Dr. Hall’s Answer:

I’m sorry to hear that your child has been ill. Certainly frequent colds are part of the package when your child starts daycare. In fact, studies estimate that a child in their first year of daycare will experience up to 10 colds! Unfortunately, if your child doesn’t attend daycare, they aren’t off the hook – he or she will likely experience that same burst of frequent illnesses when they start school.

The use of over-the-counter cough medications, such as Tussin DM, for children is strongly discouraged by the American Academy of Pediatrics (AAP). In fact, in 2007, drug companies voluntarily began withdrawing children’s preparations from the shelves due to the dangers of side effects, and in 2008, the Food and Drug Administration recommended that no cough and cold medications be used in children younger than 4 years of age due lack of evidence that they help relieve symptoms and due to the risk of side effects.

Over-the-counter adult preparations are especially dangerous because:
¹ no safe dose for children or infants is known – toxicities and dangerous side effects can occur at any dose and ² many medicines are combinations of several drugs, such as acetaminophen, diphenhydramine, pseudoephedrine, etc. – all of which have their own side effects and toxicities. Side effects specifically due to Dextromethorphan (the “DM” in Tussin DM) include dizziness, drowsiness, nausea, vomiting, decreased breathing, apnea (no breathing), rapid or irregular heart rate and death. Scary stuff!

So what can you do for your child when they are feeling miserable with a cold? For cough treatment, the AAP recommends for children older than one year of age, ½ to 1 teaspoon of honey, taken as needed. Honey helps to thin mucous and soothe cough. Recent research (1,2) showed that honey is better than drugstore cough syrups at decreasing the frequency and severity of coughing at nighttime. For congestion, saline nasal drops and suction, and a cool mist vaporizer in the bedroom at night is helpful.

Regarding your question of asthma, in young children, frequent viral infections are the most typical cause of cough, congestion and fever. Wheezing can occur as part of viral or bacterial infection, so wheezing alone cannot clinch a diagnosis of asthma. Predictors of asthma include eczema or allergies in the patient, and a strong history of asthma in the parents of the patient. Pulmonary testing is usually not practical before school age. Careful follow-up with your pediatrician and monitoring of the breathing symptoms over time is required for a diagnosis of asthma.

^{1) Paul IM, Beiler J, McMonagle A, Shaffer ML, Dada L, Berlin CM., Jr Effect of honey, dextromethorphan, and no treatment on nocturnal cough and sleep quality for coughing children and their parents. Arch Pediatr Adolesc Med. 2007;161:1140–6.}

^{2) Shadkam MN, Mozaffari-Khosravi H, Mozayan MR. A Comparison of the effect of honey, dextromethorphan and diphenhydramine on nightly cough and sleep quality in children and their parents. J Altern Complement Med. 2010 Jul;16(7):787-93.}

I’m typing this from 30,000 feet in the air, with a runny nose. All I want is my Neti Pot.

I’ve had a two-day allergy attack, no doubt caused by my cats plus the cleaning that I was doing in advance of going on this airplane. Let’s just say I’m getting used to sneezing and finally dug out the lovely cotton handkerchiefs handed down from my Grandma Comfort because I was so tired of piles of wadded-up tissues all over my house.

If you’re not already a fan on the Neti Pot, give it a shot. Here are some first- and second-hand personal anecdotes to draw from:

1. I use it (sporadically) and it always gives me a feeling I can only describe as a “nasal high.” I also think of it as “nasal floss.”
2. My kids, after a few false starts, now LOVE the Neti Pot and beg me to let them do it.  Of course, this is usually requested at bedtime, when they are stalling.
3. My mom, who has suffered sinus problems her whole life, now uses the Neti pot and has seen huge improvement.
4. My friend Caroline used to snort mugs of warm salt water up her nose and then shoot it back out—a primitive, violent, messy method, but roughly the same idea. I sent her a Neti pot. I think she used it, but then it broke, and she went back to the mug. But there are cheap, plastic Neti pots, available in most pharmacies—so maybe I’ll spring for another one.

My yoga practice led me to awareness of the ida and pingala, which are the subtle “moon” and “sun” currents of chi that spiral up and down the central energy channel in our bodies, intersecting at the chakras. Just like nadi shodhana pranayama practice, I believe the Neti pot helps balance these subtle energies to promote overall wellness.

Finally, the Neti pot is an exercise in prevention…it doesn’t work when your passages are already closed, though it does get a little salt water up there to start working out the clog. It’s better to use the Neti when you are already feeling fine OR just on the verge of being stuffy OR when you are trying to rinse irritating allergens out of your nose. I might have to start traveling with mine, just in case.

Once again, my take is different than that of most. About 70 percent of Americans measure their liquid medicines in kitchen spoons. But when smart college students were asked to pour a real teaspoon of liquid medicine into a kitchen spoon, they averaged either eight percent less or twelve percent more than the amount prescribed, depending on which kitchen spoon they used, according to a report in the January 5, 2010 Annals of Internal Medicine. This happened in a well-lit room, in the middle of the day, after having been shown the correct amount. Imagine how far off an exhausted parent might be in the middle of the night, distracted by a crying baby.

The obvious response to this data? Always use a dosing cup or dosing spoon instead of a kitchen spoon. One dose may not matter too much, but repeated several times it could quickly add up to danger or to an ineffective medicine.

My response?

1. When possible, choose medications where there is not a tight window between what works and what is dangerous. Cough syrup in children is one great example of this. A controlled study compared a DM cough syrup versus buckwheat honey. Children aged 2 to 5 years received ½ tsp, aged 6 to 11 years received 1 teaspoon, and 12 to 18 years received 2 teaspoons.  The honey worked better – at reducing the number of coughs, the severity of coughs, and the bother of coughs, and at increasing sleep for the children (and for the parents). Too much DM can cause diabetes, hallucinations, psychosis – even death. Too much honey? Not a big deal.
2. When the dose matters, don’t trust yourself to estimate accurately. Choose a dosing spoon, dropper or syringe. Acetaminophen is one place where correct dosing really matters. It’s easy to give too much. (And remember – fever is a friend – and kids often get better faster treating a fever only when it interferes with sleep or keeping down fluids).
3. Choose smaller spoons and plates for food and tall, slim cups for drinks. Overdosing food in children is an even bigger health problem in the US than overdosing medicines. Container size matters: In this experiment, those using the larger spoon poured 20 percent more liquid, even though they were confident they had poured the same amount. Container shape matters: The same authors found previously that even confident veteran bartenders pour 28 percent more alcohol into short, wide glasses than into tall, slender ones of exactly the same volume. Use smaller plates when you want your child to be happy eating less; use larger plates and bigger, wider cups when you want your child to automatically eat and drink more.

^{Wansink, B. and van Ittersum. K. “Spoons Systematically Bias Dosing of Liquid Medicine.” Annals of Internal Medicine, 5 Jan 2010, 152(1):66-67.}

^{Paul, I.M., Beiler, J., McMonagle, A., Shaffer, M.L., Duda, L., and Berlin, C.M. “Effect of Honey, Dextromethorphan, and No Treatment on Nocturnal Cough and Sleep Quality for Coughing Children and their Parents.” Archives of Pediatrics & Adolescent Medicine, 2007, 161(12):1140-1146.}

^{Wansink, B. and van Ittersum, K. “Shape of glass and amount of alcohol poured: comparative study of effect of practice and concentration.”  BMJ, 2005, 331:1512-4.}

^{Fisher, J.O., Rolls, R.J., and Birch L.L. “Children’s Bite Size and Intake of an Entrée Are Greater with Large Portions Than with Age-Appropriate or Self-Selected Portions.” American Journal of Clinical Nutrition, 2003, 77(5):1164-1170. [Discussed in Feeding Baby Green]}

One of the best ways to keep your toddlers healthy during flu and cold season is to keep their hands clean. A good washing with soap and water is very effective in reducing the spread of contaminants that may make your kids sick. But frankly it can be tough to get our little ones to wash up, and even tougher to get them to scrub thoroughly and often enough to do get the job done – especially when you’re out and about.

Hand sanitizers, recommended by the Centers for Disease Control, are both a time-saver and hassle-reducer for busy parents. With a little squirt of gel, about 99.9 percent of the germs that cause illness can be history – even the H1N1 virus. These are a great advance for keeping families healthy.

Not all hand sanitizers are the same. Some depend on ethyl alcohol, some on the quaternary ammonia chemical benzalkonium chloride (sometimes labeled “Alcohol Free!” to imply that it’s safer), and some on Thymol, a safe, plant-based ingredient that gets the job done. Of the three types, I prefer Thymol for thumb-sucking toddlers, although I’m not opposed to using alcohol-based sanitizers on young children if that’s what’s available.

If you’re using any hand sanitizers on your little ones, I suggest you supervise. Rub the gel in thoroughly and keep your child in sight until it dries. Evaporation is your friend. If your child’s thumb starts moving towards the mouth immediately after application, don’t panic, but do try to distract him for a few minutes if you can.

For effective hand washing, I teach kids to sing “Twinkle, Twinkle, Little Star” or “The Alphabet Song” while washing to remind them to scrub long enough and hard enough to make a difference. Besides washing before meals, the most important times to wash are after sneezing or coughing, after using the toilet, upon leaving “high-risk” places such as doctors’ offices, daycare centers, playgrounds, etc, and always upon arriving home.

How can you tell the difference between cold and flu? I recorded this video with A.D.A.M. to give you information that will help you determine the difference between the two.

How do you know if you have swine flu (H1N1)? There’s a great new online tool that can help you find out — and it’s free! Just go to http://www.FeelingFlu.com

Amoxicillin is an antibiotic used to treat many different types of bacterial infections in children. It does not help in viral infections such as a cold or flu. It’s often called “the pink stuff” or “the bubblegum-tasting one” by children. You might see a brand name such as Trimox, Moxatag, or Amoxil on the label. This common antibiotic comes as liquid, chewable tablets, regular tablets, and capsules. Any form can be given with or without food.

Liquid amoxicillin should be shaken before giving each dose. It’s fine to give the amoxicillin directly or to mix the medicine with another liquid if you’re fairly sure your child will drink it all. To get the correct dose, skip the silverware spoon and use a measuring spoon or dose-measuring device (ask your pharmacist for one if you don’t have one). Store it in the refrigerator between doses. It should not be allowed to freeze. Discard any unused amoxicillin 14 days after it was first prepared by the pharmacist. It may last only 7 days if stored at room temperature.

Whenever antibiotics are given, consider also giving your child probiotics (beneficial bacteria). Out of ten well-designed studies, nine showed significantly less diarrhea in the children receiving probiotics (the studies used between 5 and 40 billion cfu per day). Probiotics are available as supplements or in some foods and beverages (yogurt, kefir, juice). Whatever you choose, look for at least 5 billion colonies.

Amoxicillin is the recommended first choice antibiotic for most children with ear infections. When used to treat ear infections, the recommended dose is about 36 to 41 mg per day for each pound that the child weighs, up to a maximum of about 1500 to 1750 mg per day. This is much higher than the dose used for most other infections in children. The total daily dose is divided into two or three doses per day.

If you happen to miss a dose, you can go ahead and give it late – but try not to do two doses within about three hours of each other. If you happen to give too much at once (more than two doses), seek medical advice.

If your child is taking amoxicillin for an ear infection, you should expect improvement within 48 to 72 hours. If not, contact your doctor to discuss switching to a stronger antibiotic, such as amoxicillin-clavulanate or ceftriaxone.

Do Not use amoxicillin if your child is known to be allergic to this or to any of the penicillin-type antibiotics.

Depending on the type of allergy, other antibiotic options might include cefdinir, cefuroxime, azithromycin, or clarithromycin. Sometimes a non-itchy rash is a side effect of taking amoxicillin, and not an allergic reaction. If your child has had a rash with amoxicillin, discuss this possibility with your doctor.

Be sure the prescribing doctor knows if your child has any other medication allergies, or has mono, asthma, liver or kidney disease, or a bleeding problem. Be sure to report any other medicines your child might be taking. Get emergency care if your child is showing signs of a serious allergic reaction, such as difficulty breathing, spreading hives, or swelling of the lips, tongue, or throat. Black hairy tongue, a fairly common temporary side effect of amoxicillin, is not an allergic reaction.

Other side effects are possible with this or any medication. Be sure to report unexpected new symptoms to your healthcare provider. Whether they are caused by the antibiotic or by the illness getting worse, unexpected symptoms are important to report.

Johnston BC, Supina AL, Ospina M, Vohra S. Probiotics for the prevention of pediatric antibiotic-associated diarrhea. Cochrane Database of Systematic Reviews 2007, Issue 2. Art. No.: CD004827. DOI: 10.1002/14651858.CD004827.pub2.

AAP Clinical Practice Guideline. Diagnosis and management of acute otitis media. Pediatrics, May 2004, 113(5):1451-1465.

Amoxicillin-clavulanate is a strong combination antibiotic used to treat many different types of bacterial infections in children. The clavulanate makes it difficult for some resistant bacteria to withstand the amoxicillin, resulting in a very powerful antibiotic. Nevertheless, it does not help in viral infections such as a cold or flu.

This common antibiotic comes both as liquid and as chewable, regular, or extended release tablets. You might see a brand name such as Augmentin on the label. Different forms contain different proportions of clavulanate and aren’t simply exchangeable with each other at the same dose of the amoxicillin portion (e.g., a 400 mg tablet is not the same dose as 400 mg of liquid).

No matter which form of amoxicillin-clavulanate you use, it’s usually best to take the medicine at the start of a meal to reduce stomach upset. The tablets also should be taken with a full glass of water. The chewables should be chewed thoroughly before swallowing; the other tablets should not be chewed so that the medication is released in the body at the appropriate rate.

Liquid amoxicillin-clavulanate should be shaken before giving each dose. To get the correct dose, skip the silverware spoon and use a measuring spoon or dose-measuring device (ask your pharmacist for one if you don’t have one). Store it in the refrigerator between doses. It should not be allowed to freeze. Discard any unused amoxicillin-clavulanate 10 days after it was first prepared by the pharmacist.

Whenever antibiotics are given, consider also giving your child probiotics (beneficial bacteria). Out of ten well-designed studies, nine showed significantly less diarrhea in the children receiving probiotics (the studies used between 5 and 40 billion cfu per day).1 Probiotics are available as supplements or in some foods and beverages (yogurt, kefir, juice). Whatever you choose, look for at least 5 billion colonies.

Amoxicillin-clavulanate is the recommended first choice antibiotic for most children with severe ear infections who have high fevers and/or severe ear pain. It’s also recommended for most children with ear infections whose first antibiotic didn’t improve the symptoms within 48 to 72 hours.²

If you happen to miss a dose, you can go ahead and give it late – but try not to do two doses within about four hours of each other. If you happen to give too much at once (more than two doses), seek medical advice.

If your child is taking amoxicillin-clavulanate for an ear infection, you should expect improvement within 48 to 72 hours. If not, contact your doctor to discuss switching to another antibiotic, such as ceftriaxone.

Do Not use amoxicillin-clavulanate if your child is known to be allergic to clavulanate, to amoxicillin, or to any of the penicillin-type antibiotics. Depending on the type of allergy, other antibiotic options might include ceftriaxone or clindamycin. Sometimes a non-itchy rash is a side effect of taking amoxicillin, and not an allergic reaction. If your child has had a rash with amoxicillin, discuss this possibility with your doctor.

Be sure the prescribing doctor knows if your child has any other medication allergies, or has mono, asthma, liver or kidney disease, or a bleeding problem. Be sure to report any other medicines your child might be taking.

Get emergency care if your child is showing signs of a serious allergic reaction, such as difficulty breathing, spreading hives, or swelling of the lips, tongue, or throat. Black hairy tongue, a fairly common temporary side effect of amoxicillin, is not an allergic reaction.

Other side effects are possible with this or any medication. Be sure to report unexpected new symptoms to your healthcare provider. Whether they are caused by the antibiotic or by the illness getting worse, unexpected symptoms are important to report.

Think twice before picking up that remote if someone in your home has a cold! Researchers from the University of Virginia, armed with DNA swabs, did a CSI-like evidence hunt in the homes of 30 people with early cold symptoms. Where did they find the virus? The most reliable spot was on salt and pepper shakers, found on every single one tested. The virus was also found on 80 percent of bathroom faucet handles, 75 percent of dishwasher handles, 60 percent of remote controls, 57 percent of refrigerator handles and phones, 33 percent of doorknobs, and 23 percent of light switches. Next, the researchers tested to see if the virus would stick to the fingers of healthy folks when they grabbed a handle, answered the phone, or flicked a switch – 48 hours after the virus was left there. More than half the time it could be found on their fingertips. This is further evidence that the chain of infection often goes from nose to hand to object, then from object to hand to nose, mouth, or eyes. Cleaning you hands is one of the best ways to break the chain.

These findings were reported at the 2008 annual meeting of the Infectious Disease Society of America and the American Society for Microbiology held in Washington, DC. The University of Virginia team are leaders in the study of the common cold. Two years ago they showed that the cold virus survives in hotel rooms the day after people with colds check out, waiting for you when you check in.

When the American Academy of Pediatrics came out with their recommendation against cold medicines for children under the age of 6, parents started searching for alternatives. The good news is that families have a number of alternatives to traditional over-the-counter decongestants, antihistamines and cough suppressants.

It’s worth remembering that what we think of as cold symptoms are mostly tools the body uses to get rid of the virus. A low-grade fever is inhospitable to many viruses and activates our immune system. Congestion is the dilation of blood vessels, bringing needed supplies to the scene of the battle. Mucus traps virus particles and starts moving them away. Coughing and sneezing forcefully eject the virus from the body. Fatigue helps you get the rest you need to heal. The goal of any treatment is to gently do what it takes to make a child comfortable while the body does its healing work.

There are a few treatments that may actually shorten the duration or reduce the severity of a cold. One recent analysis of 30 studies of vitamin C found a consistent benefit of shortening colds by an average of 13.6 percent in children for kids who regularly take the supplement (more effective in kids than in adults). There are at least eight good studies looking at taking zinc. Four of these showed found benefit in reducing duration and/or severity; four did not. I suggest it for kids who may not be getting enough zinc in the diet – which is a lot of kids.

Echinacea appears to be effective in treating colds in nine placebo-controlled studies in adults (plus one study showing perhaps some benefit, and six showing none). But benefit has not been demonstrated in children. Moreover, children in the studies sometimes got rashes from the Echinacea.

For a cough, one option is a spoonful of dark honey for children older than 1 year. Unlike DM cough suppressant, recent research suggests it works better than placebo.

I’m also a fan of cough drops for kids who are old enough where choking is not an issue. They stimulate more saliva production, which could reduce cough and sore throat and bring more antibodies to the scene.

Heated humidified air (steam from a shower, vaporizer, or humidifier) could be a good option. Of six controlled studies, three showed benefit and none showed worse symptoms. The key is to make sure, though, that the source of the heat is not something the child could get into and get burned.

Spraying saline (saltwater) into the nose has been shown to relieve pain and congestion in a number of studies. You can find saline sprays and washes in the drugstore. Some kids enjoy Neti Pots, a way to pour the saltwater in one nostril and out the other.

Last year an advisory panel of independent experts convened by the FDA recommended that the FDA ban popular over-the-counter oral decongestants, antihistamines and cough suppressants for children under the age of 6 with colds. Recently large drug companies have voluntarily decided to advise parents not to give these medicines to kids under 4.

I agree with the American Academy of Pediatrics, many medical experts and many consumer advocates who support this ban. It’s not that we want to remove effective remedies for young children with colds. The problem is that they have not clearly been proven to be better than a placebo at treating cold symptoms at that age. These medicines were originally approved by the FDA based on studies conducted in adults. It turns out that children’s bodies before puberty behave differently than adults. These medicines appear to be both less effective and more risky.

In the absence of proven benefit, concern over their uncommon severe side effects becomes more important. Most of serious problems come from children unintentionally taking too much – often from mixing medicines that share an ingredient in common. And rarely children experience serious side effects even at the recommended dose. By giving them to tens of millions of children, it’s no surprise that around 7,000 children end up in ERs every year related to the medicines.

By volunteering to add a warning to drug labels, perhaps the drug companies hope that this will prevent the FDA from taking stronger action. With the voluntary label warnings by the drug companies, they don’t take any of their medicines off the market. The only change is that the small print that gives a dose for children age 2 to 6 will now give a dose for children 4 to 6 instead. Whatever their reasons, I don’t see this as a positive step for children’s health – but I do think it has a silver lining. Perhaps the media attention to this announcement will help people to learn that these medicines don’t work better than placebo for young kids.

When deciding about when to recommend a medication, I use something I call the Green Ratio (no ‘e’ on the end of Greene). It’s an ecological approach. The ratio is the Targeted Benefit over the Time-Tested Risk. You want the ratio to be high. If there is no proven benefit to the child, why tolerate any risk of serious side effects? On the other hand, if a remedy is gentle, with almost no risk of serious side effects, I might be willing to try something that may or may not help.

The Green Ratio for many popular over-the-counter cough and cold medicines is worst for kids under age 6, and I don’t recommend them for children under age 6.

Even for older children before puberty, I don’t see clear proof of benefit compared to a placebo for most kids. But because the risks are lower, I’m somewhat less concerned about parents trying them. Although benefit hasn’t been proven over large groups of kids, they may even work for some individual children – different people respond to medicines differently. There may be a targeted benefit for specific children.