Anaphylaxis/Epipen options

Anaphylaxis/Do you need to carry injectable epinephrine?

Anaphylaxis is a very severe allergic reaction that can occur within moments of exposure to an allergen. People can die from this if it isn't treated. It can be triggered by an allergy to a particular food (peanuts or shellfish are among the most common), biting or stinging insects (like bees), medication (like antibiotics), latex (the type of rubber many balloons are made from) or a variety of other allergic triggers. Allergic reactions occur when the body mistakenly identifies something as harmful and overreacts. With anaphylaxis, this reaction can be life threatening. Symptoms usually start within seconds or minutes of the exposure, but there are exceptions. Once in awhile, a reaction can be delayed by several hours. This of course makes it much harder to figure out the culprit. In an anaphylactic reaction there may be different parts of the body involved. Mouth: itching or swollen lips or tongue Lungs: cough, wheezing, shortness of breath Heart: weak pulse, dizziness, fainting Skin: hives, itching, redness, swelling Face: flushed, swollen (eyes and ears common) Throat: itching, tight feeling, swelling GI system: vomiting, diarrhea, cramps, nausea The first time that someone has a severe allergic reaction is very frightening. Unfortunately subsequent reactions can be even more severe. It is essential to recognize symptoms that need immediate attention. Several years ago, a patient in our practice had been given yogurt for the first time.The child’s face began to swell and she started to have labored breathing. Mom’s first instinct was to call me; I redirected her to call 911 immediately. If it feels like an emergency situation, 911 beats the advice nurse. Of course, we want to be kept in the loop and help with any follow up. This child turned out to be severely allergic to milk. Interestingly she had no trouble with breast-milk. It is very important that folks figure out what the trigger is so that the you can try to avoid future reactions, although there are cases that remain a mystery. Knowing that your child is at risk for anaphylaxis is very unnerving to say the least. It is very important to educate your child (age appropriate) and all teachers and caregivers about how critical it is to keep your child from being exposed to the allergen. One case comes to mind of a school aged patient who was at Costco with some friends. The child was allergic to nuts. The friends parents allowed him to taste something from one of the samples. They had done a cursory check of the ingredients and thought it was safe. It turned out the the knife used to cut the samples had also been used to cut something with nuts, and the child ended up in the ER. Some kids are so sensitive that cross contamination (in this case, the knife) can cause a full reaction. Here is another story of one of our patients with an anaphylactic reaction: This little 9 month old was already teething and fussy, which complicated things. She also is prone to eczema, so rashes are not unusual. The family had had a recent checkup and had come home motivated to increase solids and calories to fatten up their slender child. Dinner that evening was some Chinese take out. Our little patient was offered bits of foods from the various containers. They didn’t offer any foods that struck the parents as obviously new, but one of the containers was a shrimp dish. Although the baby didn’t actually eat any shrimp, she started to get very fussy and swiping at her face and ears. After several moments of excessive fussing from no overt cause, mom and dad opted to give her a bath and start the bedtime process. When they removed her clothing they saw that she was covered with hives. At that point they wisely opted to go into the ER. It had been about 20 minutes since the food. The baby was fairly inconsolable and her face and ears were swelling. Luckily she did not appear to be having labored breathing (that would be a reason for a 911 call.) Once in the ER she vomited. She was given epinephrine and kept overnight for observation. She was singing and happy the next morning with no seeming ill effects. The current plan is to avoid any mystery foods and follow up with an allergist within a few weeks. The family will have an epipen on hand just in case. As a caution, I recommend to try all first time foods when there is time to observe for a little while to make sure there is no reaction. Giving something brand new and then putting a baby straight to bed is not a good plan. This is especially important with high risk foods like nuts, milk, eggs, shellfish, and any medication. It is also a good idea for every household to own Zyrtec liquid (scroll down for dosage chart.) If your child is old enough,talk to them about the fact that just about everyone has a little something special going on, and it their case they need to be careful about whatever their trigger is. Check out this book, available on Amazon. Perhaps pick one up for the class and make sure the teacher reads it out loud. No Nuts for Me Make certain that any babysitters or friends caring for your child know what allergens are potential hazards so that they can be certain to avoid them They should also have an injector handy just in case. If you go to a restaurant, ask to speak to the chef so that you know the restaurant understands the importance of avoiding the ingredient in question. In serious cases, you might want to call ahead to make sure they are willing and able to accommodate you. If your child has any mystery reaction to something, it is worth having a visit with the doctor so that we can help pinpoint the cause. In some cases we will refer you to see an allergist. Mild allergic reactions can be treated with a dose of Zyrtec or Benadryl. Keep in mind that Benadryl might make some kids sleepy and it could muddle your assessment. For an anaphylactic reaction epinephrine is the only first line treatment. It relaxes the muscles in the lungs to improve breathing. To quote Dr. Fast, a local allergist, “Epinephrine is what saves lives. It is never wrong to give epinephrine." One of my mom readers shared her story with me after this post first went out. She recently spent five days in the hospital due to an allergic reaction. She had 4 of the 7 symptoms (including full body hives), but was NOT given epinephrine early because she wasn't having respiratory distress. It took several days to get the allergic reaction under control. Not only does epinephrine help with the respiratory distress, but it lessens the release of the chemicals that are causing the reaction in the first place. The world health organization  would agree with Dr Fast that using epi early is a "no Brainer" https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3666145/ Auto injector options Epipen Epipen comes in 2 strengths. The junior (0.15mg) is for anyone under 66 pounds. Anyone over 66 pounds gets the full adult strength (0.30 mg) .Epipens have been in the news due to high cost and recent shortages. If you have an epipen, check out the lot numbers, some of them have extended their expiration date  May 2019 update The avilailability of the epi pen junior has been very spotty.  Auvi Q is available directly from the website. Auvi Q Auvi Q is a competing product that I always preferred. I liked it because it is flat and easy to stick in a pocket. It also actually talks you through the steps. When you are in the midst of a patient having a reaction, that can be more helpful than you would imagine. It was recalled several years ago due to trouble with the needles. I was thrilled to find out that AuviQ is available again, and believe it or not...drum roll please…. It has a ZERO copay to anyone with commercial insurance or a household with income less than $100,00.00. Auvi Q comes in 3 strengths: 0.1 for infants from 16.5-33 pounds 0.15 children 33-66 pounds 0.30 for anyone over 66 pounds  You have several options.  You can go to the Auvi Q website and download the prescription. Have your doctor sign and fax it over to them and they will deliver it directly to your door: https://www.auvi-q.com The customer service phone number is on the website and I found them extremely helpful. Of you can now get the Auvi Q at your local walgreens. They signed an agreement just this week (July 2019)   Regardless of which one you use, the auto-injector should be administered into the upper outer thigh. It can be given through thin clothing. The leg should be restrained and the injector should be held against the thigh and then compressed, rather than jabbing it. In the case of a severe allergic reaction, give the immediate dose of epinephrine but then head over to the ER for some observation. It is possible for the symptoms to rebound. This is called a biphasic reaction. Hours after a patient seems stable, the symptoms can flare up again. Since it is always better safe than sorry, keeping a close eye on the patient is essential for the next 24 hours Children with reactive airway disease and/or eczema are more at risk for allergic reactions, but they can happen to anyone. No, of course not everyone needs to carry around epinephrine, but it is SO important to recognize the symptoms and act quickly if you are concerned about the possibility of an anaphylactic reaction. There is a law, SB 1266, effective January 1, 2015, that mandates all schools keep an epinephrine auto-injector on hand and that someone on site has been trained. Check with your child’s school to make sure that they are complying. Zyrtec Dosage Chart The dose of cetirizine depends on age as below: 6 - 12 months of age: 2.5 mg given once daily (maximum dose 5 mg daily) 12 - 24 months of age: 2.5 given once or twice daily (maximum dose 5 mg daily) 2 - 6 years of age: 2.5 - 5 mg given once daily (maximum dose 5 mg daily) Over 6 years of age: 5 - 10 mg given once daily (maximum dose 10 mg daily) Zyrtec comes in a 1mg/ml solution (so 2.5 mg = 2.5 ml). There is also a 10mg/ml oral drops preparation (so 5 mg is 1/2 ml). Make sure you check the strength of the solution.

Dealing with Motion Sickness/Something new on the horizon

It is not unusual for us to get calls from folks who have a child or family member that suffers from motion sickness. Females are more likely affected than males. People who suffer from migraines tend to be especially susceptible. While the majority of people who have the most issues with this are between 2-12, some younger babies seem to have trouble as well. We have some unfortunate moms who have babies that vomit every time they go out in the car. If you know in advance that motion sickness is an issue, here are a few natural remedies that you may want to try. If you are someone who deals with this a lot, you will have plenty of car rides ahead to do your experiments and see what works for you. Getting fresh air by having a window open is the first course of action. Do some distraction by playing a game that has your child looking out the window. Experts say to specifically look at the horizon. For those kids who are not super sensitive, you can play some 'I Spy' games. See if you can find interesting license plates or different colors or letters on signs. Don't sabotage your trip by bringing along trip activities that have your child focusing on things inside the car. Even the best passengers might be fine until they start reading or looking at a phone or map. Most kids do best when their tummies are not too full or too empty. Little crackers to snack on might be useful. There are wristbands that provide pressure to some acupressure points that seem to give relief. You can find these on Amazon. There are several brands. A popular one is called sea-bands. They come in multiple sizes and colors. Otherwise simply massage the wrist and lower arm area. The magic spot is located on the inner arm about 1.5 inches above the crease of the wrist, between the two tendons there. Ginger seems to be very helpful. For older kids, there is a ginger gum specifically made for nausea (also available on Amazon). Find your favorite ginger cookie or candy. Trader Joe's has a wide assortment. Of course don't give anything to a young child that might be a choking hazard. Check out ginger lollipops (often marketed towards pregnant women.) Motion Eaze is a topical aromatherapy that some folks swear by. You just dab a drop behind the ears and it provides relief within a few moments. Don't do this one for the first time before you embark on a long car ride. The smell is fairly pungent and other folks in the car might have a hard time with it. If you prefer not to apply a scent directly, there are several essential oils that have been found to help with nausea. Peppermint, spearmint, ginger and lemon are all on the list. Consider letting your child chose the favorite scent. You can apply a few drops to a cotton ball and put it in a baggy. The kids can take sniffs whenever they feel the need. Hylands and Boiron both make a homeopathic motion sickness remedy. As with many homeopathic remedies they gets mixed reviews. Homeopathy does seem to be the ticket for some folks, and is unlikely to cause trouble as long as it is used as directed. It might be worth a try. My husband likes to cry "placebo" I say, "Bring it on, whatever works!" If you are going on a long car ride, plane ride or boat trip and you have struck out with the natural remedies there are some medication options. Benedryl is an antihistamine that often works quite well for motion sickness. It comes as a liquid. The bottle says for children over the age of 6, but in our office we do use it for younger kids. The dose usually agrees with the tylenol dose volume. Kids over 22 pounds would get 5 ml or one teaspoon. Always check with your own doctor's office to see what their policy is. Benedryl makes most kids sleepy, but don't count on that. It gets some kids hyper. You probably don't want to find that out on a cross country flight. Dramamine is another choice. It is an over the counter medication specific for motion sickness. Children 2-6 years of age can take ½-1 tab; children 6-12 years of age can take 1-2 tabs. These chewable tablets can be repeated every 6 hours, no more than 3 doses in a 24 hour period. Start with the smaller dose first to see if it works. Giving the dose 30-60 minutes before travel is recommended. For kids over 6, Bonine is another reasonable choice. This medication can be given at the first sign of nausea and is less sedating. For patients over the age of 12, if all else has failed some people use a scopolamine patch. This is a much stronger prescription medication that I would never use as a first line drug. Some of my motion sensitive older patients have found these valuable for cruises. Luckily, kids do tend to grow out of it...except for an unfortunate few. If you or your child have chronic motion sickness issues, it can be eye related. Cover one eye for several moments to see if the symptoms ease. If this works, you may have something called vertical heterophoria. It is worth having a consult with an eye doctor. My favorite eye expert in this is Dr. Vincent Penza Some people with chronic motion sickness have also gotten relief from chiropractic treatment. There is a new product on the horizon that got my attention. The media is abuzz about special glasses that have been reported to be real game changers for folks who have tried them. https://www.smithsonianmag.com/innovation/could-these-glasses-cure-your-motion-sickness-180969722/ Unfortunately, I haven’t been able to find out how to get them in this country quite yet. If you are interested, it seems that pre ordering a pair is possible if you have connections in Europe who are able to send them to you. In the meanwhile, if you or a family member suffers from this very annoying ailment, See if any of these other methods will help you out until those magical glasses become available If you are on a car ride, assuming the kids are old enough to comply, have them try very hard to give you as much warning as they can. Ideally they should try to get in the habit of warning the driver at the first twinge. The initial signs are usually paleness, yawning and restlessness. They may feel a little sweaty. This is quickly followed by the nausea and vomiting. With enough warning you might have time to pull over and get them out of the car for a couple of moments until the motion sickness eases. Being stoic is not a good plan; it usually backfires. In my car, I actually kept barf bags in the glove compartment. I used to collect unused ones from my airplane travels.They may come in handy. If you don't have an actual barf bag, have a container or plastic bag that you can whisk out at a moment's notice. Your trunk should be prepared: A change of clothes (don’t forget socks) A clean towel A plastic bag for putting the soiled clothes in Some wet wipes A lollipop to get the yucky taste away Febreze for cleaning off the seats (you will bless me) While kids are usually the ones most apt to barf in your car, motion sickness can afflict any of us at different times. I hope that some of these tips can help you out. I remember my days as a carpool driver. One of my little passengers had Emetophobia ( fear of vomiting) and would quite literally open the car door and leap out if anyone so much as made a gagging noise. It kept things interesting!

Back to school adjustment tips for you and your child

My regular readers have heard me repeat this analogy often. Being a parent is like being the coach of a sports team. The real work is the preparation before the game when you learn and practice the plays. More work can be done after the game when you review how your team fared and work on any changes that need to be made. During the actual game, you might be able to chime in to make little adjustments, but for the most part you simply get to watch. This is not the time to effect any real teaching or change. Recognizing the difference between “game time” and effective coaching opportunities is critical. Having your child march off to a new daycare or preschool or school is game time. Doing some preparation ahead of time can be very valuable and can smooth the way. Some kids go off with a smile and wave. You win. Others weep and you need pull them off your body as they clutch at you in desperation. You end up leaving them in their new situation feeling like you have somehow failed. Welcome to being a parent. You lost this round but there are many rounds ahead that will be more successful. Keep in mind that many of the kids are putting on a big show, and are feeling stressed and sad for the moment. Most of them calm down shortly after you are out of sight and end up having a fine day. You on the other hand, will feel like you have a fist clenched inside your gut. Check in with the teachers for a reality check. They can tell you how your little one fared once you are out of the picture. Or do what Sandy did when he took Lauren to her first day of pre-school. He left her crying with her new teachers and then went to the side of the building, hid in the bushes, and watched through the window. Lauren was fine in about 5 minutes but those were among the toughest 5 minutes of his life. The teachers should be an essential part of the team helping with this adjustment period.If you feel like your child might need a little extra help separating, talk to the staff about what options they can come up with. Sometimes having a hand to hold, or a loving lap to sit on can be very helpful One friend or familiar face can make a huge difference. See if you can get a roster of the other children in the class before school starts. If you don’t know anyone, go ahead and cold call some families to see if they want to meet in a playground for an hour and let the kids play together for a bit. Once school begins, ask your child to identify a few other children who seem nice. Reach out to those families and try to arrange some playdates outside of school hours Communication is so important. Create an arena where you and your child can have safe discussion about feelings and actions. This is a basic problem solving skill. Make a list of some of the more common feelings that people might be feeling when they start a new school: Happy Sad Nervous Excited Tired Hungry Lonely Missing home Confused Bored proud I am feeling______________. You don’t need to limit it to one emotion. Identify some things, good and bad, that might be triggering  the emotion: I learned something new I made a friend I helped someone Someone made a face at me Someone wouldn’t hold my hand Someone wouldn’t share I didn’t like my lunch I am scared of the toilet I am having trouble with a skill that others seem to be able to do with ease I am feeling ______________ because_______________ If the feeling expressed is a negative one - mad, sad, nervous, and you were able to identify a source, now is the time to make a list of possible things that might help. Telling stories and teaching through play are really good methods for talking about the feelings and coming up with solutions. Make up a pretend child who also happens to be going to a new school situation (what are the odds?) For this post we will call the pretend child Pat (the ultimate non gender identifying name). Pat can be the main character in many stories. Sometimes the right moment presents itself and your child might be able to chime in and talk about what they think might be making Pat happy or sad. For some children this feels much easier than telling about themselves. Practice saying goodbye. Do it several times. Read some books: https://www.amazon.com/Best-Sellers-Books-Childrens-First-Day-School/zgbs/books/1084236 Try some play sessions with a couple of dolls or stuffed animals; one is bravely heading off to school and proudly tells all about it after they are home. The other is having a much harder time. Talk about some things that may be tools that the brave bear is using or might help the scared bear. Perhaps bringing something like a scarf that smells like home. Maybe wear a necklace with a photo. Maybe find a little smooth round stone that you both rub some energy into and they can keep in in their pocket. Maybe write a little heart or doodle on their arm and cover it with liquid band-aid "How was your day, dear?" Avoid the “How was your day? Fine” trap. Get in the habit of doing a little checklist. Tell me something you learned Tell me something that surprised you What was the silliest thing that happened? What did you do that was kind? Teach your kids the concept of a mitzvah. This is the Jewish term for doing a good deed or act of kindness. Getting in the habit of at least one “mitzvah” a day is something to strive for. Beyond simple acts of kindness, consider giving them 3 small goals to achieve each day. They can tell you how they did. If you are able to do a family dinner, that is the perfect time for conversations. Otherwise it is fine to do this at bedtime, but try to carve out a time where you can talk about the day. This is a great opportunity to review tomorrow’s schedule and list any special things that are coming up that the family might be looking forward to. Alana learned to debrief her day in excruciating detail, but it was a habit that endured for years. As my faithful readers know, she continues to share this with Sandy every day on her drive home from work. Other considerations.... Dr. Elizabeth shared a story from one of her friends. They had made quite the big deal of the first day of kindergarten and the child went in without a hitch. The trouble occurred that evening when the little 5 year old realized that this school business wasn't an isolated event and she had to go back the following day. It is essential that you make sure you are able to pick up your child on time, especially those first couple of weeks. If you are going to be late, have an alternate trusted adult who can be there. Make sure that the school has all of the current cell phone and emergency contact numbers. Lots of studies show that eating a healthy breakfast makes a big difference. Have a breakfast plan and clothes picked out the evening before to avoid stressful confrontations. Make sure your child is not overtired. Start bedtime early enough that they are getting the sleep they need. You never know when your child will decide to make transition to school a “thing”. Some children who never had issues will decide that this is the year to challenge you. My daughter Lauren was reasonably well adjusted in school so I was caught by surprise when suddenly she was in third grade and a new problem reared its head. Alana was now in kindergarten at the same school. The kindergarten kids got picked up about 90 minutes earlier than the rest of the school and Lauren was simply not okay with that. The injustice of her younger sibling going to spend some private time with mom, while Lauren had to stay in class was more than she could stand. If she saw me anywhere on the campus during the early pick up time, she would get quite upset. I would like to say that this eased after a week or two, but if memory serves, I spend most her third grade year scurrying past the window of her classroom in a low crouch . If they were outside at recess it made things even more complicated. I believe I toyed with wearing camouflage in my efforts to make certain that she didn’t catch a glimpse of me during the early pick up. Even if you are one of the lucky parents whose intrepid child marches into their new situation without a backwards glance, it is perfectly normal for you to be deeply impacted by these milestones that signal the passage of time and that your child is growing older. Lauren reminded me of a cartoon that I used to have taped on the wall above my desk. It was a sketch of a doctor, nurse  mom and a baby. The baby was about to get a shot. The caption was. “you had better hold her close, she might cry." The next frame was the nurse hugging the crying mom as the baby got the shot. Yes, this is likely to be just as tough on you as it is for your child!