September is National Suicide Prevention Month and it can make the difference in someone’s life to have emotional and mental health support with access to the resources they need. Being open to mental health education and counseling as well as finding the right medication or treatment is key. Often, parents can be hesitant to have their child on psychiatric medication. Cook Children’s psychiatrists are answering parents’ questions and raising awareness to help alleviate stigma and treatment for children.

What are mental health conditions?

Depression, ADHD, anxiety and behavior problems are the most common mental disorders found in children. According to the U.S. Centers for Disease Control and Prevention (CDC), “Mental disorders among children are described as serious changes in the way children typically learn, behave, or handle their emotions, causing distress and problems getting through the day.”

Kristen Pyrc, M.D., Medical Director of Psychiatry Outpatient Services and the Partial Hospitalization Program at Cook Children’s, said they diagnose mental health conditions when they are limiting a child or teen’s functioning.

“Worries, sadness, and anger are all normal emotions, but we become concerned when a kid’s sadness or anxiety keeps them from doing things that bring them joy, or things they need to do to take care of themselves like attending school, showering and interacting with friends,” she said.

How can mental health conditions be treated? 

Both counseling and medication can be used to treat a child with a mental health condition that affects their everyday life, but parents are often hesitant about having their child try medication.

“I’ve found medication and counseling to be equally effective for a child with anxiety and depression, but the combination of both gets kids better faster and safer,” Dr. Pyrc said.

Akemi Watkins, M.D., in Cook Children's Behavioral Health also recommends medication when needed. “If a child has moderate to severe depression or anxiety, we’ll recommend starting medication because current evidence suggests that a combination of medication and therapy is more effective than medication or therapy alone.”

Why are parents hesitant about their child taking medication?

Many parents are concerned with their child taking psychiatric medication because of potential side-effects, medication dependency, the stigma associated with it and even their own experience with mental health medications. The cost of prescription medications, especially name brand, can also be a major hurdle.

If a parent is questioning their child trying medication, Dr. Pyrc recommends, “Consider the risk of not treating anxiety, depression and ADHD, and whether that keeps them from reaching their full potential.”

Is it possible to get financial help to access medication?

The cost of medication often prevents parents from having their child try it. Name-brand prescriptions, especially when they are new to the market, are also out of most people’s price range.

Both Dr. Pyrc and Dr. Watkins help patients have access to their medication by finding similar, lower cost medications and recommending ways to find more affordable pricing.

“GoodRx can help you find the lowest cost pharmacy in your area,” they said. Dr. Pyrc also tells patients about CostPlus Drug Company which has many psychiatric medications at much lower costs that can be mailed.

How can we make taking medication a routine?

Helping a child get used to a new daily routine of taking medication can be challenging. Dr. Pyrc advises “habit-stacking” to make it easier.

“It means ‘stack on’ taking medication to something that you already do every day. Most people brush their teeth twice a day, so getting into the habit of taking medication after brushing your teeth is easier than trying to remember to take it at noon,” she said.

Setting phone notifications can also be helpful and Dr. Watkins advises the parent or guardian to be responsible for dispensing medication for safety reasons.

Medication Success Stories

Both Dr. Pyrc and Dr. Watkins have seen a lot of success stories when children and teens find the right medication.

“One of my favorite memories was a 1^st grader who had ADHD and got into trouble at school every day to the point that he did not want to go to school,” Dr. Pyrc shared. “After we started medication, he brought me his behavior log that had a smiley face for good behavior every day. I still remember the look on his face glowing with pride, and honestly, that is why I do my job.”

Dr. Watkins also experienced seeing her patients’ overall well-being and mental health improve.

“I had a teenage patient with depression and anxiety, and she was started on sertraline,” Dr. Watkins said. “After getting to a therapeutic dose, she was less socially isolated, less overwhelmed with anxiety and said that she was having fewer days where she felt depressed. She felt more motivated to attend school and her grades eventually improved as her depression and anxiety improved.”

Additional Support

When parents are still debating whether or not to have their child or teen try a psychiatric medication, Dr. Pyrc recommends they visit with their pediatrician who can help them understand what is “normal” or if something does need to be addressed. She also recommends researching the American Academy of Child and Adolescent Psychiatry (AACAP) to learn more about anxiety, depression, ADHD, sleep disorders and Autism in the AACAP Parents’ Medication Guides.

School nurse Lori Hamman provides first aid and comfort to the students at Wedgwood 6^th Grade Center who arrive at her office with assorted injuries and illnesses on any given day.

She treats nosebleeds, headaches and vomiting. She helps manage asthma flareups and the extremes of diabetic blood sugar levels.  At set times, she dispenses medication to students with chronic conditions like seizures or attention-deficit/hyperactivity disorder. Occasionally, an upset sixth-grader will need a few minutes in Hamman’s office just to calm down.

“It can vary from minor things to complex things like a broken bone,” she said of her job at Wedgwood, in the Fort Worth Independent School District (FWISD). “That’s kind of the exciting thing about being a school nurse.”

Rekha Sivadasan, M.D. at Cook Children’s Pediatrics in Frisco described school nurses as a valuable extension of the pediatrician’s office. Dr. Sivadasan hears from school nurses who may call to check on a patient’s immunization records, or to discuss a severe food allergy, or to alert her that a student has elevated blood pressure. Communication and collaboration – among pediatricians, school nurses, and parents or guardians – make the best approach, per Dr. Sivadasan.

“Ultimately, the child benefits to know that there are different people who have eyes on them to help the child feel safe, to feel cared for, to feel loved,” Dr. Sivadasan said. “If they know that there are different entities that are all working together to ensure their success and their good health, then I think that just adds to the security and confidence for the child.”  

Expert input shared by school nurses plays an important role in developing accommodations for students who have disabilities, Dr. Sivadasan said. Other critical duties may include reporting suspected child abuse to state authorities, and notifying help for a student who expresses suicidal ideation.  

 “If a child has something that is bothering him or her -- whether it’s physically, emotionally, behaviorally, mentally – the nurse is their go-to person at school,” Dr. Sivadasan said. 

School nursing is a specialized practice of the nursing profession. What difference does it make when school nurses work together with a child’s doctor and parents? The American Academy of Pediatrics explains: “Academic achievement, improved attendance and better graduation rates can be a direct result of a coordinated team effort among the medical, family, and educational homes all recognizing that good health and strong education cannot be separated.”

Tips for Parents

At Wedgwood, Hamman encourages parents to communicate directly with her at the beginning of the academic year if their child has a chronic condition. She enjoys the relationships formed when students come to her office.

“It’s a safe place,” Hamman said. “I don’t expect homework from them or written assignments or testing. They can just come in and relax and destress.”

Depending on the grade level, Hamman and her colleagues at FWISD encounter a wide array of ailments and issues, from playground bruises and wiggly teeth to drug abuse and pregnancy. Some students require specialized care for catheters or feeding tubes. Others turn to their school nurses for help with mental health. Meanwhile, the nurses are gearing up for the 2022-2023 flu season while continuing to check on students out with COVID-19. 

School nurses also implement screenings for spinal abnormalities, growth, hearing and vision. Hamman recalled one student who had trouble seeing the eye chart. 

“I made a referral and now she has glasses," Hamman said. "I rescreened her, and she can see 20/20.” 

We talked to a group of experienced local nurses about key things parents should know:

• Send any meds to school in the original packaging with a specific written request signed by a physician or licensed prescriber.
• If your phone number or address changes, or if your emergency contact’s information changes, tell the school nurse and data clerk. They might need to reach you.  
• Make sure the nurse’s office has your child’s most current shot records.
• If your child’s health history changes, tell the school nurse. This includes a new diagnosis or starting/stopping a regular medication. 
• Give signed permission for the school nurse to communicate with your family’s health care provider.

School nurses say their role involves social work, counseling, advocacy, record-keeping and disease prevention. Why do they love what they do? Here are some perspectives.

More than Band-Aids

Shannon Cooper, Director II for FWISD Health Services, said the biggest change in her 17 years of school nursing is the increase in diabetes, asthma and medications. “It has become so much more complex,” she said. Cooper said the familiar presence of nurses at school shapes in a positive way the students’ view of health care. 

Verby Nash, Health Services nurse specialist, recalled a few unusual situations in her experience, including a student with a bead stuck up the nose, and a teacher hit by a car during morning drop-off. As they gain the trust of families, school nurses might be asked to examine a baby’s rash or a grandparent’s blood pressure.

“We do what we can to help and assess,” Nash said. “We are not doctors. We cannot diagnose. We cannot prescribe. We are very, very careful about that.”

The nurses educate teachers and staff about various illnesses and what symptoms warrant a trip to the nurse’s office. 

“It’s not just Band-Aids and tummy aches, which unfortunately is still what some people think,” Nash said. “We are there to advocate for those students because if they’re not feeling good, they cannot be successful in class.”

Cassandra Miles, Health Services nurse specialist, said school nurses are a source of “safe, sound and appropriate” information when students come to their offices to talk. She considers it a privilege to serve children and teens from pre-kindergarten through high school graduation.

“For many students, we may be the only person who they see medically,” Miles said. “Or we may be the gateway to those resources in the community or to get to the pediatrician or the mental health provider.”   

Seventy-one FWISD campuses participate in free Goodside Health telehealth services. Morningside Elementary School nurse Sasha Dawkins said pointed out the benefits of telehealth appointments in reducing student absenteeism and allowing parents to stay at work.

One frequent challenge Dawkins encounters on the job is collecting the required vaccination paperwork. 

“It may take a few more phone calls or a few more letters to get parents to understand the importance of being up-to-date on their shot records,” she said. “Sometimes at the beginning of the year it can be a little bit of a struggle to get the documents you need.”

She welcomes questions and hopes to provide support and resources. And Dawkins feels motivated every day by the opportunity to help students. “I love making a difference in someone’s life. That’s the biggest joy for me. That is the reason I became a nurse.”

Event leaders will be collecting unused and expired medications in a drive-thru in the building’s parking lot, and distributing free medication lockboxes.

Stacey Vanvliet, M.D., an inpatient pediatric hospitalist at Cook Children’s, stresses the importance of locking medications up, even if they seem harmless. She said suicide attempts “have become part of my daily practice” and most are overdoses on a substance that’s “convenient for the children and teens to grab.” While most patients are in their teens, children as young as 8 or 9 are routinely admitted to Cook Children’s for attempting suicide with medication.

“Commonly, we see Tylenol, Motrin, aspirin, Benadryl—things that people just stock in their cabinets to have on hand,” she said. “We see teenagers take huge handfuls of them.”

Each year, Cook Children’s treats hundreds of children and teens for medication poisonings and overdoses. Sadly, the number of these patients continues to reach record levels year after year.

"It is a huge problem right now. We’re seeing more kids in the hospital for opioid overdoses than ever before," said Artee Gandhi, M.D., medical director of Pain Management at Cook Children’s. 

Dr. Gandhi also points out that a recent letter published in the American Medical Association reported a 20% increase in drug overdose deaths among 14 to 18 year olds from 2020. The 1,150 deaths is double the number reported in 2019.

“While teen drug use has remained relatively stable, the biggest problem is kids trying to get their hands on prescription opioids such as oxycodone or other medications such as Xanax and Adderall,” Dr. Gandhi said. “So often, counterfeit versions of these drugs are laced with deadly amounts of fentanyl. Therefore, it is paramount that parents, educators and health care providers argue against medication misuse or drug experimentation at all.”

**Dr. Artee Gandhi and DEA agents will be available for interviews at this event.

Statistics, no matter how alarming, sometimes blur into faceless numbers when parents hear them on TV or read them in a news story.

That’s until it’s your child in the emergency room, hooked to an IV while receiving treatment for ingesting too many pills—in this case, over-the-counter pain meds often used to relieve menstrual cramps—with the intent of harming herself.

And then suddenly, those numbers have a face. For Betty, a Tarrant County mom who asked not to be identified to protect her 14-year-old from any stigma attached to her attempted suicide, the face that came fully into focus was her own teenage daughter’s.

Betty’s daughter is among the many children and young adults across the country who’ve used excessive doses of common drugs, like pain relievers or allergy medications, with the intent of harming themselves. National studies have shown OTC meds as the No. 1 means used by youths in suicide attempts and the third-leading cause of youth suicide deaths.

“I really didn’t put those in the category of prescription medications, so I never put them away,” Betty said of the handful of OTC meds—a combination of Motrin and Midol—her daughter swallowed earlier this year. (Motrin contains ibuprofen, and Midol is a mixture of acetaminophen, caffeine and pyrilamine maleate, an antihistamine.) “I want other people to know, and to even have lockboxes for their medications, so that someone else doesn’t have to go through what we went through.”

Her daughter, who went to school but said it wasn’t the same because of COVID restrictions, had felt isolated and been sad because she missed her friends, she said. She faced the typical teenage stuff like low self-esteem, Betty said, but she had no idea her daughter was considering suicide.

“She’s seeking treatment now, but I want to be really clear, ‘Put all your medications away, not just your prescription medications,’” she said.

Betty is far from alone in facing this issue. Other parents across the nation also are grappling with children and teens who are intentionally overdosing with easily accessible OTC meds.

In a study published by The Journal of Pediatrics in May 2019, Nationwide Children’s Hospital and the Central Ohio Poison Center found that suspected suicide attempts by self-poisoning in children and young adults had doubled in the past decade. The research, which targeted ages 10 to 24 during 2000 to 2018, also showed suicide attempts using OTC meds had tripled among girls and young women.

The same researchers later expounded on the initial report, pointing out that the two most commonly used substances among all age groups were OTC pain relievers—such as acetaminophen, ibuprofen and aspirin—followed by antidepressants.

Last year, a study conducted by the Center for Injury Research and Policy and the Central Ohio Poison Center at Nationwide Children’s Hospital focused specifically on the use of OTC pain relievers in suicide attempts, showing a 57-percent hike in overall cases from 2000 to 2018. Children and young adults between 6 to 19-year-old made up half of the cases, and of those, 73 percent were female, the study showed.

Researchers analyzed 549,807 suicide-related calls made to poison control centers across the United States that involved OTC medications. The study, published in Pharmacoepidemiology and Drug Safety journal, also determined a 34-percent rise in the frequency of those cases during that time period, caused primarily by a jump among calls involving 6- to 19-year-old females, researchers said.

The results from the study showed the breakdown of OTC substances involved in the calls: 48 percent, acetaminophen alone; 33 percent, ibuprofen; and 19 percent, aspirin. Acetaminophen and aspirin accounted for 65 percent and 33 percent of deaths, respectively. Aspirin created the most serious medical outcomes for 36 percent of the cases and 68 percent of the cases with aspirin were admitted into a health care facility compared with other OTC pain relievers. Overall, while suicide-related cases using acetaminophen and ibuprofen climbed, the number involving aspirin decreased, researchers found.

Although local numbers on these types of cases are not yet readily available, physicians at Cook Children’s Medical Center are noticing a similar increase in intentional OTC medication overdoses.

Stacey Vanvliet, M.D., an inpatient pediatric hospitalist at Cook Children’s, said suicide attempts “have become part of my daily practice” and most are overdoses on a substance that’s “convenient for the children and teens to grab.” While it’s mostly older ones, children as young as 8 or 9 come in for attempting suicide, she said.

“Commonly, we see Tylenol, Motrin, aspirin, Benadryl—things that people just stock in their cabinets to have on hand,” she said. “We see teenagers take huge handfuls of them.”

Many people have a misconception of how dangerous these drugs can be when ingested over the recommended dosage, Dr. Vanvliet said. For example, high levels of acetaminophen (as in Tylenol) can cause liver damage or acute liver failure as well as other serious health issues.

“I think another misperception is that there’s a certain type of patient or type of teen that might try to overdose. Or that there’s a certain stressor or pattern, so to speak, that this happens and then the teen goes for pills or whatever it may be,” she said. “But in my experience, that’s not the case. We certainly have children who have undergone significant trauma and have mental health issues…but we also have children who haven’t shown a whole lot of warning signs and are very high achievers.”

When a child or teen attempts suicide, it’s usually an impulsive decision, Dr. Vanvliet said, which makes the accessibility to OTC meds more dangerous.

“You’d be amazed at some of the things that trigger them to make a serious attempt. It can be something as small as, ‘My mom took my phone away because I got a bad grade,’ or ‘My best friend is mad at me,’” she said. “It’s not necessarily anything that’s huge…but they make these snap decisions, and they go take a handful of pills, and it could be really damaging. It happens over and over, unfortunately.”

So, what can be done to keep children safe? Many health experts and researchers propose restricting the amount of OTC meds that can be purchased at one time and suggest unit-dose packaging, such as blister packs, as well as promoting safe storage for OTC and other medications.

Responding to that call, The Jordan Elizabeth Harris Foundation, a Fort Worth-based nonprofit group that targets suicide prevention, plans to launch Keep All Meds Secure (KAMS) public awareness initiative this summer. Christina Judge, the foundation’s executive director, said the initiative includes educating families and caregivers on the dangers of various medications, providing lockboxes for safe storage and advocating safe disposal of old medications. The foundation also offers free suicide prevention training to help parents to know what to look and listen for with a child who might be considering suicide.

The initiative began with a phone call that Judge received. A frantic mother, whose daughter had taken a handful of Tylenol and a handful of Advil, called the foundation seeking help in finding a bed at a mental health facility for her daughter.

“The pivotal moment was just hearing the anguish in the mother’s voice,” Judge said. “I asked her, ‘Did you know that these drugs in the hands of a suicidal child could be lethal?’ She said, ‘No. We just keep them in the cabinet above the sink.’”

“Well, that was enough for me,” Judge said, who researched the topic, presented a case for it and sought funding for the initiative.

Vanvliet believes programs such as KAMS will help with suicide prevention among children and teens.

“Education for parents and keeping those substances safe, I think, is a big part of preventing this from happening,” she said.

For Betty, what happened to her daughter has made her even more vigilant. She has always paid close attention to safety in her house. The family’s guns are always locked away in a safe, along with prescription medication. Now, she secures her OTC meds, too, she said.

She’s thankful her daughter, who’s getting ongoing treatment, didn’t suffer any long-term health effects from the incident. But Betty is highly aware that it all could have ended much differently that day her daughter tried to overdose.

“I think she got scared and came to me and told me. I’m so glad she did,” Betty said. “And I have to say if there were more pills in the bottles, we would have had a much different situation…it could have been much more harmful.”

“Like I said, we’d locked up everything else except for that. And if we had locked that up, maybe we would have avoided this,” she said.

Well, you might be surprised to hear that over-the-counter medications like Advil and Tylenol might actually be what’s triggering the headache in the first place. According to Ellie Corbin, M.D., pediatric neurologist at Cook Children’s, taking these medications on a regular basis can lead to something called ‘medication overuse headaches.’

Even if your child isn’t exceeding the prescribed daily dosage, Dr. Corbin says consistently taking several doses of these medicines over a long period of time can be harmful.

Overuse headaches are far more common than people realize, Dr. Corbin says. Close to 50% of her patients who come in with headache complaints inadvertently put themselves in this situation, by overusing headache medicine. Instead of the medicine relieving the headaches, it made them worse.

The International Classification of Headache Disorders defines medication overuse headaches as:

• A headache that occurs on more than 15 days a month, in patients with pre-existing headache conditions (migraines, or tension headaches).
• The regular overuse of headache medication like: Tylenol, Advil or Ibuprofen for more than three months.

Dr. Corbin diagnoses medication overuse headaches by asking two simple questions: how long and how often have you been taking the medication? These two questions are enough for her to know if her patient is suffering from too much medication. The only form of treatment is to immediately stop taking these medicines all together and use alternative measures the next time a headache develops.

One alternative Dr. Corbin encourages her patients to do is hydrate with fluids that have electrolytes, like Gatorade and Powerade, when their headaches start, instead of taking medicine. Preventative medicine is prescribed to the majority of children with overuse headaches during the “washout” period of over-the-counter medications, Dr. Corbin says. During this “washout” period, your child doesn’t have to suffer. A form of therapy known as “bridge therapy” is used. This is when other means are used to make your child comfortable while their body adjusts to the withdrawal of headache medicine, it usually comes in the form of steroids.

Once a patient has stopped taking over-the-counter pain medicines, relapse is rare. Dr. Corbin emphasizes that reducing the use over-the-counter medication might result in headaches at first, but in the long run, it will likely mean less pain for your child.

“A lot of patients are scared to go back after the washout period,” Dr. Corbin said. “They’re afraid that if they take these medicines again the medication overuse headaches will come back. There is the chance that a chronic headache condition is so severe that a relapse happens.”

- By Libby Collins

Parents using dosing cups had four times the odds of making a dosing error, compared to when they used an oral syringe and that the most common mistake was overdosing: 68 percent of the participants gave too much medicine, rather than too little.

Children should receive their liquid medications only through milliliters to reduce dosing errors, according to a policy statement from the American Academy of Pediatrics. The AAP recommends medicine to children be administered by a syringe with flow restrictions, but cups and spoons are acceptable, as long as the dosage is marked in milliliters.

The AAP’s research found that more than 70,000 children went to the emergency room because of unintentional medication overdoses.

The AAP says parents should not be using household spoons or any other measuring device to give kids their medicine, other than measuring in milliliters (mL).

“Sadly, some may feel that liquid medication accuracy just isn’t very important. They may think, ‘It’s just cough syrup or to reduce fever,’” said Jason Evans, a pharmacist at Cook Children’s. “While an adult may be able to tolerate a huge discrepancy from a dessert spoon, a child can be seriously hurt or even killed. There have been several children fatally overdosed in this manner from mere cold medication. “

Household spoons simply aren’t accurate. Three teaspoons are in one tablespoon and a household teaspoon can vary in size. Depending on the spoon, a parent can give a child as little as 2 mL and much as 8 mL, when the intended dose was actually 5 mL. That large discrepancy is the danger that has made the AAP take this stance.

Evans said most hospitals have been using the mL standard for 10 to 20 years because it’s a much safer practice and avoids errors. Cook Children’s follows the mL system, even for oral syringes.

“We don’t have teaspoon or tablespoon markings anywhere,” Evans said. “Syringes are more accurate than dosing spoons and dosing cups. There is scientific evidence for this. Now, we just need to complete the puzzle and use the same terminology for patients at home.”

Evans gives the following advice to parents:

• Know your child’s medication in terms of the metric system.
• Ask your pharmacy for a medication syringe, not a dosing spoon or cup.
• Use a medication syringe, even if a dropper came with your prescription.
• Ask for a bottle adapter that will allow you to turn the bottle upside down to draw out the medication.
• Hand wash syringes to avoid melting or rubbing the markings off.
• Ask your pediatrician or pharmacist if you are confused about how much medication to give.
• It might not just be the parent giving the medications. If necessary, have your babysitter or other caregivers (e.g. grandparents) demonstrate to you how to measure the medication with the syringe.

Read more from the American Academy of Pediatrics on this topic here.

You don’t expect tragedy and you certainly don’t expect that tragedy to occur as a result of negligence by your child care provider.

Unfortunately, for Katie Mulkey of Reynoldsburg, Ohio, this is exactly what happened. On May 13, she dropped her son Haddix off at the babysitter’s house where his unlicensed childcare provider allegedly gave him two tablets (an adult dose) of Benadryl to help him sleep because he was fussy. When the babysitter went to the back room to check on him later, he wasn’t breathing.

Of course, the family is devastated but they have taken the opportunity to educate and advocate against the use of medications to help babies sleep.

Here are the lessons to learn:

1. Medications have indications for use and they should be used for those reasons and those reasons only. Benadryl works fine for allergies and even for itching. Benadryl is not a baby sedative, period. The promotion of its use for sleep in babies is irresponsible and dangerous.
2. Medications have dosing for children. The difference between the effective dose and the fatally toxic dose is not always as big as you think. Kids are harmed and die from overdoses of just about every over the counter medicine you can imagine. Know the dose and use the appropriate one.
3. Medications come with a dosing cup. Use the cup or syringe to measure out your child’s medications. Using a teaspoon from home doesn’t work because they will likely under or overdose your child.

Use of medications is a huge responsibility.

Giving medicine to your child should only be done by you or by your explicit instruction. They should be given for the right reasons at the right doses.

It can be a hard thing for adults to deal with. Unfortunately, many children suffer the same pain. For some, it’s a genetic condition that’s been passed along to them. But for others, migraines are the result of injury. For 15-year-old Olivia Gillespie, her migraine problems began when she received her third concussion.

“It happened in cheerleading practice, I was kicked in the head,” says Gillespie. “I was fine. I didn’t think it was that big of a deal.”

Then months later, Gillespie was on a ski trip with her youth group when a headache came on and never went away.

“I just kept doing what I was doing and tried to not let it have an effect on me,” she said.

Gillespie tried to ignore the pain for two months before she said anything to anyone, but then the pain got worse.

“Olivia had an ongoing headache that would not fade. On a scale of one to 10, it was a consistent five," said Amelia Gillespie, the teen's mother. "It wasn't until her pain reached level seven that it really began to affect her.”

When Cynthia Keator, M.D., pediatric neurologist at Cook Children’s, first saw Olivia, she wanted to make sure her headaches could be treated without medication. Together, they worked on her sleep habits and diet. Dr. Keator also suggested supplements such as B2, and Omega 3, which has shown to help with headaches. In addition, Gillespie was referred to the Biofeedback Clinic at Cook Children’s.

“Biofeedback teaches patients how to control their pain by controlling their breathing, heart rate and body temperature,” says Dr. Keator.

Biofeedback specialist Nanny Christie, Ph.D., has been teaching the painless technique for decades.

“We place the child in a reclining chair and use pads to measure their body activity,” says Christie. “The equipment plugs into a laptop so the kids can see everything on the computer screen. If they tighten a muscle, a line goes up. If they relax, the line goes back down.”

Christie says teaching children to harness their breathing and muscle movement this way allows for real time learning. She says about 80 children are seen in her clinic each month. A typical visit is 45 minutes to one hour and each child is seen roughly four times.

While it wasn’t the end-all, be-all cure for Gillespie, it did help. She says she uses the technique to curb her head pain. If she feels a headache becoming worse, she can focus and calm her anxiousness which in turn can help the headache.

Also, ask your doctor about preventative medication. Your doctor may prescribe something prescription strength or a natural supplement to ease the pain.

Make sure you DON’T ask your child this question:

“How’s your headache?”

You may want to, but remember that asking about a headache is like scratching a mosquito bite. By asking, you’re reminding your child about their pain.

A recent study done in the adult oncology world and published in JAMA, found that doctors had a perception that patients were demanding extra treatment and testing. Review of the patient encounters showed that doctors perceived demands that did not actually occur. Many of the requests that did occur were medically appropriate.

In pediatrics, the most common issue where this comes to a head is the desire to give children antibiotics. It can also play out in other areas as well. Another common one that comes to mind is request for further testing for diagnosis.

Fortunately, in my experience, parents are becoming more informed about what situations require antibiotics and which illnesses will pass with a little time and TLC.

The problem is that many doctors have gotten into the unfortunate habit of wanting to provide what the parents are requesting without actually asking the parent what they expect. Doctors may perceive that parents want antibiotics or further testing when, in fact, they simply want reassurance that waiting is OK. This becomes a particular problem in urgent care or retail clinics where patient satisfaction plays a bigger role in getting patients to come back and see you.

So, how can you prevent this from happening to you?

Here are five casual statements that you might use the next time you visit the doctor to help them understand your expectations:

1. I’m pretty sure I’m just over concerned. I just wanted you to check things out so I can be sure.

2. I don’t really like to give my kids medicine but I wanted your opinion about what we should do next.

3. I’m totally OK with waiting, if that’s what you think is best.

4. What would you do if it were your child?

5. Are there other things we can try first or other options?

Your doctor should not feel threatened by these statements. If antibiotics are the only right choice, they should be able to explain the reasons why that is.

“Hey bud, how did you get that BAND-AID^®?”

“I just climbed up on this and got it (from the medicine cabinet).”

Those are 2 conversations that happen frequently and just yesterday, respectively, in my house.

A study released this month in Pediatrics (the journal of the American Academy of Pediatrics) looked at out-of-hospital medication errors in patients less than 6 years of age.

There were many questions that the study looked to answer:

How common are medication errors?

Almost 700,000 errors in these children over the 10 year period, that is equal to 1 error every 8 minutes.

Many of these were minor and required no medical care, but there were almost 2,000 children who required intensive care and 25 death due to medication errors.

What type of medications were associated with more errors?

Liquid medications were the most common, accounting for 81.9% of the errors. These kids are more likely to be taking liquid medications so this might be expected but it’s still a good reminder we need to be cautious.

Where do the ingestions occur?

The child’s own home was the location of the ingestions 96.9% of the time.

What errors were the most common?

The 5 most common errors were:

1. Medication accidentally given twice.
2. Confused the units of measure (1  milliliters (mL) vs 1 teaspoon (tsp).
3. Wrong medication taken/given.
4. Medication given too soon.
5. Accidentally was given or took someone else’s medicine.

So what can you do to protect your child?

1. Be aware. These errors are common and we need to be aware.
2. Be cautious with liquid medications. Kids can find and ingest them more easily and dosing errors are more common.
3. Protect your own home. Make sure that medications are locked away in a safe place.
4. Double, triple and quadruple check your dosing. You know the saying measure twice and cut once? For meds it should be measure 5x and give once.
5. Assign a primary medication giver for the house. If anyone else is giving meds, run it through them first.

When deciding about starting a medication as a breastfeeding mother, here are some questions that need to be considered:

1. Has the medication been studied in humans or other mammals?

2. How important is the medication to the mother?  For example, what would happen if the mother did not take the medicine?

Clearly if something is well studied, safe and very important for mom, go for it. If something has been shown to be unsafe and not important, then skip it. In my mind, everything I see is a gray area. If you are not impressed with the helpfulness of this “brilliant” analysis, here are some resources you can use:

1. Your pediatrician or obstetrician. I don’t memorize all the possible drugs, but I do know where to look them up.
2. Infant Risk -Dr. Hale from Texas Tech is one of the national leaders in medication use during pregnancy and while breastfeeding.
3. LactMed –The National Library of Medicine’s Drug and Lactation Database

A Special Consideration: Anti-Depressant and Anti-Anxiety Medications

Because of the relatively small number of breastfeeding mothers on anti-depressants, they are still mostly unstudied. Many have been found to enter the bloodstream at less than 2 percent of the dose (adjusted for the babies weight), but some do reach higher levels (near 10 percent).

Here are some of the ones that enter at higher levels:

• Buproprion
• Fluoxetine
• Lithium
• Venlafaxine
• Diazepam
• Citalopram
• Lamotrigine

Even though we know this, we still don’t know the effects of the medication on the baby is in many ways. The AAP statement highlights the fact that these medications tend to have a build up over time. It is important to note also that baby’s kidneys and liver function (the primary way the we get rid of medications) are not fully mature. Because of this, I evaluate each mother/baby combination by these 3 criteria:

• Benefits of breastfeeding
• Risk of the medication
• Risks of mom’s depression on the child

In summary, I believe we should use caution with all medications with breastfeeding mothers.  If you are breastfeeding, please consult with your pediatrician or obstetrician prior to taking any medication.