From the Pharmacy to Kitchen Counter

I became a pharmacist long before I became interested in baking. In fact, my first batch of chocolate chip cookies were too salty. The second and future batches were too hard and oddly shaped. I did master oatmeal-craisin cookies, which made it into my repertoire of baked goods. Soon this list expanded to banana bread and chocolate cake from scratch. Recently, I made pumpkin bread, pumpkin pound cake, banana-chocolate chip bundt cake, and oatmeal-chocolate chip-craisin cookies. I noticed that I have been bringing my pharmacy skills into the kitchen. Perhaps, like my techniques used on the pharmacy counter, my baking skills just needed practice and, more importantly, accuracy with the measurements and the order of combining ingredients. Baking is essentially compounding the extemporaneous formulations that I used to love making in the hospital pharmacy. So, now I'm measuring milk, oil, and water with a measuring cup instead of cherry syrup or water in a graduated cylinder. I'm molding cookies instead of suppositories. I'm crushing cloves instead of tablets with a mortar and pestle. I'm storing the finished products in Tupperware instead of medicinal bottles and jars. The ultimate users were pediatric patients; the ultimate consumers are my children. Who says I'm not practicing?

Is it a positive or negative PPD?

I took my 4-year-old daughter for her physical the day after her birthday. Since she will be entering kindergarten next year, she needed some vaccines (MMR, varicella, DTaP, and IPV) and a PPD (purified protein derivative) skin test for tuberculosis (TB). I was prepared to bring her back to the office in 2 days (usually 48-72 hours after being placed) to have her forearm read, but was told by the nurse that I just have to call an extension and leave a message. Did I make a face when I heard that? Surprise is probably a good word to describe how I felt. At work, they were very religious about making a worker return to the clinic for the reading by a nurse. If one were to miss it, then a new test had to be planted. I know, different situation. It's a good thing I was a clinical pharmacist and have seen what positive PPD results can look like. I am also confident about reporting negative PPD results through personal experience. However, I cannot imagine placing this kind of responsibility on a parent, especially without any written instructions. Granted my daughter is not at high risk for having TB, nor has she been recently exposed to someone with TB, but some pictorial guidance would be helpful. What if the parent forgot to look at the arm or call the office? Hopefully the nurse will call and remind the family. My daughter's arm has no raised bumps or redness, and yes, I called and left a message. When in doubt, though, ask the doctor to check it out.

For more information about TB and testing, check out:

• Tuberculosis Facts for Parents (about.com)
• Tuberculosis (keepkidshealthy.com)
• Tuberculosis tutorial video (National Institute of Health)
• Get the Facts about Tuberculosis (Centers for Disease Control and Prevention)

Take the key and lock 'em up

I'm talking about medicine bottles. I just saw a blurb in a recent issue of Fairfield Parent about the new MedSafe, "a first-of-its-kind electronic lockbox...to help parents safely and conveniently store prescription medications and keep their children safe." It holds up to 15 (standard) bottles of prescription medicine. (Bottles for liquid medicine would probably change that number.) Good to know that if your child figures out the combination, there are over 19, 000 changeable ones (yikes, another password to remember with mommy brain)! Affix it to the inside of any medicine cabinet (a medicine cabinet within a medicine cabinet?) or store it in a dresser drawer, kitchen cabinet, or closet. Personally, I'm content with storing my family's medicines on a high shelf where even I need to tiptoe to reach.

While MedSafe looks like a good idea, it does not replace education. Begin explaining early in a child's life that medicine is not candy or food. Try to avoid taking medicine in front of children. Mimicry is amazing to watch, but it could be deadly if children have access to your medicine. Oh, and if you do decide to get the safe, please don't store your child's epinephrine pen or other emergency items in there! Precious seconds might be lost from trying to remember the key.

I like to move it, move it

Well, my son is almost 19-months and he still isn't walking. He is one heck of a scoocher, though, and he just started crawling at about 17 months. Although the pediatrician has stated that he will pick up walking at his own pace, I decided to start up once weekly physical therapy for him again through Connecticut's Birth to Three system (early intervention). In a matter of days, he has picked up crawling up stairs on his own. I've also noticed stronger leg strength when he's standing (with support). He's also pulling himself into a standing position more readily. Yesterday, I showed him how to cruise. He can also climb up the steps and put himself into a sliding position on a portable slide that we picked up from a tag sale. This is all great progress within a matter of weeks! It helps that his new physical therapist is more successful in engaging him into activities, whereas our last therapist was not able to connect with him due to his separation anxiety. What have I learned? A little help makes a huge difference sometimes. Also, a little denial can be a setback for major milestones.

Do the Elephant When You Sneeze

Rather than getting caught up and frustrated about the availability (or lack) of the different flu vaccines, why not channel that energy into finding fun ways to teach your child how to stay healthy? Here is a cute song and video by the Jimmies called "Do the Elephant." If you have Satellite Radio, you may have heard it on Kids Place Live.

Click here for a handwashing Video for Children (13-minute musical) by the Handwasher's Brigade about handwashing.

Click here for a 1-minute rap video by DocRock that includes 5 tips on how not to get the H1N1 infection.

Have you or your child come across a video you'd like to share? Please add it to the comment section. Thanks!

Disclaimer of Conflict of Interest: The author has no conflict of interest to state.

Why is my pharmacist asking so many questions?

I remember not too long ago, a friend of mine was complaining that the pharmacist asked her too many questions when she was getting her prescription filled. "What were you asked?" I wondered aloud. It turns out she was prompted to provide information about her weight, whether she was pregnant or breastfeeding, what other medications had she taken in the past, and what other medications is she on now. I explained to her that these questions are meant to help complete her profile so that the pharmacist can identify potential drug therapy problems with her medications before any adverse effects occur. She accepted that and later felt appreciation rather than the initial resentment.

In Connecticut, "a pharmacist shall make a reasonable effort to obtain, record, and maintain...:

(1) name, address, telephone number, date of birth or age, and gender;

(2) individual history where significant, including disease states, known allergies, and drug reactions;

(3) a comprehensive list of drugs and relevant devices dispensed by the pharmacy within the last 180 days; and

(4) the pharmacist's comments relevant to the individual's drug therapy."

This information will be helpful to the pharmacist when a patient presents a new prescription to identify any potential problems with the overall drug therapy. Basically, the pharmacist is looking for any:

• duplication of therapy (e.g. is the patient taking multiple medicines that work the same way or multiple products that contain the same active ingredient?);
• contraindication between the medicine and a disease (e.g. does the patient have a condition that precludes him/her from taking the medicine?);
• drug interactions (e.g. will this medicine increase or decrease the effects of the other medicines the patient is currently taking or vice verse?);
• issues with the dose and length of therapy prescribed (e.g. if the patient stated that he has kidney problems, is the dose going to be too high? or does the patient need to be on 3 weeks of high-dose steroids by mouth for an acute asthma attack? or if the patient is pregnant, she should not be taking certain medicines for blood pressure or cholesterol control);
• interaction of a medicine and allergy (e.g. if the patient stated that she is allergic to soy, she should not be given Atrovent as an inhaler); and
• clinical abuse or misuse and any other significant clinical issues relating to the appropriate use of drugs (e.g. is the patient really still in pain 4 weeks after a root canal treatment?). One's weight can be used to determine the appropriateness of the dose.

It is our duty as pharmacists to ask these questions. Unfortunately, as a patient, I've only been asked about my allergies and nothing else when I have had my prescriptions filled. In fact, I had to ask about the effect of the medications on the breastfeeding baby. I also wish I was asked my children's weight when I present their prescriptions. Well, it's not relevant when it is for a topical cream, but it could be for an oral antibiotic. It really doesn't matter what state you live in, because all pharmacists have been well-trained in all aspects of medications and common disease states. So, if you're visiting a pharmacy for the first time, and your child has a chronic illness or is currently on multiple medicines from a different pharmacy, ask if there is any other information the pharmacist might need for your child's profile. To make it easier, fill out a medication list (The Pediatric Pharmacy Advocacy Group has a sample you can download) and have a copy available for the pharmacist to review. It could save you some hassle later on.

Cold vs. Flu Symptoms in Children

I have already received the e-mail below twice from two different moms, and it is undoubtedly being spread like a cold virus from mom to mom. The email was meant to be helpful, but the information is not accurate. It is not always easy to tell which is which. It is also unknown where the content is from. The American Academy of Pediatrics (AAP) has a good FAQ about cold vs. flu (and a good explanation about swine flu), the Centers for Disease and Control and Prevention (CDC) has thorough information about the flues, and WebMD does a decent job differentiating cold vs. flu symptoms. While one of the ways (not the only way) to stop the epidemic is to share information, the ultimate way is to protect yourself and others by washing your hands with soap and water (for 20 seconds or sing Happy Birthday to you twice) frequently and to cover your mouth and nose when you sneeze or cough (with your sleeve and not with your hands, please). If your child is sick, keep him/her home to rest and get better. Do call the pediatrician for advice if you suspect it is not just a common cold. Over-the-counter cold and flu medicines do not cure either the cold or the flu; just rest, plenty of fluids, and flu antiviral medicine (if recommended by the pediatrician). Pass it on...

My additions are in blue in the table. H1N1 flu is about to be upon us and we need to be on top of information regarding it. Here is a comparison to the normal cold symptoms . Know the Difference between a Cold and H1N1 Flu Symptoms Symptom Cold H1N1 Flu (seasonal flu, too) Fever Fever is rare with a cold. A slight fever is typical in children with a cold. Fever is usually present with the flu in up to 80% of all flu cases. A temperature of 100.4°F or higher for 3 to 4 days is associated with the H1N1 (or seasonal) flu. Coughing A hacking, productive (mucus- producing) cough is often present with a cold. A non-productive (non-mucus producing) cough is usually present with the H1N1 (or seasonal) flu (sometimes referred to as dry cough). Aches Slight body aches and pains can be part of a cold. Severe muscle aches and pains are common with the H1N1 (or seasonal) flu. Stuffy Nose Stuffy nose is commonly present with a cold and typically resolves spontaneously within a week. Stuffy nose is not commonly present with the H1N1 flu. Actually, stuffy nose can sometimes occur with the flu. Runny nose is common with the flu, but antihistamines will not help. Chills Chills are uncommon with a cold. 60% of people who have the H1N1 (or seasonal) flu experience chills. Tiredness Tiredness is fairly mild with a cold. Your child should be able to keep up with usual activities. Tiredness is moderate to severe with the H1N1 (or seasonal) flu and can last 2-3 weeks. Sneezing Sneezing is commonly present with a cold. Sneezing is not common with the H1N1 flu. Actually, sneezing sometimes occurs with the flu. Sudden Symptoms Cold symptoms tend to develop over a few days. The H1N1 (or seasonal) flu has a rapid onset within 3-6 hours. The flu hits hard and includes sudden symptoms like high fever, aches and pains. Headache A headache is fairly uncommon with a cold. A headache is very common with the H1N1 (or seasonal) flu, present in 80% of flu cases. Sore Throat Sore throat is commonly present with a cold. It may also be a scratchy throat and/or hoarse voice. Sore throat is not commonly present with the H1N1 flu. This is false, children with the flu can have sore throat also. Chest Discomfort Chest discomfort is mild to moderate with a cold. Chest discomfort is often severe with the H1N1 (or seasonal) flu (more so in adults). Other symptoms of the flu may include nausea, vomiting, and belly ache. The only way to stop the spread of the epidemic is to spread the awareness. Colds and flues spread via contact with droplets from sneezes, coughs, and runny noses. Have your child wash his hands frequently with soap and water (use alcohol-based hand sanitizers if soap and water are not available) and cover his mouth when he sneezes or coughs. Throw away tissues and wash hands immediately.

Fake H1N1 Products Harm More Than Help

It's understandable that parents are concerned about the H1N1 flu virus, but it is not safe to purchase products offered for sale over the internet (or in stores) that claim to diagnose, prevent, or otherwise act against this virus. These products (shampoo that protects against the virus, dietary supplement to protect infants and young children from contracting the virus, a "new" supplement that cures the infection within 4-8 hours, a spray for the hands that claims to leave a layer of ionic silver that kills the virus, diagnostic tests, and an electronic instrument that uses "photobiotic energy" and "life-force energy waves" to strengthen the immune system) have not been approved by the Food and Drug Association (FDA), so they have not been tested for safety and effectiveness. Furthermore, they will not prevent the spread of the virus or offer any remedies against infection. They might also give parents a false sense of protection, causing them to neglect the most basic ways to prevent getting the infection (vaccination, handwashing, sneezing/coughing hygiene, and staying home when sick). Do not buy Tamiflu (oseltamivir phosphate) or Relenza (zanamivir), FDA-approved, prescription-only products from unlawful websites. There are specific guidelines issued by the CDC and FDA for emergency use of these two medicines. Buying unapproved medicines and medicines from unlawful sites or other countries increases the risk of harm to your family, especially when there are unknown ingredients found in the drugs. Don't buy non Fda-approved products. More importantly, keep washing those hands frequently with soap and water instead.

Happy National Pharmacy Week!

How did I get interested in pharmacy? I didn't know I was going to be a pharmacist until I attended a college fair in Chinatown and went to the first booth listed alphabetically. There, a tall, friendly Dean and an Asian upperclassman (who actually finished pharmacy school and went to medical school) told me fascinating things about the profession of pharmacy. I applied to Albany College of Pharmacy right away and got accepted within weeks during rolling admissions. Yes, I applied to 5 other colleges, too, including Buffalo for the pharmacy program. Before I heard from them, I decided 3 hours from home was far enough and I accepted. Senior year flew by and then I was off to college, excited to learn more science and math. Seventeen years later, I am still glad fate took me down that route. Here is a description of a pediatric pharmacist.

Oftentimes I get asked, why pediatric pharmacy, it's so sad? Kids have always been naturally drawn to me. I have been called the "baby whisperer." I wanted to use this "ability" to help sick kids feel better. The most memorable question I got asked, though, popped up during a residency interview, "Did you ever watch a child die?" I was stunned and speechless for a few long seconds, and I answered, "No." Thankfully, to this day, I still haven't. I have helped take care of two sets of Siamese twins, watched an autopsy on an adult who had widespread aspergillosis, taught multiple families about asthma, excited many students and residents about pediatric pharmacy, advocated for many parents, shared experiences with my colleagues, and now I have my own kids to keep healthy and safe from medication errors.

It's the tail end of National Pharmacy Week 2009. Normally, I would rally up the students and set up a table in the lobby of the hospital to talk about the services pharmacists can offer. Brown bag sessions at the senior centers and pediatric asthma clinics were also on the schedule. Although I'm taking a hiatus from the daily grind of a pediatric pharmacist in a health-system, I am remaining active in the profession through blogging, tweeting, and contributing to the Pediatric Pharmacy Advocacy Group, my beloved association. With a daughter in preschool, you can bet that I'll be giving some talks in the near future.

"Does she have allergies?"

It is inevitable. Every time I put my daughter into a new aquarium of preschoolers (camp, play group, school), she gets a cold. I know better than to send her to school, or swim lessons in the summer, if she has had a fever overnight, or is lethargic and just not herself. This time, she just woke up over the weekend congested and she sneezed out a lot of clear "gook," but nothing else was different. Her activity level and appetite remained the same. So, on Monday, I sent her to preschool equipped with tissues and a small bottle of hand sanitizer. I even reviewed proper respiratory etiquette with her. I went home and waited by the phone in case the teachers wanted to send her back to me. Her preschool is only 2 hours in duration, but it could feel like a long time to a sick kid. No phone call on the first day, or any day thereafter for the next 2 weeks. She continued with swim, gymnastics/dance, and soccer without a problem. Just on day 13 of her cold, a politely phrased question was posed to me by two of her teachers when I dropped her off, "Does she have allergies, maybe? It's been 2 weeks already with this sneezing." I replied confidently, "No, I don't think so. I have allergies, but she doesn't. It's really just a cold. She's much better now, really." Granted I've noticed that her mucus changed from clear to yellow to green, but, again, she never had a fever and no other symptoms. Remember that the color of one's mucus is not a tell-tale sign that antibiotics are needed. Colored "gook" could mean that the viral infection is actually getting better. I just persisted about getting her to blow her nose so that it didn't become a sinus infection (easier said than done) and to drink a lot of fluids. More importantly, I did not cave and bring her to the pediatrician. Gradually, her sneezing only occurred in the morning upon awakening. Then the noisy breathing and "gook" production stopped altogether. After three weeks with the common cold, she's been happy as a clam, and without allergies. It also turns out my daughter wasn't the only kid with a cold in her class.

Colds do take a while to cure, but medicine will not speed up the process. It just takes a "tincture of time," lots of rest and fluids, and good drainage of the nose. We didn't use the saline drops and bulb syringe that I bought, but these can help with clearing the nasal passages. Finally, to prevent your child from spreading or catching a cold, teach him/her good respiratory etiquette and proper handwashing techniques. Know the signs and symptoms of the common cold, and be prepared to give a lot of hugs and kisses.

Helpful Videos From the FDA

These are good quick (about 2.5 minutes, or less) consumer update videos from the FDA. For more information, go to www.fda.gov/consumer.

FDA 101: Product Recalls (video) - This explains why products get recalled by the FDA.

Avoiding Drug Interactions (video) - Foods are ok to mix, but medications and herbs may not be.

Avoiding Medication Mistakes (video) - Wonderful tips on how to avoid medication mistakes.

Food Allergies: Reducing the Risks (video) - Great information about food allergies.

Don't forget:

1) Keep a list of all the medications, herbal supplements, allergies, vaccinations received, and contact information about your doctors and keep the list handy.

2) Learn as much about your medications by asking the pharmacist or doctor.

3) Take medications the way they are prescribed or are recommended on the label for over-the-counter products. Use the correct measuring devices for liquid medicines.

Recall of Certain Lots of Infants' and Children's TYLENOL Products

Did you buy TYLENOL brand infant's or children's products between April 2008 and June 2008? Certain lots are being recalled by the company, McNeil, because when they examined the bulk raw material, they found that one of the inactive ingredients did not meet internal testing requirements. A type of gram-negative bacteria, B. cepacia, was found and isolated in this portion of raw material. NOTE: no bacteria were detected in any of the finished products, but, as a precaution, the company has volunteered to recall all product made when that particular batch of raw material was present in the factory. Again, no need to panic because the bottle you have at home does not contain bacteria and it was not made from that specific batch of raw material. No side effects have been reported to the company or FDA from these products. Also, one cannot get an infection from this bacteria by taking the medicine. If your child has an underlying lung disease, cystic fibrosis, or a weaker immune system, the bacteria could cause adverse effects. To check to see if the bottle you have at home is being recalled, look for the lot number at the bottom of the box that came with the bottle, or on the sticker that surrounds the bottle. Below is the complete list of recalled lots. If you determine that you have the affected product, please call McNeil's Customer Care Center at 1-800-962-5357 to be sent a coupon for a new bottle. Please contact your child's doctor if you have specific concerns or if you have recently given your child Tylenol purchased during April and June 2008.

Recalled Products - Full List

Lot #	Product Description
SBM041, SBM067, SCM037, SDM027, SEM109	Children's Tylenol Plus Cold MS Suspension 4 oz. Grape
SBM042, SCM015, SCM036, SDM034	Children's Tylenol Suspension 4oz. Grape
SBM043, SBM044, SCM029	Children's Tylenol Suspension 4oz. Bubble Gum
SBM045, SCM011, SCM030, SDM035	Children's Tylenol Suspension 4oz. Strawberry
SBM064, SCM033, SDM020	Infant’s Tylenol Grape Suspension Drops 1/4oz.
SBM065, SCM005, SCM006, SDM032	Infant's Tylenol Suspension 1/2oz. Cherry
SBM066, SCM068	Children's Dye Free Suspension 4oz. Cherry
SBM068, SCM035, SCM070, SCM080, SDM005	Children's Tylenol Suspension 4oz. Cherry
SBM069, SBM070, SCM081, SDM006	Children's Tylenol Plus Cough & Runny Nose 4oz. Cherry
SCM012, SCM067, SDM007, SDM068	Infant's Tylenol Suspension Drops 1/2oz. Grape
SCM013, SCM014, SCM069	Children's Tylenol Plus Flu 4oz. Bubble Gum
SCM016, SFM024	Children's Tylenol Plus Cold Suspension 4oz. Grape
SCM017	Children's Tylenol Plus Cough/ST Suspension 4oz. Cherry
SCM082, SDM039, SDM040	Infant's Tylenol Suspension Drops 1oz. Grape
SCM083, SCM084, SDM008	Infant's Tylenol Dye Free Suspension 1oz. Cherry
SDM064	Children’s Tylenol Pediatric Suspension 1oz. Cherry
SDM038, SDM009	Infant's Tylenol Suspension Drops 1oz. Cherry
SDM033	Children's Tylenol Plus Cold/Allergy 4oz. Bubble Gum
SDM078	Infant's Tylenol Drops 1oz. Grape
SCM034	Infant’s Tylenol Grape Suspension Drops H/G 1/2oz.
SDM028	Children's Tylenol Suspension 4oz. Cherry, Hospital Govt.

The Hunt for Gentian Violet

What's that white stuff on his tongue? Looks like cottage cheese. I can't brush it off. Wait, he's bleeding somewhere. Did he bite his tongue? His lip? Ah, the telltale signs of oral thrush (yeast infection in the mouth). He has no other symptoms and his eating habits have not changed. Breastfed babies commonly acquire oral thrush. Other risk factors include breastfeeding, use of antibiotics or inhaled corticosteroids, a weakened immune system, and diabetes. No, he is not taking inhaled corticosteroids, but I was on a course of antibiotics a month ago for 10 days. I'm not rushing to the pediatrician just yet because his daily activities do not indicate that he is in pain or that the thrush is bothering him. I am, however, increasing his yogurt intake to restore the balance of normal gut bacterial flora to minimize the overgrowth of the fungus. A trip to the pediatrician will buy him a prescription for nystatin suspension, which will have to be swished and swallowed for a couple of weeks. Gentian violet 1% is an over-the-counter remedy that I am considering a brief trial of 3 days before taking him in.

Growing up, my mother used gentian violet on my cuts, scrapes, and mouth sores. I remember taking a class picture with a purple scab on my upper lip. As a pharmacy intern, I ordered and stocked the shelf with this product. This past weekend, I could not find it in any pharmacy, chain or independent. Some pharmacists thought it was an herbal supplement and sent me to GNC. Another pharmacist tried to order it for me for $17 when it used to be $1.69 (or something like that 10+ years ago). Walgreen's ordered it for $2.09. Interestingly, gentian violet is not made of gentian or violet, but is named after the deep purple color. It is used in laboratories as a stain to identify bacteria via the Gram stain test. If you read the label, it is an antiseptic for minor cuts and burns. When used sparingly, it can treat oral thrush [1]. It is generally safe, as long as it is not doused on the lesions repeatedly (just 2-3 times a day) and it is not drunk like medicine. The most common side effect is staining of the skin and clothes. Other concerns that have not been soundly supported are the risk of ulceration and oral cancer (probably due to the 10% alcohol the product contains). In the breastfeeding community, gentian violet has been used frequently with good results. Here is a guide on how to administer the gentian violet, that is, after you locate it in your local pharmacy. Actually, just call and ask them to order gentian violet 1% in a 1 ounce bottle. Make sure it's kept out of reach when you get it.

[1] Weisse ME and Aronoff SC. Chapter 231. Kliegman: Nelson's Textbook of Pediatrics. 2007. Accessed via MDConsult.

Don't let the flu get to you or your children

Everyone is at risk for getting seasonal (aka regular) influenza (flu), but some people (including parents and children, working adults, those aged 50 and up, and those with chronic illnesses) have a greater risk and should try to get the seasonal “flu shot” every year. Vaccination typically starts in the fall and continues until spring; I already got mine when I was at my doctor’s last week. If a doctor’s appointment is not in your foreseeable future, then below is a list of placesthat will be offering the seasonal vaccine for a small fee. Your children should still visit their pediatrician(s) as many of these “flu clinics” do not offer the vaccine to children, or only to children 9 years and older. My children's pediatrician has not opened the schedule for vaccination, yet.

The American Lung Association can help you locate the nearest flu clinicanywhere in the U.S.. You may even have seen signs at the community pharmacies. To learn more about the seasonal flu, visit the CDC’s web site. Here are also their tips on how to fight the flu, or just to stay generally healthy. Consider the flu shot for you and members of your family. Although it will not prevent your child from being sick from all of possible flu viruses, it will minimize the chances of getting the most common ones, reduce the severity of the infection if your child should acquire it, and prevent spread to others.

The FDA approved four new vaccines against the H1N1 virus yesterday. They will be available for adults next month. Studies are still under way to find the optimal dose for children. The vaccines have been tolerated well by the patients.

A Salty Lesson

We have been to the beach multiple times this summer. The kids love to make their own mud, so I thought it might be useful to prefill a water bottle with sea water so that they could play while I set up the blankets. Unfortunately, the bottle fell out of the beach bag and into the trunk. Of course, I had forgotten about it. I was so thirsty yesterday that I just took a guzzle and sprayed it right out, not realizing it was: (1) an opened bottle and (2) sea water not spring water. It was a great teaching moment for my preschooler, though!

The lessons to be learned here: (1) not all clear fluids are water, (2) parents should not refill bottles with any substance without labeling them (if the substance is toxic, please keep out of reach of children), and (3) remind your children to check with an adult before putting anything in their mouth. I was quick to drink sea water from an unsuspecting water bottle, but imagine your little one taking a mouthful of chlorine or some other cleaning liquid, especially if it's colorful and has a sweet smell! Just as a reminder, the Poison Control Center's number is 1-800-222-1222.

Get ready for flu season 2009-2010

This week, the CDC released a new guidance to help minimize the spread of any flu virus in child care and early childhood programs during the 2009 and 2010 season. This toolkit contains resources for providers and parents, including action steps for parents to protect your child from the flu, action steps for parents of children at higher risk for flu complications; action steps for parents if children are sick, or if the child care/early childhood programs are closed, and must stay home; and action steps for providers regarding daily health checks for children, staff recommendations, and decision-making about closures. These can be found at the CDC website.

General tips from the CDC to protect you and your child include:

1. Get you and your child vaccinated for seasonal flu AND H1N1 flu (when available); caregivers for children under 6 months should consider vaccination
2. Stay home if you or your child is sick for at least 24 hours until after a fever breaks (temperature is < 100 degrees Fahrenheit or < 37.8 degrees Celsius) or there are no more feeling of chills, feeling warm, flushed appearance, or sweating
3. Practice good hand hygiene with proper handwashing using soap and water or an alcohol-based hand sanitizer
4. Cover the mouth and nose with a tissue when sneezing or cough/sneeze into elbow or shoulder, not hands
5. If someone at home is sick with the flu, children in the household should stay home for at least 5 days from the time the first person got sick
6. Keep your child home for at least 7 days if your child is sick, even if they are ready to run and play before that. If your child is still sick after 7 days, keep him/her home until 24 hours after the symptoms have completely gone away.
7. Seek urgent medical attention if one or more of the following signs are noticed:

fast breathing, trouble breathing, shortness of breath, or stopping breathing;

bluish, purplish, or gray skin color especially around the lips and the inside of the mouth, or around the nails;

not drinking enough fluids, refusing to drink;

not urinating, decreased number of wet diapers, or no tears when crying;

severe or persistent vomiting;

not waking up or not interacting (e.g., unusually quiet and inactive, no interest in playing, no interest in favorite toy);

being so irritable that the child does not want to be held, or cannot be consoled;

pain or pressure in the chest or stomach;

sudden dizziness;

confusion; and

flu-like symptoms improve but then return with fever and worse cough.

Quick Guide to Childhood Vaccines From the FDA

There is some good information in this Parent's Guide to Kids' Vaccines, including benefits and risks, types of vaccines, steps to take when your child is vaccinated, and some commonly used vaccines. Adverse reactions, or other problems, suspected to be caused by vaccines should be discussed with your child's health care provider and reported to the Vaccine Adverse Reaction Reporting System (VAERS). Yes, you can file a report anonymously as a consumer. Also, it is ok to ask your health care provider questions about the vaccines if you have concerns. Vaccine information sheets (VIS) are required by federal law to be given to the caregiver prior to vaccination of each vaccine. They are available in languages other than English. Be sure to ask your child's health care provider for a copy of the VIS in your native language, if you prefer.

Solution for Infantile Spasms

One of the biggest challenges when dealing with drug therapy and children is finding the right dose of the medicine, especially if there aren't any dosage recommendations from the manufacturer that are FDA-approved. Another challenge is delivering the medicine to the child, especially a young child who cannot swallow solid dosage forms. Oftentimes, tablets are crushed or capsules are opened to make a solution or a suspension (depending on how well the particles dissolve in water), but this cannot be done with all medicine. Nor should this be done at home, unless advised by the pharmacist or your child's doctor for single doses to be given shortly after preparation.

It is always exciting to see that a drug that has been available for adults become approved for use by children. Additionally, it is going to be available as an oral solution and in a strength that can be easily measured by a parent. It certainly broadens the treatment options and may even increase the adherence of the regimen. One such addition is Sabril (vigabatrin) oral solution for infantile spasms in children aged 1 month to 2 years. This is the first drug to be approved by the FDA for this condition. Vigabatrin has been available as tablets for adult use in the treatment of complex seizures in combination with other medicines. More about infantile spasms and Sabril is found in the press release. May many more pediatric oral dosage forms become available soon.

"Pokey" in the thigh or arm?

My daughter knows vaccinations as "pokeys" and so we introduced that term to my toddler son, who was due for his measles-mumps-rubella (MMR) and varicella (chicken pox) vaccines on last Friday. He accepted the two shots in each thigh with some discontent, but was easily distracted from his pain. He has really thick thighs at close to 32 pounds. One might wonder, shouldn't he have gotten them in his arm because of the size of his thighs? Well, the MMR and varicella vaccines are given in the fat tissue (subcutaneous injection) just below the skin, so it was fine for my son. This also explains the lack of injection site reactions (redness, hardness, or warmth) that I noticed with the other vaccines that he has received. Of note, most of the routine childhood vaccines are given into the muscle area on the side of the thigh (anterolateral) or arm (deltoid muscle). Whether it is given in the arm or leg depends on the age of the child and the muscle mass available in the arm vs. leg. The routine childhood vaccines that are given subcutaneously are MMR, varicella, and inactivated polio. When he is due for his diptheria-tetanus-pertussis vaccination at his next visit, it will be an intramuscular injection that will go into his deltoid muscle. In the meantime, I'll be watching out for the rash and fever in the next couple of weeks.

Don't wait on managing preschooler's weight

I have a 40-pound preschooler, but she's been steady at this weight for almost a year. She is also very tall for her age. Still, I need to make sure she eats right and stays active so that she does not become a statistic quoted by the CDC: 1 in 7 children ages 2 to 4 years is obese. Obese preschoolers are at risk for developing diabetes, high cholesterol, and asthma later in life. Don't wait on managing the little one's weight. Reduce the risk of obesity by avoiding sugary drinks and high-calorie snacks and encouraging fruits, vegetables, and maintaining an active lifestyle (no more than 2 hours of television per day). Breastfeeding is also recommended, but I also have a 30-pound toddler, so I have some work ahead of me. Here are some tips on how to help your child maintain a healthy weight.