usually caused by viruses (like Norovirus, especially this time of year.) If there had been one or two episodes like this, and Sally otherwise seemed OK, the story wouldn’t necessarily seem unusual. After all, she’s in day care, and probably is exposed to a lot of yuck.

But, still, there are some clues that there’s more to this story. Most vomiting illnesses do not require IV fluids – Sally’s needed that twice. And overall her weight isn’t great. Could there be a connection?

Making a medical diagnosis is like detective work. First collect the clues (which are almost always in the story), then find a diagnosis that fits. But keep in mind that every diagnosis is a “work in progress” that may have to change as new facts come it. Sally seemed like she had a viral gastroenteritis (a “tummy bug”), until the story continued to unfold. I warn medical students and residents: don’t lock yourself into a diagnosis. Stay curious!

Sally’s “mystery” diagnosis turned out to be “FPIES”, or “Food Protein Induced Enterocolitis Syndrome.” It’s a rare-ish allergic condition usually affecting young babies and toddlers, who react to certain foods with episodes of intense vomiting, often with diarrhea. Sometimes FPIES can be more of a chronic presentation, including lower-grade, ongoing symptoms like poor growth. Common triggers include cow’s milk and soy, but also grains like oats and rice. There’s no test for FPIES – ordinary ‘allergy testing’ is often misleading – so the diagnosis rests on the story.

The prognosis for PFIES is very good. Children usually outgrow it. The trick is making the diagnosis early, so parents can avoid the trigger food(s). And the key to making the diagnosis is paying attention to the clues your patients and their parents are trying to tell you.  I tell my medical students and residents: stay curious and pay attention!

More about FPIES

Interested in learning more about how doctors think, and how the best diagnosticians work through the clues to figure out the answer? I’ve made three courses about this, available from The Great Courses, in audio or video formats. They can be watched or listened to in any order. You can buy ‘em (money back guarantee!), or stream them from TheGreatCoursesPlus.

• Medical School for Everyone: Pediatrics Grand Rounds – Pediatric mystery cases for you to solve – get in the mind of a pediatrician! (Me!)
• Medical School for Everyone: Emergency Medicine – Fast-paced mystery cases from the ED – and in this course you get to juggle multiple cases at once. Stay on your toes!
• Medical School for Everyone: Grand Rounds Cases – Step by step, hear the story, listen for the clues, and figure out the case! (This was my first course, and it covers a broad range of medical cases.)

Help fight childhood cancer!

Hey hey! My teenage daughter and I will be getting our heads shaved on Saturday to help raise money to fight childhood cancer! Please donate to me, my daughter, or our team! (Since it is in fact my birthday today, you should probably donate to me. But any donations are appreciated!)

Pediatric cancer is more common than you might think. Every year in the US about 16,000 kids (birth through 19 years) get cancer — that means 1 in 285 people will be diagnosed with cancer during their childhood. That’s a lot of children and families affected.

In some ways, the statistics are encouraging. The rates of these cancers, overall, hasn’t changed much over the last 40-50 years — but the survival rates have improved dramatically. Overall there’s an 80% five year survival. But there’s a lot of variability in types of cancer, with some cancers making very little progress. Many types of childhood cancer still have a poor prognosis.

And sometimes the treatment itself can be very difficult. The goal of treating most pediatric cancers is a cure, which means that the treatment itself — surgery, radiation, chemo — is often more aggressive than the treatment for adult cancer. Two-thirds of childhood cancer survivors struggle with health problems related to their cancer or the treatment. There’s still a lot of progress to be made.

The funding for pediatric cancer research is far less than what we might expect. The NIH budget for adult cancer research was 5.6 billion in 2009; for pediatric-specific cancer research, it’s probably in the range of 30 million dollars a year.

Pediatric cancer research needs better funding. We’ve already shown that better treatment leads to dramatically better outcomes, but we need to keep making progress. And public awareness can support both charitable giving by individuals and better support for pediatric cancer among foundations, endowments, and large national cancer organizations.

That’s my why daughter and I will be shaving our heads with the St. Baldrick’s charity. It might seem like a silly sort of stunt — and in a way, it is — but it draws attention to the problem of pediatric cancer in a uniquely pediatric way. We’ll have fun with it, and we’ll have fun with the kids, but in a serious way we hope to raise more money and improve more lives. Please give if you can.

Spring is here! Allergy therapy update

The Pediatric Insider

© 2019 Roy Benaroch, MD

Ah, the sounds of spring. Birds tweeting, bees buzzing, and noses sniffling and sneezing. Fortunately, there are some great medicines out there to help reduce the symptoms of spring allergies, and most of them are inexpensive and over-the-counter. Here’s an updated guide to help you pick the medicines that are best to relieve your family’s suffering.

But first: before medications, remember non-medical approaches. People with allergies should shower and wash hair after being outside (though it’s not practical or good to just stay inside all spring!) You can also use nasal saline washes to help reduce pollen exposures.

For my medicine guide this year, I’ve included some photos to make these easier to find. A new trend seems to be color coding, with generics matching the brands in color and “look and feel”. That’s good if it makes the cheaper generics easy to find — they work just as well, and really should be your first choice for any of the options below.

Antihistamines are very effective for sneezing, drippy noses, and itchy noses and eyes. The old standard is Benadryl (diphenhydramine), which works well—but it’s sedating and only lasts six hours. There are better choices. Benadryl products are usually packaged in a pink, hidden sad and lonely in the bottom row.

Pink Benadryl makes people sleepy. There are better options.

It’s better to use a more-modern, less-sedating antihistamine like Zyrtec (cetirizine), Claritin (loratidine), or Allergra (fexofenidine.) All of these are OTC and have cheap generics. They work taken as-needed, or can be taken every day. Antihistamines don’t relieve congested or stuffy noses—for those symptoms, a nasal steroid spray is far superior.

Zyrtec and cetirizine come boxed in springtime green.

 

If Claritin’s for you, it comes in friendly blue.

 

Very few words rhyme with purple. This is Allegra.

There are a just a few differences between the modern OTC antihistamines. All are FDA approved down to age 2, though we sometimes use them in younger children. They all come in syrups, pills, or melty-tabs. Zyrtec is the most sedating of the three (though far less than Benadryl). Zyrtec and Claritin are once a day, while Allegra, for children, has to be taken twice a day. A 2017 study showed that Zyrtec is marginally more effective than Claritin, so I’ve been recommending that one first.

This year, there is one new player among the OTC antihistamines, called “Xyzal.” OK, I admit the name is cool — but it is therapuetically identical to Zyrtec. I don’t think it’s worth its typically-higher price.

Arresting orange says “XYZAL!”

Decongestants work, too, but only for a few days—they will lose their punch quickly if taken regularly. Still, for use here and there on the worst days, they can help. The best of the bunch is old-fashioned pseudoephedrine (often sold as generics or brand-name Sudafed), available OTC but hidden behind the counter. Don’t buy the OTC stuff on the shelf (phenylephrine), which isn’t absorbed well. Ask the pharmacist to give you the good stuff hidden in back.

Nasal Steroid Sprays include many choices, all of which are essentially equivalent in effectiveness: OTC Nasacort, Flonase, Rhinocort, Sensimist, and many generics are available. All of these products are essentially the same. They all work really well, especially for congestion or stuffiness (which antihistamines do not treat.) They can be used as needed, but work even better if used regularly every single day for allergy season.

Lots of steroid nasal sprays. They’re all essentially the same.

Some minor distinctions: Nasacort is approved down to age 2, Flonase to 4, and Rhinocort to 6, though there’s no reason to think any are more or less safe for children. Flonase is scented (kind of an odd, flowery scent, which seems weird in an allergy medicine), and seems to be a little more burny to some people than the others. My personal favorite is Nasacort or its generic version. Here’s a quirk: Nasacort comes in 2 differently-packaged versions, for adults and for children. But the product itself is the same. The pediatric version sells for less, but it’s a smaller bottle. I guess because children are smaller. Weird.

Children’s and regular Nasacort (and generic triamcinolone) are the same product in a different-sized bottle.

Nasal oxymetazolone (brands like Afrin) are best avoided. Sure, they work, but after just a few days your nose will become addicted, and you’ll need more frequent squirts to get through the day. Just say no. Steroid nasal sprays are much safer than OTC Afrin.

Eye allergy medications include the oral antihistamines, above; and the topical nasal spray steroids can help with eye symptoms, too. But if you really want to help allergic eyes, go with an eye drop. The best of the OTCs is Zaditor. There’s a generic version, though some people have told me the generic stings a bit.

Zaditor? Who names these things?

Bottom line: for mild eye or nose symptoms, a simple oral antihistamine is probably the best first line. For more severe symptoms OR symptoms dominated by clogging and stuffiness, use a steroid nasal spray. You can also use both, in combination, an antihistamine PLUS a steroid spray, for really problematic symptoms. Anything not improving on that combo needs to see a doctor.

This is an updated version of previous posts.