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.

Two New Services; Patient Portal and Phreesia Check In

Pediatric Associates Inc. has TWO new electronic services for patients. The first is the patient portal. At your request, you will get the invitation in your email and can set up your own user name and password. The portal allows you to send messages to your doctor, ask a nurse a question, request refills and access some health information securely.

The Phreesia electronic check-in emails are sent to you separately without an invite 1-2 days before your visit as long as we have your e-mail address. This email allows you to securely update demographics, insurance, and health information as well as pay your bill prior to your visit.

These two systems operate separately, so if you are interested in the patient portal, please ask a staff member!

New Check-In System Begins- Please Check Your E-mail

This week our office begins the new electronic registration system, Phreesia.

Please verify that we have your correct e-mail address when you schedule your appointment.

We will be contacting YOU via e-mail prior to appointments, giving you the opportunity to pre-register. The Whitehall location will begin January 24th, Hilliard January 25th, Lewis Center January 26th, and Pickerington January 27th. Thank you for your patience while we get started!

Phreesia will allow you to securely pre-register, update demographics, answer medical questions and complete annual paperwork on your smartphone, tablet or PC prior to your child’s visit. We hope this will make your waiting room experience much more pleasant and efficient!

Please note, if pre-registration cannot be completed ahead of time, you may be asked to arrive 15 (established patients) -30 minutes (new patients) prior to your appointment time so you can complete info on the Phreesia tablet in the waiting room.

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”

Mononucleosis—–WHAT….I HAVE THE KISSING DISEASE????

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.

Please Verify Your E-mail for the new Check-In Process

Please verify that we have your correct e-mail address today! You will be able to contact us through the patient portal for refills, questions and more.

Also, we will be contacting YOU via e-mail prior to appointments, giving you the opportunity to pre-register in our new Phreesia check-in system beginning in late January.

Phreesia will allow you to securely pre-register, update demographics, answer medical questions and complete annual paperwork on your smartphone, tablet or PC prior to your child’s visit. We hope this will make your waiting room experience much more pleasant and efficient!

Please note, if pre-registration cannot be completed ahead of time, you may be asked to arrive 15-30 minutes prior to your appointment time so you can complete info on the Phreesia tablet in the waiting room.

Flu Vaccines Still Available

It is not too late for flu vaccines.  We continue to have supply in all of our offices.  Please call to schedule a time for your child to attend one of our flu clinic sessions (an “immunization only” visit).  Remember, that if your child is under 9 years old and he/she has not had at least two previous influenza vaccines, she/he should receive two vaccines THIS year, at least 28 days apart.

Also as a reminder, it is absolutely fine to receive a flu vaccine even if your child has a minor illness like a cold or an ear infection.

Also important: egg allergy is NO LONGER a reason to defer the flu injection.  Even persons with severe egg allergy can safely receive this important vaccine.

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:

http://www.stlouischildrens.org/articles/kidcare/fever-myths-versus-facts# 

Doctor Talk: Why Is My Toddler Such A Picky Eater?

The “Picky” Toddler Appetite

By Bill Long, MD

Parents often will describe their toddlers as becoming “picky” eaters. This could mean one of a couple of things, as there are several types of “picky” eating.

The first (and the most common) type is that toddlers just “pick” when they want to eat, and when they don’t want to eat.  They do this based on their natural hunger cues, and NOT necessarily on a schedule.  Since toddlers don’t have a rigorous school or work schedule, they don’t NEED to eat at each and every scheduled meal time.  We need to remember this.

The second kind of “picky” is the toddler who eats, but has a very limited selection of foods he/she will eat.  This is common in children with developmental problems such as autism, prematurity, and children with severe problems with textures in the mouth.  The following advice will not apply to those children with those special conditions.

However, in otherwise “normal” children, more often than not, we, as parents, MAKE our children “picky” eaters.

It’s a natural reaction to worry when our toddlers don’t want to eat.  But when our kids are that FIRST kind of “picky” and they don’t want to eat, we must remember two things:

  • DON’T play with, coax, argue, or try to convince your child to eat.
  • DON’T go to the cupboard or fridge to get them something else to eat or drink so “at least they have something.”

When we DO the above things, our children (with their toddler logic) think these thoughts:

  • When I don’t eat, mom and dad pay MUCH more attention to me.  I love that!  I’m might want to do that more often!
  • If I keep refusing to eat, I will get more attention AND eventually I will get what I want.  I love that too!  This is great!

The “key” to keeping our kids from becoming the second kind of “picky” is to follow these general principles:

  • Offer your toddler a variety of foods at every meal and snack.
  • If your child has no other developmental or medical conditions, he or she will know when they are hungry, and when to eat or not, based on normal hunger cues. Don’t force the issue.
  • Give them enough, but limited time to eat at each meal/snack.
  • Make meal times  (breakfast, lunch, dinner) family times—eat together.
  • NEVER coax, cajole, or FORCE your toddler to eat.
  • Show POSITIVE attention when your toddler eats well, and when they don’t eat well, stay relatively quiet, and put the food away when the meal time is over.
  • Toddlers will go through phases when they stop eating one or more foods they had eaten before.  Be patient and keep trying those foods again.
  • NEVER make meal times a battleground.  Meals should be positive experiences for the family.