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.