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.

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.