New! Ways to keep your child with asthma out of the ER

We’ve added a new asthma self-management tool to help patients and families avoid expensive and lengthy trips to an ER or Urgent Care.  In addition to following your asthma action plan, click here to learn more helpful hints to keep asthma patients OUT of the ER.

Spring is a common season for flare-ups of asthma.  Be prepared.  Make sure your child has his/her controller medicine and all inhalers available.  Call our office if you need help!

Important Facts about School Sports Forms

Is your 7th-12th grade child going to play a school sport during the upcoming school year?  If so, they will need to have the most recent edition the OHSAA sports clearance form completed prior to the first day of practice or tryouts.  For most fall sports, that deadline is in early August.

We can complete the sports form during your child’s regular annual physical exam.  It is very helpful to have this form completed (at least partially) prior to the checkup visit.  We will have the forms available in the office, but you can also download and print the form from here to have before the appointment.

OHSAA 2018-19

The most important health questions to have answered for the checkup are Questions 5 through 16, about heart health in the patient and family history.

We look forward to seeing you this summer and hope you ALL have a great school year this year!

Warm Weather means Hand-Foot-Mouth (HFM) season

by Jumana Giragos, MD

Hand-foot-and-mouth (HFM) disease is a common childhood infection caused by a virus that results in a characteristic rash. The rash consists of small, blister-like bumps in the mouth (usually in the back near the tonsils) and a rash on the palms and soles. The rash also commonly appears on the legs, arms, around the mouth, and in the diaper area, especially the buttocks; in those areas, the rash can also appear as small red bumps rather than blisters.

As stated, HFM is caused by a virus, mostly commonly by specific strains of the enterovirus family. It is very common in children, especially those younger than 10. It is more common during warmer times of the year such as summer and fall. The virus is spread primarily through fecal-oral contact, although it may also be transmitted through other modes such as saliva. The rash itself is NOT considered contagious by contact.  To prevent the spread, it is very important to have good hand washing.

The signs and symptoms of HFM consist of the rash (described above), and fever. The oral lesions can cause pain, so affected children may not eat or drink well. Overall, children do not feel well with this illness. Due to the distinctive rash, the diagnosis is made based on the rash and associated symptoms, and usually no further testing is needed.

Symptoms typically last 5-7 days. Because it is caused by a virus, antibiotics will not help. The main goals of treatment are to make the child as comfortable as possible due to the pain associated with the oral blisters and to encourage the child to stay hydrated with fluids. Acetaminophen and/or ibuprofen can be used to manage the fever and also help with pain control. It is very important to make sure your child is hydrated as dehydration is the biggest potential complication of this virus. Frequent sips of fluids, popsicles, etc are different ways to make sure your child does not get dehydrated.

To prevent the spread, hand washing is very important. Also contaminated surface can be cleaned with disinfectants. The virus can be shed for a few weeks even after the rash is gone. For that reason, we do not limit children from attending daycare while they have the rash unless they also have a fever at the time.

Real Answers about Adolescent Contraception

Contraception & Why It Is Important

Dr. Molly Falasco

Adolescence is a magical time fraught with hormones, angst, and that feeling of invincibility.  Between the acne breakouts and school dances, however, teenagers have to figure out how to grow up.  More difficult still is “getting through” to a teen on his/her quest to independence.  Friends’ opinions tend to “rule the day.”  Parents never seem to be “cool enough” to even warrant the time of day.  Whether at home or the doctor’s office, topics especially dreaded by both parent and child pertain to puberty and sexual health.  Let’s face it, that stuff is awkward.  Luckily for you, Pediatric Associates has trained pediatricians, and our very own Reproductive Health Clinic, to educate families on reproductive health and contraceptive options.  While having a face-to-face encounter with your pediatrician is best, use this article as a guide to the basics of contraception.  This is not an easy subject, so discuss it with your family and/or your pediatrician.

Contraception (birth control) is any method, device, or medicine used to prevent pregnancy.  Especially for a busy teenager’s schedule, it is important to choose a method that is easy and effective.  There are three arms of contraception: abstinence, barrier devices, and medical interventions – all described below.

Abstinence is the decision to not have sex.  This is the most effective method of contraception, and always our first choice for teenagers.  While 100% effective in preventing pregnancy and STIs (sexually transmitted infections), abstinence may sometimes be difficult for an adolescent or young adult to practice in a mature, stable relationship, or in a “heat of the moment.”

Barrier devices block the sperm from meeting the egg.  These devices are less effective than medical contraception due to inconsistent use.  Barrier methods may be purchased over-the-counter.

Condoms: Made of latex or polyurethane, a male condom is unrolled over the penis and a female condom is inserted in to the vagina.  Condoms prevent bodily fluids from mixing when two people have sex.  Condoms provide the best protection against STIs.  Even when used perfectly, however, male condoms are only 82% effective while female condoms are only 79% effective in preventing pregnancy.

Cervical Cap, Diaphragm, Sponge, Film, or Suppository:  Usually used with spermicide (a chemical used to kill sperm), these devices are manually placed over or near the cervix (the muscular opening to the uterus at the end of the vagina).  These devices have a high failure rate (<80% effective) and are often the most difficult to use correctly.

Medical contraception (consisting of progesterone with/without estrogen) regulates hormone fluctuations in a woman’s body, thereby preventing the release of an egg from a woman’s ovary (ovulation) and thickening her cervical mucous, making it more difficult for sperm to meet egg (fertilization).  Additional benefits of medical contraception may include improved menstrual cycles, clearer complexions, and better moods.  Some forms of medical contraception even reduce a woman’s risk of ovarian and endometrial cancer!  All medical contraception requires a prescription from a healthcare professional.  Also, all medical contraception is reversible and has no lasting impact on fertility once stopped.

Long-Acting Reversible Contraception (LARC): The Implant* and the IUD* are the easiest, longest lasting, and most reliable forms of contraception recommended by the American Academy of Pediatrics (AAP).  With 99.9% effectiveness, LARCs are effective, hassle-free options for teenagers.

*The Implant (Nexplanon): A certified healthcare provider performs an easy outpatient procedure to insert a small plastic rod approximately the size of a matchstick underneath the skin of a woman’s inner upper arm.  The Implant slowly releases progesterone and lasts for 3 years.  Drs. Molly Falasco and Bill Long are certified Nexplanon providers at Pediatric Associates who are able to place Nexplanon the same day of consultation.

*The IUD, Intrauterine Device: Through an outpatient procedure akin to a pap smear, a certified healthcare provider places a small, flexible piece of T-shaped plastic in a woman’s uterus through her cervix.  The progesterone IUD (Mirena, Skyla, Liletta, Kyleena) lasts anywhere from 3-6 years, whereas the hormone-free, copper-based IUD (ParaGuard) lasts for 10 years.  A referral to Adolescent Medicine or Gynecology is necessary for administration.

The Shot (Depo Provera): Like a vaccine, a medical professional administers a progesterone shot in a woman’s arm once every three months (four times per year). When administered on time, The Shot is 94% effective.  A referral to Adolescent Medicine or Gynecology is necessary for administration.

The Pill, Oral Contraceptive Pill (OCP): A combination of estrogen and progesterone (or just progesterone alone), a woman takes one pill at the same time every day.  In a typical monthly pack, there are 21 hormone pills followed by 7 placebo pills, allowing for a shorter, lighter, less painful period in the final week of the month.  When administered on time, The Pill is 91% effective.  Even missing a dose by a few hours or taking certain other medication at the same time  might significantly reduce The Pill’s effectiveness.  Many OCPs exist on the market (Sprintec, Ortho Tri-Cyclen, Seasonique, to name a few), so an experienced healthcare provider should offer guidance in determining the ideal pill.  Any pediatrician may prescribe The Pill.

The Patch (Xulane): A combination of estrogen and progesterone, a woman places the patch anywhere on her body, replacing once per week for three weeks.  The woman then removes the patch for one week, allowing for a shorter, lighter, less painful period in the final week of the month.  Like a nicotine patch for smoking cessation, the body absorbs medication through the skin.  When administered correctly, The Patch is 91% effective.  Any pediatrician may prescribe The Patch.

The Ring (Nuvaring): A combination of estrogen and progesterone, a woman manually places a rubbery ring inside her vagina once every three weeks.  At the end of the three weeks, the woman then removes the ring, allowing for a shorter, lighter, less painful period in the final week of the month.  When administered correctly, The Ring is 91% effective.  Any pediatrician may prescribe The Ring.

Emergency Contraception or “The Morning After Pill” (Plan B, Next Choice, LNG, Ella).

Taken within five days of unprotected sex, Emergency Contraception (EC) prevents pregnancy in a number of ways.  EC delays ovulation, prevents sperm from meeting egg, and may even inhibit implantation (when a fertilized egg attaches to the wall of a woman’s uterus).  This is not an abortion drug.  Sometimes adolescents may purchase EC directly from a pharmacist, but EC usually requires a prescription from a healthcare professional.  Any pediatrician may prescribe Emergency Contraception.

As you can see, an experienced pediatrician may tailor contraception to fit a teenager’s specific needs and preferences.  Learning about reproductive health in no way opens proverbial floodgates for sexual promiscuity, but instead empowers adolescents with the knowledge of how to make a responsible transition to adulthood.  Whether that is a 14-year-old looking to better handle her heavy menses or a 18-year-old looking for a hassle-free form of birth control before heading off to college, contraception is an effective way to guarantee an adolescent’s reproductive safety.  There are risks and benefits to each option, which is important to address with your pediatrician.  For a more in-depth discussion and possible same-day intervention, consider the Pediatric Associates Reproductive Health Clinic!  And the best news is: most insurance companies will completely cover both the visit and any contraception prescribed.

Rashes: When to call, and when to relax

by Diana Wagner, MD

Rashes- When to Call

Rashes are very common, from infant to adolescents.  Most of the time, they look worse than they are, in terms of your child’s health.  It is rare that a rash would need to be seen in an emergency room or urgent care.  But some rashes are more worrisome than others.  When the rash is associated with the following symptoms, you should call our office:

  1. A rash associated with a high fever
  2. A rash that is painful, or tender to the touch
  3. A rash that does not blanch (that means will not lighten when you put gentle pressure)
  4. Rashes that start soon after eating a food or after taking a medication
  5. Rashes associated with your child acting sick
  6. Rashes in young infants

The bottom line though, even if the above conditions don’t apply, if you are that worried about your child’s rash then you should have your child seen in our office.

Rashes are often difficult to describe over the phone –one person’s pimple is another person’s blister.  Since these rashes are easy to misidentify without actually seeing the child, a visit to the office is warranted.  There are times, however, that even with the best history and physical exam in the office, the exact cause of your child’s rash may not be found in all cases.  For example, we can tell an infectious rash from a contact rash but cannot tell what the irritant was that caused your child to get the contact rash.  And if a rash has just started, and is only a few patches or “dots,” it may be difficult to make a diagnosis and prescribe treatment until the rash has had time to “blossom” so to speak.  While MOST rashes can be diagnosed by your primary care pediatrician, there may be some that require a referral to a dermatologist.  As you may know, this could be a long process, but we will try to help you through every step of the way.

Acne Tips: Caring for Your Adolescent’s Skin

By David Ward, MD

Acne is one of the most commonly discussed issues at teenage checkups.  Recent studies indicate that 87% of teens have to deal with acne at some point.   Here we’ll discuss basic causes and treatment of acne to try at home, and when to see your doctor.

Let’s first discuss the cause of acne.  Our skin’s pores contain oil glands and dividing skin cells whose activity is ramped up by the hormonal changes with puberty.  Acne arises when excess skin cells and oil build up and clog skin pores forming something called a “comedone.”

You’ve probably heard the common names for the two types of comedones – blackheads and whiteheads.  The only difference is where the clogging happens: white = clogging near the surface of the skin; black = clogging deeper down in the pore.  This buildup can then trap bacteria in the pores and cause the redness and irritation of the skin often seen in acne.

So, what can we do about it?  The first step is to wash the face twice daily.  This will help open up the pores by clearing away excess oil and skin cells.  There are specific face washes for acne that you can use – look for ones containing 2% salicylic acid or benzoyl peroxide.  A common myth is that cosmetics and makeup can cause acne – this is largely false.  Look for cosmetic products that are oil free and/or “non-comedogenic” (these days, most are).

Benzoyl peroxide is the primary over the counter medication used to treat acne.  Look for this as the active ingredient of the common acne medications at the store.  It comes in many forms – face and body washes, cleansing pads, and creams/gels.  Start with a 5% formulation, and if no improvement after 4-6 weeks, you can either try 10% or see your pediatrician to discuss further treatment options.

The most common side effect is dryness or a burning feeling of the skin on your face.  Look for lotions that say “won’t clog pores” or “non-comedogenic” on the packaging to treat this side effect.  Two other things are worth mentioning.  Because it contains peroxide, benzoyl peroxide can bleach clothes or bedding if not completely absorbed.  It can also increase your skin’s sensitivity to sunlight, so it’s best to use at night.

If your acne does not respond to the basic treatment described above, it is time to see your pediatrician.  Several prescription medications are available to treat acne.  Your pediatrician will need to see you to prescribe the proper treatment based on the type and severity of your acne.  Remember to be patient, as every treatment available tends to take at least 4-6 weeks before improvement is seen.

Miralax (PEG 3350) for childhood constipation: Is it safe?

by William W. Long, MD, FAAP

There have been recent reports about children on Miralax® osmotic laxative and psychiatric side effects.  Reports of this type and questions of Miralax safety first came out in 2012, and have resurfaced on social media in the past several months.

The Children’s Hospital of Philadelphia is conducting a safety study of Miralax in children, partly in response to some of these reports in 2012.  This is not because there is widespread worry.  This is because as science-based physicians, we want to make sure our evidence is continues to be tested and proven when we are treating our patients.

What is Miralax?  It is a large molecule that is commonly called a polymer in chemistry terms.  The generic name for the laxative is Polyethlene Glycol (or PEG).  It is a connected chain of many ethylene glycol molecules.  This sounds kind of scary because ethylene glycol is what is in antifreeze.  But PEG is something different.  It works by staying in your intestinal tract (which technically is outside your body) and helping to keep water in the intestines to make the stools softer.  It does not break down in your body into antifreeze or anything else.

Multiple studies in thousands of children have shown PEG to be a safe treatment for constipation.   This laxative has a very low side effect profile compared to other laxatives used in children.

That being said, there can be incidents of intolerance to these agents, just like someone can have an intolerance of certain foods, or gluten.  It is rare, but can happen.

But, if a rare reaction to PEG occurs, it will not cause any permanent harm if it is stopped.

Constipation is a common, sometimes serious problem in children that can lead to lifelong bowel issues and sometimes severe illness and hospitalization.  The first line of treatment for constipation is a well-balanced diet, with plenty of water, and exercise (yes, running around can make your bowels move better!).  For patients who have more severe problems, Miralax (PEG) is a very safe laxative that can be given to almost all patients for years at a time.

Please see our recent Dr. Notes article by Dr. Burns on constipation for more information on this condition.

Why won’t my child poop? Basics of Constipation

by Shari Burns, MD

Poop. It’s something we don’t like to talk about as children, but we can’t stop talking about it once we have children of our own. We all focus on bowel movements once we become parents – frequency, color, consistency, straining, discomfort, and gas. Constipation is one of the most common topics we discuss at routine well child care visits. And it is probably one of the more misunderstood topics as well.

Constipation, by definition, is not only having infrequent bowel movements, but it also includes passing hard stools. Painful stools. Stool size can vary from very large to small and pebble-like. The confusing part, though, is that stool can also be loose or liquidy, which often causes us to not consider constipation as a diagnosis. Constipation is also very common. It affects nearly 30% of children at some point.

The ability to stool requires a lot of coordination within the large intestine (also known as the colon). The muscles of the colon contract regularly, which leads to successful stool passage in most cases. However, as stools become harder, this contraction and ability to pass stools becomes more difficult. If there is large and hard stool in the colon, this can often lead to the passage of loose stool from around the hard stool, which then results in what many report as diarrhea. Stool can even leak in those patients that are potty trained, which can result in messy accidents. Making things worse is that children will try to hold stool once it becomes painful, which only leads to more difficulty passing stool.

Newborns typically stool many times per day, but this pattern can change within a few months. Some infants pass stool about once per week, and this is normal in most cases. We suggest that you talk to your child’s doctor with all concerns, but as long as the baby is eating well and appears comfortable, then this is not usually a major medical cause for concern. Stool frequency changes as children get older, and most potty trained children will stool once to twice daily. This stool should be soft and easy to pass.

The keys to normal stool include adequate water intake, adequate fiber intake, and adequate time to pass the stool. These factors are often neglected, especially as our toddlers get pickier about their eating and our children forget to drink enough water. Then there is the time issue – kids don’t want to take the time to poop. Maybe those adolescents and their cell phones will contribute to healthier bowel habits!

For best results, make sure your children are drinking plenty of water and eating a high-fiber diet. Encourage them to take the time to use the bathroom. It is often best to have them sit on the toilet after meals, as this is when we can be expect the muscles of the colon to help us most. They might need to use a foot rest to get the best position. Sitting on a toilet with your feet dangling in the air is a very UNNATURAL way to pass stool. Some straining can be normal, but passing stool should not be painful. And if there is blood present, you should talk to your child’s doctor.

There are many things we can try to help with passing stool, from diet changes to medications. The suggestions will vary with the age of the child, so there is no advice that fits all children, other than what is mentioned above. If you have questions, please schedule an ill appointment, or discuss them at your routine well child visits. As Pediatricians, we are very comfortable talking about poop!

Fast Facts about “MONO”


by Barbara Jo Rayo, MD

Mononucleosis, which is often called “mono” or “kissing disease,” is an infection caused by the Epstein-Barr virus. It is very common and affects more than 3 million people in the US per year. It mostly occurs in people ages 14-18 but can occur at any age. It is spread by saliva…kissing, sharing a glass or food utensil with someone infected with mono or even through a sneeze or cough.

The symptoms of mono are swollen glands in your neck, tiredness, fever, swollen tonsils, sore throat, a swollen spleen and sometimes a rash. Teenagers and young adults often show these signs and symptoms but young children usually have few symptoms.

Mono usually isn’t very serious. The fever and sore throat usually will lessen within a couple of weeks but, fatigue, enlarged lymph nodes and swollen spleen can last several weeks longer.

There are blood tests to diagnosis mono. Our office can perform a monospot test. It’s great if it is positive and we can say “yes, you have mono!”. If it is negative, we still don’t know if you have it or not. That’s when your doctor may order EBV titers. This requires going to an outside lab to have blood drawn. This is the definitive test for mono.

THERE IS NO TREATMENT FOR MONO. Antibiotics won’t work because this is a virus. So… rest, drink lots of fluids and eat good, healthy foods. An over the counter pain reliever such as ibuprofen or acetaminophen can be taken for comfort. DON’T TAKE ASPIRIN. It has been linked to a life threatening condition called Reye’s Syndrome when you have a viral infection.

When should your child be seen in the office? We’d like to see your child anytime there has been a fever for longer than 2-3 days. If there are symptoms of a bad sore throat, we can look for mono or strep throat. It is wise to be seen anytime your child is ill with these symptoms and it seems more than the common cold. If your child has been diagnosed with mono and the symptoms are worsening, ie unable to eat or drink; problems sleeping due to swollen tonsils causing breathing issues; developing yellowness of the skin or the whites of the eyes; development of a very sharp pain in the left upper part of the abdomen….please have your child seen in the office right away.

What about school and activities? It’s recommended that your child stay home until feeling better. Most people feel better in 2-4 weeks. Some kids can only go to school for half days until the fatigue improves. Athletes should not return to contact sports for three weeks, until they have been examined and shown that their spleen is still not enlarged.

BOTTOM LINE…Mono is VERY common and usually resolves without any problems within 2 to 4 weeks.

Fever: Is It Dangerous? The REAL Story

by Amy Deibel, MD

Fever phobia is a very common cause of visits to the emergency room and late night calls to our on-call doctors. Why do parents fear fever so much? No doubt about it, a fever makes your normally pleasant child look and feel miserable. They may look red in the cheeks, cry because they feel achy, or want to lay around and sleep more. These things may look scary, but they are all a part of our body’s amazing response to fighting off infections!

Parents ask me all the time, “How high is too high? When should I take them to the emergency room?”. If your child’s temperature is 100.4 F or higher AND your child under 1 month of age or has a known immune disorder, you should always call our on-call doctor or follow the plan given to you by your child’s specialist. For ALL other cases, there is no temperature that your child can reach on their own that is a medical emergency! “Dangerous” temperatures occur when a child’s body temperature is forced up by an external source ( such as being left in a hot car). When the child’s own thermostat responding to an infection, normal fevers can occasionally reach as high as 105 F or 106 F! The higher the number, the worse your child will feel, but it is not harmful or any sign that they are more ill than if their temperature was 101 F. Fever reducers, such as acetaminophen (if over 2 months old) and ibuprofen (if over 6 months old) can be used to improve a child’s comfort. They won’t necessarily bring the temperature back to normal, but that’s okay and not a sign of a worse infection. Be sure to always these medicines at the recommended dose for your child’s age and weight. Dosing charts are available in your yellow book and on our website.

So, when should you be concerned? You should decide whether your child needs seen immediately more by whether they are breathing comfortably, hydrated, and interacting appropriately with you – whether they have a fever or not. If there are other more concerning symptoms present (severe headache, abdominal pain), a call to our on-call doctor can help you decide if emergency care is needed. A fever that lasts for more than 2-3 days should be evaluated in our office to see if an infection that needs treated is present. Otherwise, some TLC, increased fluids, rest, and fever reducers for comfort are all that is needed!

The following link is very helpful in understanding fever fact versus fiction: