But medications can be expensive!  Your insurance plan’s drug benefit should help cover the cost, but sometimes there’s a problem.

If you arrive at your pharmacy and discover that your prescription is much more expensive that you expected, please have the pharmacy call us right away.  Perhaps we’ve prescribed a brand that your insurance company doesn’t cover.  Or perhaps there’s an equivalent medicine that works the same but costs less.   Or maybe the drug manufacturer has a “trial program” that would get you started at minimal cost.

We are quite happy to make a switch if we think it will work as well.  But we don’t know about the cost problem unless you tell us.   Don’t be shy!  Unfortunately, we can’t keep track of all the insurance formularies, because they’re all different.   And we don’t keep drug samples in our office.  But with the help of your pharmacist, we can find out which effective treatment will result in the lowest out-of-pocket expense for your family.

I’m always sad to hear that a family has decided not to purchase medication that I’ve prescribed because they can’t afford the cost, or that the family spent more than necessary.

Whether the medication is for eczema, asthma, ADHD or an infection, there’s almost always a way to make sure that you can afford your medication.   PLEASE call us before deciding that you can’t afford a medication that we’ve prescribed!

–  David Epstein MD

People ask if I recommend the Swine Flu vaccine.  Yes, I certainly do!  When we receive it, I’ll administer it to my staff and myself (at the direction of the Division of Public Health).  Then we’ll offer the vaccine to our most frail patients (with cerebral palsy, chronic lung diseases, etc).  Then we’ll invite you to schedule an appointment to receive it.

Just as for the regular “seasonal” flu vaccine, there will be a nasal mist Swine Flu vaccine, as well as shots.  We’ll offer these to our patients as we receive them.  I doubt that we’ll receive our entire allotment at once, so some patients may have to wait to receive it.

Are you worried about the vaccine?  Please be reassured.  The H1N1 vaccine has been tested on thousands of patients already.  The manufacturing processes are the same as for the “regular” seasonal flu vaccines.  So the new vaccines can be expected to give the same immunity, and the same low chance of side effects, as the vaccines against “regular” flu.  And we are certainly seeing cases of H1N1 flu in the office (perhaps two cases a week now), so it’s a good idea to get immunized.

–  David Epstein, MD

For patients with “Commercial” insurance (Blue Cross, Aetna, Coventry, etc.): we have all “regular flu” vaccines:
-  shots for all children under 3
-  nasal spray for all children over 2 (EXCEPT those with asthma)
-  shots for all children over 3 (INCLUDING those with asthma) (This is *new!* as of 9/25/09; so if we delayed giving flu vaccine last month because your child has asthma, NOW you can call us to schedule a flu shot.)

For patients with “Medicaid” insurance (Delaware Physician’s Care, Unison, etc.):
-  We have flu vaccine ONLY for patients over 8 years old (healthy or asthmatic).  I will post a note here when they are delivered; we hope to have them by Halloween.

“Swine Flu” (Novel H1N1) vaccines:  As of 10/7/09:
-  NO vaccines yet.  They will be delivered in shipments spread across many weeks.  The CDC is just starting to distribute Swine Flu vaccine to hospitals.
-  Eventually we will have both nasal vaccines and injections
-  “High Risk” patients will be vaccinated first
-  I will post a note here when they are available, we hope by Halloween.

We are able to immunize most of our patients against “seasonal” (regular) flu.  We have been immunizing kids under 3 with flu shots since mid-August.  We are also able to immunize most kids over 2 with the nasal “FluMist,” except kids with asthma; we can give them flu vaccine injections.

Separate vaccinations against both regular flu and Swine Flu are needed for the best protection.  I strongly recommend that all patients receive flu vaccine, both “seasonal” and H1N; parents should also be vaccinated if possible.

Currently, physicians are being asked to “prioritize” testing for the H1N1 flu virus.  In general, we are advised not to run tests unless the patient is sick enough to consider hospitalization.  If we test everyone with fever, the labs will be overwhelmed, which will delay really sick patients from getting test results.  Also, not every case of Swine Flu must be treated with Tamiflu.  There is concern that overuse of antiviral medications like Tamiful may induce the Swine Flu virus to mutate and develop resistance.

Some patients have asked about taking the children out in public.  But I don’t think it’s necessary to “huddle” at home.  Only a general curfew would be effective at curbing transmission; most people who contract flu (H1N1 or regular) will recover anyway; and in the meantime we have to live our lives.  Kids need social stimulation too!  Frequent hand washing (or hand sanitizer) is your best protection.

–  Dr. Epstein

In order to stop the bleeding, a clot must form.  The quickest way is to have the child sit calmly, with the head tilted slightly forward (as if looking at the floor at the far end of the room).  Pinch both nostrils closed, and hold them closed for 10 minutes or longer, while the child breathes through his mouth.

Pinching the nostrils creates a closed cavity; the blood flows forward into the cavity and sits, forming a clot.

Do not tilt the head backward!  If you do, the blood will flow back, down the throat.  No clot will form, and the child will swallow the blood, which may cause a stomache upset.

Do not open the nostrils before waiting the full 10 minutes.  If you release the nostrils too early, the partly-formed clot dislodges, and the process must start again.

If the nosebleed does not stop within an hour or so, you may need to go to an Emergency Room to have the bleeding cauterized.  (Keep the head down and the nose pinched on the trip there – maybe the bleeding will stop!).

–  Once the bleeding has stopped, you can think about how this happened.

Was the nosebleed caused by a blow to the face?  If so, and if nasal stuffiness persists, the child should see an ENT surgeon within a few days.  (This might indicate a possible hematoma).   If the tip of the nose is pushed to one side (when viewed from the chin with the face turned up), there may be a dislocation (”broken nose”) that requires a visit to an ENT surgeon.  “Raccoon eyes” (bruising around the eyes a couple of days later) may also indicate a nasal fracture.

Are the nosebleeds recurrent?  You can can reduce the frequency and severity of nosebleeds by treating the child’s chronic hay fever, avoiding cigarette smoke, using a humidifier, and using saline drops in both nostrils twice a day.

Does the child always bleed from the same nostril?  If so, there may be a “bleeder” inside the nose that an ENT can cauterize.

If the nosebleeds seem severe, last excessively long, or are increasing in severity and frequency, please give us a call!

–  David M. Epstein, MD

So far, Swine Flu hasn’t seemed very serious.  Most cases have recovered fully; fewer than 500 people have died from it in the US so far this year.  This is a remarkably low number, considering the high rate of transmission.

But the concern is that if the Swine Flu virus mutates into a more virulant strain, but retains its high contagiousness, things could get much worse.  This is what happened during the 1918 pandemic of H1N1 flu, which killed 100 million people (5% of the world’s population).

Our medical care is certainly better than it was in 1918, and we hope that another pandemic like 1918’s would not be as lethal.  We now have antiviral medications, better hospitals, antibiotics, and better worldwide communications.  But we are not completely protected:  strains of Swine Flu resistant to antiviral medications have been reported.  And many people in the world have never seen a doctor and can’t get to a hospital at all!

I recommend that everyone get a flu vaccine.  Adults should get them, for their own protection and so that it doesn’t spread to the kids.  Kids should get them, for their own protection and so it doesn’t spread to their friends and classmates.

Flu shots are routinely given to kids 6 months and older.  (Nasal spray vaccination is a nice alternative for kids over 5 years old who don’t have asthma.)  Two vaccinations, one month apart, are required if you’ve never had flu vaccine; one vaccine per year is required after that.  This year, vaccine against Swine Flu will be administered separately; we probably won’t get ours in stock until Thanksgiving according to the Delaware Division of Public Health.

Never had a flu shot?  This year is a good time to start!  Afraid of the flu vaccine?  There’s no reason to be; people who claim that the “flu vaccine made me sicker” are usually confused by a coincidental illness unrelated to the flu vaccine.

Keep checking my website (click here); I’ll keep posting updates about flu vaccine and Swine Flu.

–  David Epstein MD

Everyone is concerned.  However, worldwide, fears of a global “pandemic” are starting to recede.

For the latest information about the status of Swine Flu in Delaware, click here to go to the Medical Society of Delaware’s website.

For information about the symptoms and medical care of Swine Flu, click here to go to the CDC’s website.

Without fever, there’s not much concern about Swine Flu.  Don’t forget that most kids with fever have something else!! Our office is still seeing several kids a week who have been sickened by Strep Throat, for example, which is treatable with standard antibiotics.  Viral tonsillitis is also giving our patients high fevers as well; these kids get better in a few days with supportive treatment.

Some patients have asked to stockpile Tamiflu at home.  I urge my patients to resist this temptation.  I am very concerned about the flu bugs developing resistance to our medications (which they do very easily).  The Tamiflu should not be administered without a good indication, such as a close eposure to a sick child with culture-proven flu.  Exposure to a sick child who has not been tested, no matter what country they’re from, is not a good indication for starting Tamiflu.

But our office does have the ability to obtain nasal swabs for Swine Flu testing, for transport to local laboratories.  Please call if you are concerned about your child.

–  Dr. Epstein

Double-check your cell phone; if you have *any* other phone number recorded (2078 through 2084), you will reach an internal number that will sound legitimate but will not record a message.  (This may have occurred if we ever called you from our office on any of our 8 phone lines, and you saved the number on your phone.)

This is a feature of our phone system that we cannot disable.  Thanks for your understanding!

–  David M. Epstein, MD

The first thing, of course, is to ensure that the fever doesn’t represent something dangerous.  Meningitis or dehydration come to mind; parents should use their best judgement about when to call the doctor or run to the emergency room.  (Click here to see my guidelines.)

On the other hand, fever is not dangerous.  It makes kids feel lousy, and it’s worth treating for that reason, but the fever itself does not hurt otherwise healthy kids, despite “folk tales” that you might have heard.  (Read here for more information.)

Most kids with fever can be helped to feel better at home for a couple of days.  Tepid baths can be given as frequently as desired.  Fluids are really important, no matter what else is wrong; a couple of ounces every hour while awake is usually enough.  Any kind of fluid is fine; milk, tea (avoid caffeine), soup, jello … anything!  If the child’s urine is dark yellow, he needs more to drink.

Fever reducers (such as acetaminophen or ibuprofen) certainly help febrile kids feel better.  Some people feel that fever shouldn’t be treated with fever reducers, because the fever might “help the immune system fight the infection.”  Actually, this idea comes from studies that were performed in infected iguanas!  They got better faster if they were allowed to increase their temperature by crawling into into warmer areas.  But I am not convinced by this; there’s no such data confirming that infected humans get better faster if their fever is untreated.

So I do recommend fever reducers.  Acetaminophen (7 mg per pound) can be given every 4 hours, while the child is awake.  Ibuprofen (4-5 mg per pound) can also be given safely every 4 hours (even though the label may suggest a 6-8 hour interval).  (For more exact dosing recommendations, click here.)

If the fever is very high, or the child has an underlying medical illness that makes the fever itself a danger (such as a history of seizures, congenital heart disease etc.), the doctor might recommend alternating acetaminophen and ibuprofen every THREE hours: acetaminophen at noon, ibuprofen at 3 pm, acetaminophen at 6 pm, etc.  It’s probably best to discuss this with the doctor.

Most kids can wait until regular office hours to take care of a fever — no need to call in the first few hours!  And remember that fever always goes higher at night; this is to be expected.  But if there’s any question in your mind, give us a call!

– David M. Epstein, MD

There is no doubt that physicians should prescribe steroid medications carefully.  However, I am not convinced that these studies should alter our standard treatment for wheezing and allergy in children.

One study enrolled 687 children younger than 6 years old, admitted to hospitals in England for wheezing.  Those who received prednisolone (Orapred and other brands) stayed in the hospital 11 hours on average; those who received placebo stayed 14 hours on average.  There was no difference in side effects.  The authors concluded, despite the 20% reduction in hospital stay, that the prednisolone was unnecessary.

These results are puzzling.  Typically, young children might wheeze from asthma, or from a viral infection.  Many previous studies have found a big benefit from using prednisolone to treat wheezing children with known asthma, often quickly relieving their breathing difficulty.   However, the benefit is less clear for children wheezing due to a viral infection.  In my practice, I have found that prednisolone in short courses is effective in reducing wheezing in some, but not all children.  Side effects have been minimal.  I will prescribe it sometimes, if there is a family history of asthma, to try to keep a child out of the hospital.

I am concerned that this study lumped these two groups of wheezing children together, diluting the apparent benefit of the short course of prednisolone.  Steroids have been used for decades as a safe and effective treatment for asthma-related wheezing, when carefully used along with albuterol and other treatments.  Further research might show a diminished role for steroids in the future, or find better rescue treatments for children with asthma attacks, but the weight of evidence still leads me to feel comfortable treating asthmatic children with prednisolone for wheezing and difficulty breathing when necessary.

The second study, performed in Canada, enrolled 129 healthy toddlers and preschool children to receive 10 months of either high-dose inhaled fluticasone, or placebo, hoping that the fluticasone would prevent wheezing.  It did; wheezing severe enough to require oral steroids was reduced from 18% to 8% of children.  However, children receiving fluticasone gained less weight (1 pound) and less height (1/4 cm).  The authors concluded that the benefits of preventative high-dose fluticasone might not outweigh the risks.

I agree with their conclusions, as far as they go.  High dose fluticasone appears to carry potential risks of slowed growth.  However, the study used doses of fluticasone that are 4 to 8 times higher than the standard doses of Flovent, Flonase and Veramyst that we use in children.  Previous studies, with larger numbers of children over longer periods of time, have shown minimal or no measurable effect on height growth from daily use of the usual doses of steroids.  This study does not persuade me to avoid using standard doses of fluticasone and other steroids for children who need them.

No medication should be prescribed without weighing the potential benefits against possible side effects, and discussing them with the family.  And further research may change expert opinion.  But as things stand now, I remain reassured that our usual, standard treatment of asthma and hay fever remains safe and effective, when used properly.

–  Copyright 2009,  David M. Epstein MD

Folklore would have us clean ears with a cotton swab or Q-tip.  Unfortunately, this is a bad way to clean the ears; usually the cotton swab simply pushes the wax farther back into the ear canal, which may form a ball that is difficult to remove.  I don’t recommend cleaning ears with cotton swabs.

Sometimes I will recommend rinsing the ears regularly, since removing excess ear wax might allow me to see eardrums that might otherwise be difficult to examine.  If your baby gets excessive amounts of ear wax, I suggest that you run clean water into the ears at bath time, to loosen the wax and perhaps flush some of it out.  Folklore says that water in the ear canals might cause an ear infection, but fortunately this is not true.

–  David Epstein, MD