"Isn't he a little young to see the dentist?"

Not too long ago, I blogged about my son's decaying teeth from breast milk. We just finished a series of visits to remove the decay and then place crowns on his four front teeth. He was a champ overall, despite waterfalls of tears. However, every morning he has been asking, "No doctor? No doctor?" The poor boy has suffered through immunizations, local anesthetic injections, drilling, and discomfort in the last couple of weeks. Fortunately, the medical staff who have worked with him have been marvelous and my son has not been too traumatized, though he hasn't chuckled in his sleep lately.

Anyway, while we were sitting in the waiting room one time, a mom asked me, "Isn't he really young? Why is he here? When should children start seeing the dentist?" It depends on what you read and who you ask. I remember when my son was 14 months old I had asked my daughter's dentist if I should set up an appointment to see him now that he has teeth. The dentist looked in his mouth and said, "He just had his first visit." That was all that was said. I might have been more diligent about wiping his gums after feeds if he had mentioned it. Six months later, I brought my son in because I noticed the brown discoloration on one of his incisors. We were told to brush with adult toothpaste and go back when he turns two for his first visit. Unfortunately, the tooth that I had been worried about broke off. It was later restored with a crown placed over it (by the way, the process of making crowns for young children is not as painstaking as it is for adults). To prevent the other three front teeth from collapsing, we opted to clean the teeth and make crowns for them.

So when should you take your child in for the first check up? The American Dental Association (ADA) recommends that the first "well baby checkup" for the teeth as soon as the first tooth erupts or no later than the child's first birthday. They have a great summary about baby teeth. Other experts say not until the age of three. If you're not sure, ask your child's pediatrician. Parents can find pediatric dentists in your area via an online search, including federally funded health centers that provide dental check ups at http://findahealthcenter.hrsa.gov/. A smile with healthy teeth starts with good dental hygiene at an early age. Even if the dentist just shows you how to wipe the gums or brush the few teeth that your child has, it is important to start getting into the habit. Tooth decay is preventable. Don't let the first dentist appointment be when the first sign of decay is visible. It can leave a lasting emotional effect on the child.

"Manufacturing Deficiencies" Lead to Recall of Some McNeil Products

A voluntary recall of certain children's over-the-counter liquid medicines has been issued by the McNeil Consumer Healthcare unit of Johnson & Johnson. These products include Tylenol Infants' Drops, Children's Tylenol Suspensions, Infants' Motrin Drops, Children's Zyrtec Liquid in bottles, and Children's Benadryl Allergy liquids in bottles. "Manufacturing deficiencies" may affect affect the potency (strength), purity, or quality of the products. Parents are urged to check the products they have at home and stop using them if the lot number matches one on the list of recalled medicines. According to the company, some products may actually have too much of the active ingredient in the product, others may have tiny particles or inactive ingredients that fail testing requirements. Even though it is unlikely that a serious medical problem will occur as the result of giving the recalled medicine, it is not recommended that these products be given to children.

Be sure to talk to the pharmacist or doctor about alternative options to these recalled medicines for children to treat pain, fever, or allergies. For additional information, please visit McNeil's website or call 1-888-222-6036 (8 am - 10 pm ET on Monday-Friday and 9 am - 5 pm ET on Saturday and Sunday). Any suspected reactions may be reported to the FDA's MedWatch program on the FDA's website.

By the way, generic products are not affected by the recall. They are made by other companies that have been approved by the FDA and distributed by the pharmacy/drug store. Generic drugs have been tested and meet the standards of the FDA and work just as well as the brand name equivalents. If you are interested in knowing if a generic version is available, you can check the Orange Book, which is an official list of approved generic drugs.

Freeze pops and meds

Both of my children needed to take antibiotics for their Strep infections a couple of weeks ago. My 4 year-old daughter did not like the appearance or taste of cefdinir (OMNICEF) suspension and my 23 month-old son was suspicious about the cold, pink liquid known as amoxicillin suspension. In fact, my son actually sprayed out the first dose in its entirety. Funny, but these two antibiotics are supposed to be the better tasting of all the liquid antibiotics. With my daughter, I coaxed her to take the cefdinir with gummy bears to chase the medicine taste away. That didn't work the second time. I tried using a freeze pop and let her choose the flavor. This worked to numb her tongue first so that she wouldn't taste the medicine and then it cleansed her palette afterwards. I completed her course with the freeze pops and some water. The same tactic was used with my son when I decided I wasn't going to hold his nose. After several doses with half servings of freeze pops, I was actually able to use grapes and other favorite foods of his to get him to take the medicine. There was no more fighting. It also helped that I made it sound like fun with my singsong voice. "It's medicine time!" I exclaimed. Since the antibiotic was dosed twice daily, I coordinated the doses with breakfast and dinner. This worked really well. When choosing foods to go along with the medicines, just check with your pharmacist to make sure that the antibiotics won't interact with the foods. Some antibiotics should not be taken with dairy products (for example, ciprofloxacin). Also make sure that taking the medicine with a meal will not affect the medicine's overall effects.

A few other things to point out are:

• Some antibiotics need to be refrigerated and others should be kept at room temperature to keep them stable. Amoxicillin can be refrigerated or kept at room temperature. Refrigerating it may make it taste better. Cefdinir can be kept either way. If you're not sure, ask the pharmacist before you leave the counter.
• Make sure the entire course of the antibiotic is given, even if your child looks and feels better after a few doses. Note that finishing the course does not necessarily mean to finish the bottle of medicine. There may be a couple of extra doses left if the bottle has enough for 7 days and your child only needs to take it for 5 days. Do not save it. Throw it out.
• Use the right measuring tool that is appropriate for your child's age. For my 4 year-old, I used a medicinal spoon. My son was given an oral syringe. I gave him the 1 teaspoonful in 2-3 portions. Some pharmacies have these to give away.

Do you have a tip to share with other parents?

Mommy and Me - Strep

Of course, while we're worried about my toddler catching the strep, I'm the one who falls. The night my daughter was diagnosed with Scarlet Fever, I felt cold, achy, and my throat bothered me. Maybe it was psychosomatic. Too bad I was feeling the same way the next day. My worst fear is having another ear infection like the one I had last summer. I described it on another blog and thought you might enjoy reading about the events that lead up to my perforated ear drum.

Don’t ask me how it happened. I probably blew my nose too hard and burst the bulging eardrum, or it just happened. I remember feeling this acute, sharp pain in my ear the other night and it kept me up for hours. I couldn’t even blog about it because it hurt so much. I could feel the pressure inside my ear. A couple of red and white pills later [acetaminophen], I felt better. Hours later, I started hearing liquid moving inside my ear [when I was laying on my side]. It was like a bottled up ocean right inside my ear! I also wondered if one of those pests I try to kill every day ended up in my ear and was drowning in my ear fluid. It was not just sloshing, but I could hear bubbling. What I didn’t tell you is that I have had a “cold” for a week and a half. Also, I’ve been told my ear canal is crooked. You heard me, crooked, so essentially it’s like a clogged drain. Great, huh? So even if a visible pest didn’t make it in, the [microscopic] bugs have already started [enjoying] their sauna, mud bath. Anyway, [after taking my antibiotic and using my eardrops] I can hear fine, but there is constant ringing and it feels like there is someone covering my ear all the time. I hope it heals on its own, because otherwise I have to start thinking about where I want to take skin from to patch it up. Hmmm…

"She has Scarlet Fever"

It started with a low-grade temperature, sneezes, and general fatigue on Thursday. She did mention a sore throat (which made me think Strep throat right away). I kept my daughter home from preschool. Each time I measured her axillary (under armpit) temperature it was normal, but her tactile temperature felt much warmer. She even looked flushed. In the afternoon, it actually was 98.9 degrees F (at or above 99 is considered a fever). I didn't quite trust the digital thermometer because she still felt warm and she kept saying she was cold. By the way, KidsHealth offers a terrific summary of fever in children. My daughter was actually very whiny and looked ill. I offered her chewable acetaminophen (generic Tylenol) tablets to help her rest better (note, I expected her to refuse). She took all 3 tablets and actually liked it. After a while, she took a nap. I kept asking her if her throat still hurt, and she kept denying it. So much for my strep theory. She also slept through the night.

The next morning, she asked for more acetaminophen, but she clearly did not need it. She claimed that her throat hurt a little. After she drank some water, she said it was better. Maybe because I kept offering to take her to the pediatrician if her throat still hurt. In any case, she looked 100% better and was jumping, singing, and dancing. I wondered if I should let her go to school, but it was suggested that she go because she's turned around. "Does your throat hurt?" "Just a little." Later, "no." She was fine the rest of the day; just one or two sneezes. There was a case of strep reported in the 3's class. Since she didn't ever have a fever, I kept it on the back burner. What my daughter has is probably just viral; the common cold.

Saturday morning, my husband noticed a rash on her cheeks. He relayed that to me, but I must not have heard him. Her throat hurt in the morning, but then it didn't. We went to a ballet performance and then a late lunch/early dinner. No sneezing. She ate like a champ. In the evening, though, when I gave her a bath, I noticed a rash on her back, her trunk, and her pelvic area. There were a few blotches of red, but the rest were small and skin colored. They felt like sandpaper. They reminded me of goose pimples. We thought she might have fifth disease, which is caused by parvovirus. She did develop the rash 2 days after the "fever" and she was flushed (slap cheek). Since she didn't have a fever, I decided to wait until Monday to bring her to the pediatrician to take a look. In 5th disease, once the rash breaks out, the child is no longer contagious. Here is a good collection of skin rash photos.

On Sunday, she developed a few little red lesions around her mouth, but otherwise fine. We ran errands and all was well. The red lesions on her body were fading in color, but the sandpaper rash was still there.

On Monday, the lesions around her mouth were still there. She woke up a little later than usual, but was chipper. I brought her to school and then was able to schedule an appointment with the pediatrician. When I brought her in, he took one look at the rash and said, "She has scarlet fever." He then looked at her throat and took a sample for a throat culture. She was started on cefdinir (Omnicef) twice a day for 5 days. Sure enough, the culture was positive for strep in less than 24 hours. I should have trusted my initial instinct.

Cefdinir liquid is white and tastes bitter (not like the acetaminophen chewable tablets), but I explained to my daughter the rationale for taking this. I let her eat a piece of gummy candy and then drink from the medicinal spoon. We repeated this a few times. I even diluted the remaining volume (1 mL with water), but she quickly asked if she had to drink it all. Next time I will not dilute it with so much water. This morning, she refused to take it, but I gave her a freeze pop to numb her tongue and to cleanse her palette after each swallow. It worked like a charm.

We're home for a couple of days because scarlet fever is highly contagious. She will be allowed to return to school after being fever-free for 24 hours and after taking a full day of her antibiotic. The nurse also told me to change her toothbrush after 48 hours of starting her antibiotic. We're expecting some peeling later on in the week, but she' recover. Scarlet fever is not as life-threatening as it seems if treated in a timely manner with appropriate therapy. I'm glad I brought her in.

Talking Poison to Preschoolers

Today wraps up National Poison Prevention Week, but educating families about poison prevention is a passion that I can and will sport all year round. I love surprising parents and kids about how much some medicines look like candy, how some cleaners look like drinks, and how children can access child-proof items.

Yesterday, I went into my daughter's preschool class of four and five year-olds. I didn't go all out with my props this time, but I did find things around the house to show and tell. These included a bottle of green multi-purpose cleaner, a bottle of water (which I tore off the label and asked if they would still accept my bottle to drink), gummy vitamins, real gummy bears, my daughter's purple fluoride tablets, toothpaste, my orange nasal inhaler, freeze pops with electrolytes and some without, a bar of soap, spray on sunscreen, and a tub of red finger paint. I thought I would only take 10 minutes, but I ended up with a 20-minute presentation. The children were able to tell me what a poison is ("something that makes you sick or die"). I was glad one of them brought up death because I wasn't sure if they were ready for that term. My daughter is familiar with it because we have had quite a few recent deaths in the family, but she has asked us to define the term.

I also made a STOP sign with "Stop! Ask First" and wrote out the Poison Control Center's phone number on a large piece of construction paper. Every time I showed them something that they weren't quick to comment about, I waved the stop sign. The three main points I had wanted to get across to them were: 1) stop and ask a trusted adult first, 2) medicine is not candy, and 3) call 1-800-222-1222 for poison emergencies (yes, someone is available to take calls 24/7). I also emphasized that poisons aren't just harmful when swallowed, but also when touched, smelled, and brought to the eyes. The final activity was teaching them the phone number. Yes! The teachers have taught them how to read numbers (although there are lots of 2's). I always get a kick out of hearing them recite the phone number with me! I'm glad I was able to show the teachers something new: freeze pops with electrolytes. They were still talking about it as we were leaving the school.

Take home packets included an activity book about Lenny Lendahand, brochures about plants being poisonous, general information about the Poison Control Center, a checklist of what to do in case of an accidental poisoning (no more syrup of ipecac, mind you, for ingestions), a game that I created about medicine vs. candy, and telephone stickers with the 1-800 number. These were all free from the CT Poison Control Center. I'm sure you'd be able to get them from your local chapter. Find yours here and make a difference in your child's classroom next time. You don't have to be a health care professional to talk about poisons to children of any age at home or at their schools. Just spread the word that they can be prevented and the phone number.

Here are some links to give you ideas:

Poison Prevention Preschool Lessons

Poison Education Resources

Poison Prevention from the University of Buffalo

Poison Prevention.org

Scrapes and cuts may hurt, but words are comforting

I let my daughter run hand-in-hand with her friend from the library to the playground under the supervision of the friend's nanny. In the meantime, I was getting her jacket from the car. As soon as I turned my back, I heard a cry. I ran to her with my son in my arms. She was holding up her arm and I saw a spot of blood. The nanny said it was just a bruise, but I wanted to be sure. I took her back to the car, where I had a bottle of water and first aid supplies. My daughter wanted to go home and wouldn't let me touch her wound. After much coaxing and reassuring her that I was going to take care of it, she calmed down a little. Before I flushed the blood off with some water, she asked me if it was going to hurt. I didn't lie, "It might sting a little, but it's important to wash the boo-boo so that the germs can't grow on it. Then I'm going to put some of this medicine on it. This won't hurt; it will make it better. You choose the bandage you want me to put on it." It took two to cover it up, but by the time I was done, she was ready to continue with her playdate. I didn't realize she actually had a small scrape on her knee, as well, until I gave her a shower that evening. It didn't bother her as much, but I also put some antibiotic ointment on it. Convincing her to let me change the bandages and to take a shower was challenging, but they were both accomplished. Although I needed a little help from my husband to distract her when I pulled the old bandages off and put new ones on after putting more ointment on. I did not let her arm get wet, as promised. Before she went to bed, we had a discussion about her swim lesson the next day. She was willing to try it. We talked about it again in the morning when she seemed less anxious about her wounds and she was still in agreement that she should try going in the water. It turned out to be her best class! She did well enough to advance to the next level. When it was time for her shower, she was reluctant to wash her arm with the wound until I gently reminded her that she had just gone swimming and nothing bad happened. That went well. In fact, she didn't even whine about putting new bandages on. I guess my baby is a big girl now.

It's always a good idea to have an antibiotic spray or ointment handy, along with some gauze and bandages handy. Prepackaged first aid kits can be purchased from your local pharmacy. Here are some sites with great information on wound care in kids:

• First Aid Fundamentals
• Cuts and Scrapes: First Aid and When to Call the Doctor
• First Aid and Safety
• Teaching first aid to kids
• First Aid Checklist for Campers

Not all Maalox are Equal

Not all Maalox products are interchangeable. Most parents think of antacids (for heartburn) when they hear the name Maalox, but Maalox Total Relief contains an anti-diarrheal agent. Recently, the FDA warned consumers to avoid Maalox mix-ups because the active ingredient in Maalox Total Relief, bismuth subsalicylate (related to aspirin), can cause serious side effects if it is taken by children and adults who are at risk for bleeding excessively. One such risk factor is having a history of gastrointestinal ulcers or bleeds. Another risk is taking anti-diabetic medicines, blood-thinning medicines (warfarin, aspirin), and nonsteroidal anti-inflammatory agents (ibuprofen, naproxen). Children and teenagers who are recovering from viral illnesses (chicken pox or flu-like illnesses) should also steer clear of aspirin-containing products to avoid Reye's Syndrome. Finally, patients allergic to aspirin should not take anything containing bismuth subsalicylate.

Novartis, the manufacturer, has agreed to rename Maalox Total Relief to remove the name Maalox and change the graphics to make it clearer that these are different products. You won't see these new packages until later in September. Until then, ask your pharmacist to make sure you're buying the right product for your child or yourself. Ask yourself: what is it that's bothering your child?

• Is it just gas? You can just get plain simethicone (Gas X, Mylicon, or generic equivalents) for gas relief.
• If your child has heartburn, acid indigestion, sour stomach, or upset stomach from these symptoms, but no gas, then Maalox Children's Relief will be appropriate.
  
• If your child is 6 and older and also needs gas relief, then choose Maalox Junior Plus.
  
• For children 12 and older with diarrhea and upset stomach and not recovering from a viral illness, try Maalox Total Relief. For heartburn, sour stomach, and acid indigestion relief without gas, try Maalox Regular Strength Chewable.
  
• Gas is also the problem? Then try either Maalox Advanced Maximum Strength Chewable Tablets or Maalox Advanced Regular Strength Liquid. Note that the Advanced Maximum Strength (as compared to Regular Strength) chewable tablets and the Advanced Regular Strength liquid both have simethicone, but they have different antacids. Here it becomes a preference of dosage form, as both will be effective against heartburn, acid indigestion, sour stomach, and upset stomach from these symptoms.
  

To identify which active ingredients each product contains, read the label under "Drug Facts." Below is a table that lists the active ingredients and the products that contain them. Please visit the manufacturer's web site for more detailed information. Report and side effects to the Medwatch program (that's how the FDA picked up that there is a potential danger when these products are confused).

	Active Ingredients	Indications
Maalox Children’s Junior Relief Chewable	Calcium carbonate	Acid indigestion, heartburn, sour stomach, upset stomach due to these symptoms
Maalox Junior Plus	Calcium carbonate, simethicone	Acid indigestion, heartburn, sour stomach, upset stomach due to these symptoms, bloating and pressure (gas)
Maalox Regular Strength Chewable Tablets	Calcium carbonate	Acid indigestion, heartburn, sour stomach, upset stomach due to these symptoms
Maalox Advanced Maximum Strength Chewable Tablets	Calcium carbonate, simethicone	Acid indigestion, heartburn, sour stomach, upset stomach due to these symptoms, bloating and pressure (gas)
Maalox Advanced Regular Strength Liquid	Aluminum hydroxide, magnesium hydroxide, simethicone	Acid indigestion, heartburn, sour stomach, upset stomach due to these symptoms, pressure and bloating (gas)
Maalox Total Relief	Bismuth subsalicylate	Diarrhea, upset stomach associated with nausea, heartburn, and gas from overeating

Nose bubbles

My 21-month son had a cold for about 2 weeks. I know my mother-in-law wagged her finger at me (even over the phone) when I told her we didn't visit our pediatrician. I didn't even call him. No, no medications either for his runny nose or cough (I presumed from postnasal drip). Yes, we did have a few rough nights, but I wasn't worried because he was drooling so much. Teething. It really wasn't fun changing his outfits 3-5 times a day. My fingers also became his teething ring. Ah, the joy of parenthood; my shirts also became his snot rags. In any case, I watched the mucus from his nose change from runny and clear to thick and green. He also made big nose bubbles. Still I did not worry, since he never had a fever and his activity level was normal. He even tolerated physical therapy. I did, however, use a bulb syringe to help clear his nose and petroleum jelly to soothe the chafing from all the wiping with tissues.

The bulb syringe we have is one that allows you to run water right through it with its removable flap at the other end. Just rinse with mild soapy water and air dry without worrying whether it's been thoroughly cleaned.

\My son's nose eventually dried up and his cough and drooling stopped, too. Until the next teeth erupt...

Timing is Everything - Scheduling Your Child's Physicals for Insurance Purposes

Something I never thought about until I had to appeal to the health insurance company: schedule annual physicals at least 366 days after your last one if you want to avoid insurance claim nuisances. My daughter had her physical on 12/16/08 and her next one exactly a year later on 12/16/09. Maybe I should have taken it as a sign when it turned out that the appointment was never actually placed on their schedule and I never got a reminder call. I called on the day of the appointment to confirm and was told that there must have been a mix-up, but she was able to fit us in. Well, we received statements from the insurance company that the claims for the visit, including the vaccines that she endured, were denied because we reached the maximum allowed. I thought, how could that be? We were there in 2008, the visit was in 2009. Then we got the bill from the pediatrician's office. When I called the insurance company, the only thing that the associate was able to come up with is that the computer was counting days and it's exactly 365 days. "I always tell people to wait 367 days." That doesn't make sense to me, but when I schedule her next physical, I'll be sure to make it on 12/17 or after. The claims have been resubmitted, and we'll see in a week if the humans are more practical than the computer.

The Breast Time to Wean

The decision to wean your child from the breast can either be an easy one or a hard one with strong emotions attached. Breastfeeding exclusively (without supplementation) is recommended by the American Academy of Pediatrics for at least "the first 6 months of a baby's life and support should be given for breastfeeding for the first year and beyond as long as mutually desired by mother and child." Despite the encouragement to breastfeed for as long as moms feel comfortable with, our society has different views. In any event, my decision to stop was based on my concern for my 20 month-old son's dental health, though I had been recently contemplating about weaning him off. My husband always said that if my son could ask for it, then he's too old. His babble consisted of asking for it. Anyway, I was brushing his teeth one night and noticed some brown spots on his incisors that were just coming out. Also, there was occasional bleeding from the gums that I had attributed to teething. The brown looked like decay, so I immediately scheduled a consultation with the first available dentist in the office my daughter receives care from. Lo and behold, my son has a textbook case of early childhood caries (or baby bottle tooth decay). He has not used a bottle and will drink water and diluted juice from a sippy cup or with a straw, so the frequent nighttime feeds without proper dental hygiene after each feed was deemed the cause. Yes, breast milk can cause caries. The dentist did say that it looked worse than it is. While he did not mandate stopping the breastfeeding immediately, I felt terrible and wanted to rectify the situation and avoid further damage. Having had multiple root canal treatments and unsightly fillings, I didn't want him to have to endure that in the future. So, in addition to brushing his teeth daily with adult toothpaste (I got the ok) and applying more fluoride to the affected teeth, I decided to stop nursing my son cold turkey. It's been 2 weeks now and it really wasn't that bad. Initially he was very upset about it. Oh, there were tears and dirty looks, but he did stop asking for it. We used a baby bottle with water as a transition. He actually took it the first couple of nights (especially since he had a fever the second night), but now he's fine. Although he is still a bad sleeper, he does not need the breast to help him fall back asleep (just reassurance that mommy's around). And the brushing part? He welcomes the toothbrush, but fights as soon as he tastes the mint. It's tough love, but it will make a tremendous difference in his oral health. We go back to the dentist in 4 months for his official first visit. Hopefully he will not need major restoration of his teeth.

Moms, if you are still breastfeeding, follow these tips from the American Dental Association to prevent early childhood tooth decay.

Is e-Prescribing the answer to reducing med errors?

At my last doctor's visit, I asked for a new prescription for hydrochlorothiazide. Expecting my doctor to pull out her prescription pad like she always does, she surprised me with her iPod Touch. After a few questions and some brushes on the screen, the gadget emitted a sound to indicate that the prescription had been sent to my pharmacy. New decade, new technology for the practice? E-prescribing is still relatively new; it has been available in the last few years. Theoretically, electronic prescribing has a huge potential to reduce the number of prescribing errors associated with paper and verbal prescriptions, but after having seen the errors made with computerized order entry (CPOE) in the hospital setting, I remain skeptical. Undoubtedly, this advanced technology will increase accuracy. As a pharmacist, I can see that less time would be spent on deciphering the scrawls or making phone calls to verify the guess. As a patient, I was happy to see that the label finally had the right doctor's name on it. Now supposedly insurance coverage of the medication would be checked against the formulary ahead of time, so less time would be spent on phone calls by the pharmacist to the insurance companies. Hydrochlorothiazide is an easy one. The only catch was that I had a new insurance plan so the pharmacy could not complete the transaction until I went to pick it up. Convenience is definitely an advantage for e-prescribing on a device that could send and receive data wherever there is wi-fi. Thus, my doctor could send a prescription from home or a coffee shop, if need be. By the way, e-prescribing is not available for controlled substances.

According to an article in the Br J Clin Pharmacol 2008, fewer prescribing errors would lead to fewer pharmacists' interventions, thus improving the quality of prescribing. Some organizations project improvements of patient safety with the avoidance of:

• dosing errors, since the program would be able to calculate doses based on weight for children (hopefully it would know what to do with weights that are off the charts for their age);
• drug-drug, drug-allergy, drug-disease interactions (only if there is a complete drug and disease history on the patient's electronic profile); and
  
• duplication of therapy (again, need a complete profile).

Human errors can still occur, though. The prescriber can still make an error in selecting the drug, dose, strength, route, and instructions. The pharmacist can still misinterpret the prescription and dispense the incorrect product. However, with proper use of e-prescribing, both professionals can be more efficient in their roles to offer better care for the patient. Both would have more time to spend with patients.

E-prescribing is definitely convenient and will help reduce prescribing errors, but it can also open up a can of new errors. My advice? Be as informed as possible. Know what you or your child is being prescribed, how much to give, how often, and for how long before leaving the doctor's office. When picking up prescriptions, make sure they are correct before leaving the pharmacy. Take a few minutes to talk to the pharmacist if the prescription is new to learn about side effects to look out for. Finally, keep that medication list handy and double check that all of the health care professionals (including pharmacists) who care for your child have the most updated information about allergies and current medications.

To Tell or Not To Tell

I am a firm believer of prepping the kids about doctor's visits and "pokeys". I explain everything to my 4 year-old daughter, sometimes too much, but she seems to get it. Maybe I should have taken it as a sign that she cried a bit when she got her DTaP, IPV, and PPD test just a couple of weeks ago. Removing the bandage? That was another fight in itself. Anyway, as we got closer to her next appointment to get her MMR, varicella, and H1N1 vaccines, I started telling her about the upcoming visit. She was not happy about it, but eventually agreed that this was important as long as she didn't need the finger prick again. My husband even played doctor/patient with her all weekend and focused on administering shots. Right before leaving the house, I let her choose a princess figurine to take with her. All seemed fine. She took a nap in the car and she didn't cling onto her booster seat when it was time to go in.

We walked into the examination room and waited. And waited. The vaccine nurse finally came in with her tray (after 15 minutes) and asked me to fill out paperwork and then hold her. I couldn't because I had my son on my lap. After shifting some weight around, I managed to put her on my lap, too. Then the nurse fussed about whether my daughter's shirt should be removed or should she attempt stretching the collar to reach her deltoid (arm muscle). There was more fuss about holding her down and that's when everything fell apart. I was asked to put my son down so I could hold her, but that wasn't going to happen. He doesn't like the office to begin with and he's in his separation anxiety phase again. The other nurse was called in to help hold her down. More fuss about my daughter's clothes occurred. All this time my daughter was screeching and kicking. Boy, she is STRONG! At last, she got an injection in one arm and, after more fuss and fighting, the other two in the other arm.

I don't doubt that the act of injecting into the arm was painful (though two were subcutaneous, or injections into the fat layer) but the anticipatory pain was really off the charts. The delay, the fuss, the insistence of holding her down were major contributing factors. An unfamiliar face can also be a detriment. Our former pediatrician actually administered all the immunizations and drew all the blood samples herself. That was probably why my daughter never ever cried when she got vaccines. All the immunizations were also given on one day without a problem.I also found the immunizer to be unfriendly. I don't remember if she tried to win my daughter over to begin with or not. She could have introduced herself in a friendly voice, tell her it will just be a pinch (or three), and ask if my daughter wanted me to hold her. We had talked about just holding her hand and having her look the other way. The process could have been much quicker. It also didn't help that my daughter forgot her princess in the car.

The bottom line? It is torturous to submit the child to the anticipatory pain twice; she was better off taking the pain of multiple injections on one day. If it weren't for the timing of her second H1N1 vaccine dose, I would have chosen to have all the vaccines given to her during one visit. She has not complained about any soreness. When I asked her if her arms hurt, she said, "no." I asked her what she was so scared of and she said that the pokeys hurt going in. Do I think she would have benefited from local topical anesthetics? Maybe, but that won't take away the anticipatory pain. Improving the external factors alone could have made experience better. Immunizers, please take note, it's not just about paperwork and injections. Make the experience more pleasant for the child (and caregiver) by being more efficient and not insist on having the child held down (unless necessary). Little things make a lot of difference. And I'm still going to tell them ahead of time what to expect.