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Family Health Magazine - PHARMACY CARE

When Your Child is Sick
Products and remedies can help

With thousands of over-the-counter (OTC) products on the market it can be challenging for parents to choose the ‘best’ therapy for their children. What do you do? Most parents would answer, “Ask your pharmacist.” Great! But if you have three screaming children you may not have time to wait in line. Furthermore, are you sure it’s not serious? Can you make an appointment with your family doctor? What do you do in the middle of the night when pharmacies and doctors’ offices are closed? Visiting the hospital emergency room isn’t always appropriate for minor problems. Some areas have 24-hour health information lines staffed by nurses that parents can call. Check with your local community health centre. First, try some of the following measures.

Stomach Upset

One of the most common complaints of sick kids is tummy ache. Many things can cause ‘stomach upset,’ such as the flu, constipation, gas, and even certain foods. A good way to rule out anything serious is to determine the timing of the pain. If the pain begins suddenly or interferes with the child’s movement, it should be attended to by a doctor immediately. Additional symptoms such as bloody stools (bowel movements), vomiting, diarrhea, and recent loss of appetite may also be cause for concern. If fever is also present, your child should be seen by a doctor.

Diarrhea and Vomiting

If the cause is not something serious, try some non-drug therapies. If there is diarrhea or vomiting, replacing lost fluid is essential since these can be very dehydrating, especially in young children. Offer your child lots of water. If diarrhea or vomiting has lasted for less than 24 hours, flat ginger ale or 7-Up™, diluted juice, and soup broth may also help. Bananas are good too and can help replace potassium lost in the stools. Rice, applesauce, and toast are easy on the stomach. These are often referred to as the BRAT diet. Sometimes avoiding dairy products and sticking to clear fluids for 24 hours helps settle an upset stomach.

Certain over-the-counter products can help. Gastrolyte™ and Pedialyte™ are two preparations that restore lost fluids and minerals when there is diarrhea or vomiting. Gastrolyte™ is available in plain or fruit flavour and comes in packets of powder you can mix with water. These are great if you have no access to a fridge. Pedialyte™, on the other hand, comes already mixed, and is available unflavoured or in grape, fruit and apple. Unlike Gastrolyte™, Pedialyte™ needs to be refrigerated and must be used within 48 hours after opening. For those children who refuse to drink these solutions, there are Pedialyte™ freezer pops. There are homemade alternatives to these preparations. Ask your family doctor or pharmacist about them.

Medications for diarrhea are also available. However, they are generally not recommended for children, especially if bacteria are involved. If the diarrhea is due to a bacterial infection, these medications can make the situation worse. They can cause the infection to linger in the gut. Watery, explosive, frequent, and green diarrhea is a clear sign of a bacterial infection.

Determining the cause of diarrhea is key. Parents should note what their children eat. If diarrhea worsens after a child eats foods containing milk sugar (lactose) or gluten (from wheat) and settles after these foods are withheld, avoid these foods. A child who cannot tolerate lactose or gluten may not have any other symptoms besides watery, soft, brownish stools, sometimes mixed with mucus. Seek the advice of a doctor.

Nausea can be treated with the old famous remedy: dimenhydrinate (Gravol™). Dimenhydrinate may be purchased from behind the pharmacy counter after talking with the pharmacist. This product is available in many forms, including suppositories, liquid, and chewable pills. Although it is a useful medication, dimenhydramine can cause drowsiness and is not recommended for use in children under two years old. Other agents like scopolamine, which is available as a patch (Transderm V™), are not recommended for children.
If diarrhea or vomiting lasts longer than 48 hours, there is blood or pus in the stool or blood in the vomit, the child should be seen by a doctor.

Constipation

The most common cause for stomach upset is constipation. In children, this is usually due to poor bowel habits. Encourage younger children to answer “nature’s call” as soon as they get the urge to go. If you see that your child is straining on the toilet without success, try again later. A child doesn’t always need a bowel movement every day to be ‘regular.’ Unproductive straining can make constipation worse. A diet low in fiber and fluid may also be the cause of the problem. Try increasing your child’s daily fibre intake. Look at the fibre content on the nutrition label of cereals, and choose one that has a higher content per serving. Other options include bran muffins, hot oa™eal or adding bran cereal to yogurt (a crunchy treat). More fruit and vegetables eaten will also help. Prune juice is another helpful option which can be mixed with another juice. In the first 24 to 48 hours, extra fluid, fibre and exercise are the treatment of choice. If that doesn’t work you can certainly try an OTC product.

One good place to start is with glycerin suppositories. They are inserted into the rectum and usually require about 30 minutes to work. Glycerin suppositories are highly recommended for use in infants and children. If these don’t help, a stool softener like liquid docusate (Colace™) may do the trick. For children over six years who have not had success with stool softeners, mineral oil based laxatives (such as Lansoyl™) can be used. This product is a favorite for children who dislike liquid medicine or for parents who find it hard to insert a suppository into a squirmy child. Mineral oil is available as a red-colour jelly and can be spread over toast or crackers. One disadvantage to using this product regularly, though, is oily staining of the underwear from rectal leakage. Not something a parent wants to deal with in the middle of a shopping mall! Mineral oil may also decrease the absorption of vitamins, so avoid giving it at meal times and with vitamins. It should not be used before laying a child down for a nap since oil may be breathed into the lungs.

For more stubborn bowels, lactulose may help. It is popular with children because of its sweet taste. It is popular with parents because it works quickly, usually within 24 to 48 hours. If all else fails, bisacodyl and senna can be used as a last resort. These stimulate the muscles of the gut to push the stool along. Although they are available without a prescription, they are not recommended for children. One of their possible side effects is stomach pain. More important, they can lead to a condition called “lazy bowel” where the bowel is unable to stimulate itself and relies only on the presence of the laxative.

In general, OTC medications used for constipation should not be used for longer than seven days. Excessive use can lead to diarrhea and problems with dehydration. If constipation lasts longer that seven days or is accompanied by bloating or excess pain, see your doctor.

Gas

Gas can also cause stomach upset. Unlike constipation, gas is sometimes harder to detect. Children younger than 14 weeks old who cry for three consecutive hours, three days a week, for three or more consecutive weeks are said to have colic. Colic is a condition where gas is trapped in the gut and causes a very uncomfortable feeling. Swallowing air is a common cause. Bottle-fed babies who gulp too fast may run into this problem. Change the nipple of the bottle to one with a smaller hole, or try hydrolyzed milk. For those mothers who are nursing, be aware that your diet may contribute to baby’s discomfort. Moms may consider avoiding large amounts of artificial sweeteners, large doses of vitamin supplements, and caffeine. You should also avoid alcohol as this may cause the baby to nurse less and to be fussy. If your child is eating solid foods, avoid whipped foods and carbonated drinks like pop. These products have a high air content that can lead to gas buildup. Another tip is to prevent your child from overeating at a single sitting. Provide smaller, more frequent meals. Try replacing high gas-producing foods, such as beans, brussels sprouts, carrots, apricots, prune juice, raisins, and french fries with low gas-producing foods, such as broccoli, lettuce, tomatoes, berries, grapes, and rice cakes. Warm pads on the lower part of the stomach can be a comfort; be careful with or avoid hot water bottles. If these non-drug methods don’t do the trick, try an OTC product.

The two most commonly used over-the counter agents for gas build-up are gripe water and simethicone. In previous years gripe water was popular, but it is no longer a first choice. Since the alcohol content in gripe water can cause side effects, some companies have designed alcohol-free versions. Today simethicone (Ovol™ drops) is preferred. This works to break up gas. It is best given before a meal, and is considered harmless with no side effects.

Cough and Cold

The most common question pharmacists hear from parents is, “What should I get for my child who is sniffling and sneezing?” With over 600 cough and cold products on the Canadian market, finding the right product can certainly be a challenge. Most parents don’t know where to start.

First, it is best to rule out anything serious. Colds may resemble other conditions like bronchitis, allergies, the flu, pneumonia, and laryngitis. A “cold” lasting longer than 14 days accompanied by coloured mucus (yellow, green, or orange) may indicate a bacterial infection. A combination of any of the symptoms in Table 1 would provide good reason to see your child’s doctor immediately. Don’t wait until the next morning.

After you have ruled out anything serious, what can you use to get rid of those sniffs and sneezes? Well, that’s part of the problem. There is no wonder drug that can cure a cold. Products marketed today can only reduce symptoms. But there are so many products, which is the best? Here is a secret. Despite the fact that there are hundreds of cough and cold products on the shelf, there are only four active ingredient groups: decongestants (D), antihistamines, expectorants (E), and cough suppressants (DM). The cough and cold section looks so big because there are many different companies, many different generic or house brands, and many different combinations of the four active ingredients. Often these ingredients are also combined with a medicine for pain or fever such as acetaminophen.

The key is to decide exactly what symptoms your child has and then find a product that matches those needs. For example, a child with only a dry hacking cough would need nothing else but a straight cough suppressant. Giving your child something that contains DM-D-E may not be the best solution. Yes, it contains a cough suppressant, but it also has an expectorant and a decongestant. In this case the extra ingredients are not needed. Choose products with the fewest ingredients necessary so your child is exposed to less medications and possible side effects. Besides, products with single ingredients are likely to be cheaper than those with many ingredients.

If there is a build-up of mucus in the throat, try increasing fluid intake (especially warm fluids) or adding a bit of spice to your child’s favourite meal. These methods help to break up mucus and work like expectorants. You can also try using your cold mist humidifier (keep it well cleaned according to the directions), a steamy bath or a shower. Fluids and humidity are natural expectorants.

Expectorants loosen up mucus, making it easier to cough the mucus out. Guaifenesin is the most common one found in cough and cold products. It is considered safe and effective and should be taken with lots of fluid.
What about that stubborn cough? In children two years or older start simply by giving your child some gum or a lollipop. These can help prevent a ‘tickle’ from coming on. By increasing saliva in the mouth, you can actually help prevent a cough from starting. Of course, if that doesn’t work, there is always good old-fashioned ‘cough syrup.’

Like expectorants, there are only a few cough-suppressing ingredients on the market. These include dextromethorphan and codeine. Dextromethorphan (DM) is most widely used as it has few side effects. Codeine, on the other hand, can cause problems. Although it has been proven effective in children as young as two years old, it can cause stomach upset, nausea, drowsiness, dizziness, and constipation. This is the main reason why codeine products sold without a prescription must be obtained from behind the pharmacy counter. Some children are also allergic to codeine. A rash, hives, or shortness of breath in your child may indicate a codeine allergy. Stop the medication and see a doctor immediately.

How about that stuffy nose? Spices can help as well. Ever wonder why your nose runs when you eat spicy chicken wings? Spices work to loosen mucus and can help clear a stuffy nose, chest, and throat. Try some in tacos or in your child’s favourite soup. Mentholated rubs, like chicken soup, are a ‘feel better’ method that can help reduce the incidence of side effects.

If all else fails there are certainly some OTC decongestants you can try. Decongestants are used for stuffy noses, congested sinuses, and chests. They are available in pill form, liquid, nasal sprays, or drops. The most common ones available in pill form are pseudoephedrine and phenylephrine. Do not worry, all products containing phenylpropanolamine (PPA) have been removed from Canadian pharmacy shelves.

If you give your child a decongestant in pill form, make sure not to give it too close to bedtime. These drugs can keep your child awake at night. For plugged noses, nasal sprays and drops are preferred since they work faster than pills. They also work at the site and cause fewer side effects than decongestant pills. Phenylephrine, xylometazoline, oxymetazoline, and naphazoline are the most common medications used in sprays and drops. Among these, naphazoline is the only one not recommended for children under 12 years old. Decongestants should be used with caution in children under one year of age. Regardless of the ingredient or your child’s age, make sure that your child does not use medicated nasal sprays longer than three to four days in a row. It may make the congestion worse. Instead, try a non-medicated nasal spray containing a saline solution. These agents are very safe and can be used all the time, and so are a good choice for children under the age of two years. Rhinaris™ and Hydrasense™ are popular brands.

If your child is suffering from a runny nose and is sneezing, an antihistamine may help. Some of these antihistamines can be found in “combination” cough-and-cold products (one containing a decongestant, cough suppressant, expectorant, and/or antihistamine). Antihistamines are discussed in more detail in the next section.

Allergies

Since the flu and the common cold involve many symptoms similar to allergies, parents are often confused. Not sure if your child has allergies? Keep it simple. If your child’s symptoms are accompanied by a sore throat or a fever, chances are good that it’s not allergies. Sore throats and fevers are usually absent in allergy sufferers. If your child’s symptoms are watery eyes, runny nose, sneezing, and/or congestion, it is likely that allergies are present. These symptoms are characteristic of allergies and are best treated with antihistamines. Antihistamines are generally classed into two groups: Class 1 - otherwise known as the “older” antihistamines, and Class 2 - the new generation antihistamines. Some of the chemical names and the differences between them are shown in Table 2.

Table 2

For children suffering with allergies, the most commonly used antihistamines are loratadine (Claritin™), cetirizine (Reactine™), and diphenhydramine (Benadryl™). Liquid syrups, tablets that dissolve on the tongue, or sprays are available for children unable to swallow pills. For children over 12 years, tablets are also an option. Before choosing an antihistamine, you may want to consider some things. If it’s a weekday and your child is in school, choose something that does not have to be given regularly and does not cause drowsiness. On the other hand, if your child has been having trouble sleeping because of symptoms, drowsiness may be welcomed. Despite the difference in the time it takes for the different antihistamines to work, they are considered to be equally effective. Sooner or later they will kick in. Be aware that if your child has been on a particular antihistamine for a while the effectiveness of the drug may decrease. A tolerance may develop. Try switching antihistamines to reduce this effect.

Here are some other considerations. If you want a quick-acting antihistamine but are worried about side effects like drowsiness, chances are it will go away. Children who continue on something like Benadryl™ may even build tolerance to the drowsiness. On the other hand, using a Class 1 antihistamine in children for long periods may not be the best idea, since it can lead to a condition characterized by restlessness and nervousness. In rare cases it can even cause seizures. For long-term use try Claritin™ or Reactine™.

Antihistamines work to “dry up” the nose and eyes, but they will not help your child’s congestion. If your child is congested, feel free to add a nasal or oral decongestant and keep in mind the things discussed above. Antihistamines should not be used by children under one year, and only with caution by children under the age of five.

Anti-allergy medications help relieve symptoms, but getting rid of the triggers that cause the allergies is the best way to manage them. Not sure what is triggering the problem? Look at timing. When did the symptoms start? Did they begin with pollen season? Is your child coming home with these symptoms after playing at a friend’s home? Are pets involved? Find out what your child is allergic to and avoid contact! Here are some tips to follow if the allergies are weather or “air” related.

  • Keep windows closed in the car or house
  • Use air conditioners; they keep the air dry
  • Don’t send your child outside when the pollen count is high (in the morning)
  • Ask the teacher if your child can stay inside for recess, especially on humid or windy days
  • Keep your child away as you rake the leaves, mow the lawn, or weed the flower-bed
  • Have your child change clothing after coming in from outside, and shower or bathe before bed
  • Vacuum and dust the house frequently

Flu Symptoms

Table 1
If your child has a fever above 38.5?C and any of the following symptoms, or any combination of these symptoms without a fever, take your child to a doctor immediately:

  • a severely painful throat
  • a stiff neck
  • chills
  • vomiting
  • diarrhea
  • shortness of breath
  • dizziness
  • pain in the ears

Fevers are uncommon in children with allergies and the common cold, but they are linked to bacterial infections and flu viruses. If your child comes down with a fever, it is important to know how high the temperature is. Has it developed gradually? Again, timing is key. If there is a sudden onset of a high fever, especially one that is unmanageable and accompanied by the symptoms in Table 1, see your doctor immediately. In children, a fever over 40° C (104° F) can lead to seizures. Temperatures over 41° C are often linked with bacterial infections.

Here are a few more reasons to see the doctor: a child with a fever and a serious underlying disease, a child less than two months old, fevers lasting more than 24 hours despite treatment, or fevers that have no obvious cause. A child who has fever and dry mouth, lack of tears, or skin that stays puckered up when it is pinched may be dehydrated. This calls for medical attention. Treat the fever immediately and contact your doctor.
When taking a child’s temperature, remember these points. If you are taking a temperature by mouth, ‘normal’ body temperature is 37° C (98.6° F). It is 0.6° C to 1° C lower for the underarm. If your child’s body temperature exceeds 38.5° C in the mouth, 38.5° C in the rectum, or 37.4° C under the arm, your child has a fever.

Depending on the site, the length of time required to get a true reading is also different. Hold the thermometer for two to three minutes in the rectum, three to four minutes in the mouth, and five to six minutes under the arm. If you are using a mercury thermometer, make sure that the line is below 35.5° C (95.9° F) before you begin. If using the mouth, don’t give hot or cold liquids or foods for one half hour before taking the child’s temperature.
Once you are certain that your child has a fever that is not serious, begin with some non-drug treatments. A good place to start is to remove extra clothing and bedding. Lowering the room temperature will also help body heat escape. To replace water lost from perspiring and prevent dehydration, make sure to give your child lots of fluids. As well, have your child rest. Running and jumping increase body heat.

Sponge baths are also effective in reducing body heat, but only work if the water is lukewarm (29 to 32°C). Cool water may make your child shiver, and the body will automatically increase heat production. This obviously defeats the purpose of the bath. If the child is shivering, increase the temperature of the water slightly. Be sure that the child sits in about five centimetres (two inches) of water and the skin surface is continuously bathed. This is better than completely covering the child with water. Continue sponging for 20 minutes. If these non-drug measures fail to bring down the fever, try some OTC medication.

Acetaminophen (Tylenol,™ Tempra,™ or Panadol™) remains the number one choice for treating children’s fevers. Although acetylsalicylic acid or ASA (for example, Aspirin™) was once the most widely used medication for children’s fever, it is no longer recommended to treat fever in children, teenagers or young adults. This is due to the possibility of developing Reye’s Syndrome. Reye’s Syndrome is a potentially fatal disease which may occur when ASA is given to children with a viral illness like chicken pox or the flu. As an alternative, ibuprofen (Motrin,™ Advil™) has recently become available over the counter. Currently, there is no obvious link between ibuprofen and Reye’s syndrome.

Whichever medication you choose, the dose is usually based on weight rather than age. A good guideline is shown in Table 3.

table 3

At appropriate doses, acetaminophen generally does not cause side effects. A single dose can be repeated every four hours and should not exceed five doses in 24 hours. Ibuprofen, on the other hand, can cause stomach upset and possibly ringing in the ears. Make sure to give it with a meal. A single dose of ibuprofen can be repeated every six to eight hours, and should not exceed four doses daily. Both medications are available in chewable pills and liquid, which come in many flavours. Acetaminophen is also available as suppositories. As an alternative to using medicine you can give your child a lukewarm sponge bath and some cool drinks. Removing warm clothing, running a fan or an air conditioning unit in the room can also help. If these measures fail to lower the fever, consult your family doctor.

Along with fever, nausea and vomiting may arise. Again, in order to rule out anything serious, examine the symptoms closely. Is the vomiting frequent? Is there any blood in the vomit? Is it caused by pressing on the stomach? If any of these occur, see your doctor.

The biggest hurdle that many parents face is too many choices and too little time. First, examine your child’s symptoms and consider timing and severity. This will help you decide if you should take your child to a doctor. Second, if your child is playful, urinating well and has a fever less than 38.5° C, try non-drug therapies first. They are simple, less expensive, and can reduce your child’s exposure to drugs and side effects. Third, if you need to use an OTC product, choose one with the right ingredients. Base your selection on the symptoms. Last, always read the labels. If your child has diabetes, asthma, chronic lung disease, thyroid imbalance, any chronic disease, or is taking any antidepressants or prescription medications, ask your pharmacist or doctor for advice before giving OTC medication.

Being well-informed can help you save time, money, and unnecessary stress!

FAMILY HEALTH is written with the assistance of
Alberta College of Family Physicians
FAMILY HEALTH is written
with the assistance of
The College of Family Physicans of Canada
Alberta College of Family Physicians
While effort is made to reflect accepted medical knowledge and practice, articles in Family Health Online should not be relied upon for the treatment or management of any specifid medical problem or concern and Family Health accepts no liability for reliance on the articles. For proper diagnosis and care, you should always consult your family physican promptly. Copyright 2012, Family Health Magazine, a special publication of the Edmonton Journal, a division of Postmedia Network Inc., 10006 - 101 Street, Edmonton, AB T5J 2S6  [CH_FHd02]
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