Author: Vincent Iannelli, MD

What to Do About QVAR Being Redesigned

Do your kids have asthma?

What medicines do they take?

Asthma Medications

Kids with asthma basically get treated with five types of medications, including:

  • inhaled short acting bronchodilators – albuterol nebulizer solution, levalbuterol nebulizer and HFA (Xopenex), ProAir HFA, ProAir Respiclick, Proventil HFA, Ventolin HFA
  • oral steroids – prednisolone, prednisone
  • inhaled steroids -Alvesco, Asmanex Twisthaler, Flovent HFA or Diskus, Pulmicort Respules, Pulmicort Flexhaler, QVAR RediHaler
  • inhaled long acting bronchodilators
  • montelukast (Singulair) – a leukotriene receptor antagonist that can help prevent asthma and allergy symptoms

Two of these, inhaled steroids and inhaled long acting bronchodilators, which are typically used in combination products (Advair, AirDuo, Dulera, and Symbicort), are commonly used every day to prevent asthma symptoms and asthma attacks.

How Kids Take Asthma Medications

Asthma is one of those conditions that should be a lot easier to control than it usually is.

Although many preventative medications are available, they typically have to be used every day and the medications have to be given with a nebulizer (takes time) or an inhaler (requires good technique).

A spacer allows younger kids to use asthma inhalers.
A spacer allows younger kids to use asthma inhalers. Photo by Vincent Iannelli, MD

Fortunately, younger kids who can’t yet learn to use an inhaler can get around this by using their inhaler with a spacer or a spacer with a mask.

How do spacers work with your child’s asthma inhaler?

The medicine from the inhaler goes in the spacer and then the child can just breath it in, not having to coordinate, or time when they breath, with when the medicine actually comes out of the inhaler.

What’s the problem?

More and more drug companies are switching to dry powder inhalers. These are great for older kids, who can easily master the necessary technique – a quick, deep breath. But they are still too hard to use for younger kids and can’t be used with a spacer.

“In a systematic review, the mean percentages of patients who used their inhalers without mistakes were 63% for metered dose inhalers (MDIs); 75% for breath-actuated MDIs; and 65% for dry powder inhalers (DPIs).”

Haughney et al. on Choosing inhaler devices for people with asthma: Current knowledge and outstanding research needs

Others are switching to breath-actuated aerosol inhalers that are also too difficult for younger kids to use (they must close their lips around the mouth piece and inhale deeply) and also can’t be used with a spacer.

The Redesigned QVAR Inhaler

While some companies still make two versions of their inhalers, a traditional metered dose inhaler (MDI) and a dry powder inhaler (DPI) or breath-actuated device, more and more have just one option.

QVAR, which has long had the popular inhaled steroid QVAR HFA in 40 and 80 mcg strengths, has now switched to a breath-actuated device.

While the availability of the QVAR RediHaler is good news, as some experts think that breath-actuated devices are better than coordinated devices, the bad news is that they dropped their older QVAR inhalers which could be used with a spacer.

Be careful that your pharmacy doesn’t switch your child from QVAR to QVAR RediHaler unless you think it is appropriate.

So what are your options if your child needs an inhaled steroid?

  • Is your child old enough to learn how to use the QVAR RediHaler or a DPI inhaler, like Asmanex Twisthaler, Flovent Diskus, or Pulmicort Flexhaler? Online videos and demonstration devices can help teach your child.
  • Is your child’s asthma under poor control, so that QVAR wasn’t a good option anymore anyway, in which case your child might need a step up to a combination inhaler that can be used with a spacer, such as Advair, AirDuo, Dulera, or Symbicort?
  • Is your child’s asthma under such good control that your pediatrician might consider a step down off daily inhaled steroid therapy, so that you can stop using QVAR?
  • Do you have a nebulizer and so can use budesonide (Pulmicort) respules instead?

Although the fact that it has “a spacer-free design” is being used as a selling point for the new QVAR RediHaler, that doesn’t help those kids who still need to use a spacer. For them, the easiest option is to simply switch to another brand of steroid inhaler that can still be used with a spacer. These include Flovent HFA (44, 110, and 220mcg) and Alvesco (80 and 160mcg). Both are usually more expensive than QVAR though, which is what made QVAR popular. These other inhalers also might not be covered by your insurance plan.

The Future of Asthma Inhalers

Now that the patents on HFA inhalers are expiring, instead of making inexpensive HFA inhalers, to keep drug prices high, drug companies are developing new delivery devices that they can patent. What’s surprising, is that QVAR is made by Teva, which traditionally makes “lower cost” generic medications.

“Daddy, why can’t they put my asthma medicine in a spray-can like they do hair spray?”

Stein et al. on The History of Therapeutic Aerosols: A Chronological Review

In 1955, a young girl asked her father a simple question and a few months later, the first MDI for asthma was developed.

Can asking a simple question about asthma inhalers get us such quick results today?

Let’s see…

AirDuo-RespiclickWhy isn’t someone making inexpensive asthma inhalers?

Teva did recently get approval for their AirDuo brand and generic inhaler.

A combination of fluticasone propionate and salmeterol, AirDuo is similar to Advair. It is different in that the three strengths of AirDuo (55/14, 113/14 and 232/14 mcg) don’t exactly match the three strengths of Advair (45/21, 115/21 and 230/21 mcg), but at about 25% of the cost, few folks likely care. They might care that AirDuo is only available in a RespiClick version (a dry powder inhaler), and so can’t be used with a spacer.

Ironically, Teva’s AirDuo generic inhaler, a combination inhaler, is less much expensive than their QVAR inhaler, which only contains a steroid.

We will hopefully see more generic versions of more inhalers, including more that stay in a traditional non-breath-actuated, non-DPI form. And more asthma inhalers that are much less expensive.

What to Know About QVAR Being Redesigned

The redesign of QVAR and other asthma inhalers to breath actuated and dry powder versions can mean that they can’t be used with spacers and so can’t be used by infants, toddlers, preschoolers, and younger school aged children with asthma.

More on QVAR HFA Being Redesigned

Child Access Prevention Laws and Gun Safety

There are many types of gun violence that gun safety advocates are concerned about, including:

  • homicides
  • mass shootings
  • school shootings
  • suicide
  • unintentional shootings

The problem isn’t just gang-bangers killing themselves, as some people who try to minimize the gun violence problem try to claim.

The American Pediatric Surgical Association, in an editorial about Firearms, Children, and Health Care Professionals, does a good job in pointing this out.

They state that “the risk of firearm homicide, suicide and unintentional injuries is more than 5-fold greater in the United States than 23 other high-income countries considered collectively. Firearm-related injury and death are issues for all Americans, in all communities. The risk of dying by firearm is the same for residents of the largest cities as it is for the residents of the smallest counties and holds true for adult and pediatric patients alike. This parity in risk is due to the predominance of firearm suicides and unintentional firearms deaths in the rural counties and the predominance of firearm homicides in the urban counties.”

Gun Safety Laws

Many new and proposed gun safety laws will hopefully help to reduce gun violence, including:

  • universal background checks and the closure of the gun show loophole
  • mental health restrictions for gun purchases
  • limitations on access to high-capacity magazines and assault-style weaponry
  • repealing the Dickey Amendment, which restricts the CDC from doing research on gun violence
  • child access prevention (CAP) laws

And we need to make mental health services more readily available to those who need them.

The March For Our Lives and National School Walkout events in March are already pushing lawmakers to make changes to keep kids safe from gun violence.
The March For Our Lives and National School Walkout events in March are already pushing lawmakers to make changes to keep kids safe from gun violence.

Surprisingly, many of these gun safety laws are supported by most members of the NRA, even if they are strongly opposed by the NRA itself.

CAP Laws

Most gun safety advocates are pushing for stronger CAP laws as a way to decrease the number of children injured and killed by unintentional shootings.

CAP laws work to limit a child’s access to guns in and around their home.

All too often, a toddler, preschooler, or older child will find a loaded, unsecured gun under a bed, on a nightstand, or in a closet, etc., and unintentionally shoot themselves or another family member.

“The safest home for a child is a home without guns, and if there is a gun in the home, it must be stored unloaded and locked, with the ammunition locked separately.”

American Academy of Pediatrics

CAP laws are not just about accidental shootings though. Kids who get access to unsecured guns also use them in suicides and school shootings.

Studies have found benefits to CAP laws, including declines in unintentional firearm death rates in children, decreases in non-fatal gun injuries, and decreases in suicide rates among teens.

Current CAP Laws

While some states have some sort of CAP law on the books already, many others don’t.

In Texas, “A person commits an offense if a child gains access to a readily dischargeable firearm (a firearm that is loaded with ammunition, whether or not a round is in the chamber) and the person with criminal negligence and failed to secure the firearm (to take steps that a reasonable person would take to prevent the access to a readily dischargeable firearm by a child, including but not limited to placing a firearm in a locked container or temporarily rendering the firearm inoperable by a trigger lock or other means) or left the firearm in a place to which the person knew or should have known the child would gain access.”

However, many other states, including Alabama, Alaska, Louisiana, Maine, New Mexico, Ohio, South Carolina, Washington, Vermont, and Wyoming, don’t have any kind of laws that would prohibit allowing kids access to unsecured firearms.

Again, that is a surprise since even the NRA advises that it is a gun owner’s responsibility to “store guns so that they are inaccessible to children and other unauthorized users.” They also state that it is a basic gun safety rule to “always keep the gun unloaded until ready to use.”

Some other states have weak or limited CAP laws that simply make you criminally liable if a child or teen gets access to a gun and uses it in a felony. For example, in Oklahoma, it is “unlawful for any parent or guardian to intentionally, knowingly, or recklessly permit his or her child to possess any of the arms or weapons,” but only if they are “aware of a substantial risk that the child will use the weapon to commit a criminal offense or if the child has either been adjudicated a delinquent or has been convicted as an adult for any criminal offense.”

And no states have all of the features of a comprehensive CAP law, which most experts advise would:

  • define a minor as being under 18 years for long guns and under 21 for handguns (in some states, a minor is only those who are 13 years old and under when it comes to child access prevention laws)
  • require that all firearms be stored with a locking device
  • impose a criminal liability on people who negligently store firearms where a minor could gain access, even if the firearm is unloaded and the minor doesn’t gain access or use the firearm
  • impose civil liability for damages if a minor gains access to a firearm that was stored negligently and causes damage after firing it

California is getting close though and is often thought of as being a leader in gun safety laws. Their CAP law was amended in 2013 (the Firearm Safe and Responsible Access Act) to make it a misdemeanor to leave an unsecured gun where a minor could find it, even if they don’t, in addition to being a misdemeanor or felony if they find and use the gun. Gun dealers also have to post warning signs educating gun buyers about the state’s CAP law.

Proposed Gun Safety Laws

According to the Giffords Law Center to Prevent Gun Violence, there are pending gun safety bills in at least 23 states, including many bills that would strengthen background checks.

Still, only 27 states and the District of Columbia have child access prevention laws.

And there is currently no national CAP law.

A bill that was introduced in 2013, the Child Gun Safety and Gun Access Prevention Act of 2013 would have come close by amending the Brady Handgun Violence Prevention Act to make it “unlawful for any licensed importer, licensed manufacturer, or licensed dealer to sell, transfer, or deliver any firearm to any person (other than a licensed importer, licensed manufacturer, or licensed dealer) unless the transferee is provided with a secure gun storage or safety device.”

Another version of the bill that was far more broad would also “Prohibit keeping a loaded firearm or an unloaded firearm and ammunition within any premises knowing or recklessly disregarding the risk that a child: (1) is capable of gaining access to it, and (2) will use the firearm to cause death or serious bodily injury.” It would also have raised the minimum ages that young people could purchase and possess handguns and long guns.

The Child Gun Safety and Gun Access Prevention Act of 2013 never made it out of committee though. It’s not hard to imagine that by “by raising the age of handgun eligibility and prohibiting youth from possessing semiautomatic assault weapons,” the bill, introduced by Congresswoman Sheila Jackson Lee from Texas, could have prevented the latest school shooting at Stoneman Douglas High School in Parkland, Florida.

Hopefully stronger gun safety laws will now be passed in more states and we will see fewer unintentional shootings and other tragedies that occur when kids find unsecured guns or buy their own, including AR-15 style guns.

parkland-survivor

In addition to other measures to reduce gun violence, the American Academy of Pediatrics supports safe storage and CAP laws.

What to Know About Gun Safety Laws

As we see more and more gun violence, including school shootings, something has to be done to protect our kids and keep them safe.

More on Gun Safety Laws

It’s Not Always the Flu When You Get Sick During Cold and Flu Season

We hear a lot about flu season.

It typically starts in late fall, peaks in mid-to-late winter, and can continue through early spring.

Cold and Flu Season Viruses

It’s important to understand that a lot more is going on, and going around, during flu season than just the flu.

That’s why it is likely more appropriate to think of flu season as just a part of the overall cold and flu season that we see during the late fall to early spring.

During cold and flu season, in addition to the multiple strains of the flu, we see diseases caused by:

  • respiratory adenovirus – can cause bronchitis, colds, croup, viral pneumonia, pink eye, and diarrhea
  • Human metapneumovirus (HMPV) – can cause bronchiolitis, colds, and viral pneumonia
  • Human parainfluenza viruses (HPIVs) – can cause bronchiolitis, bronchitis, colds, croup, or viral pneumonia
  • rhinovirus – the classic common cold
  • Respiratory syncytial virus (RSV) – can cause wheezing and bronchiolitis in younger children, but colds in older kids and adults
  • seasonal coronavirus – can cause colds, bronchitis, and viral pneumonia
  • norovirus – diarrhea and vomiting
  • rotavirus – diarrhea and vomiting, was much more common in the pre-vaccine era

That there are so many different respiratory viruses that can cause bronchiolitis, colds, croup, and flu-like illnesses helps explain why some kids get sick so many times during cold and flu season.

It also helps explain why some folks think they might have gotten the flu despite having been vaccinated, especially in a year when the flu vaccine is very effective.

Is It a Cold or the Flu?

So how do you know if you have the flu or one of these flu viruses during cold and flu season?

Signs and symptoms of the flu vs a cold.
Signs and symptoms of the flu vs a cold.

While the symptoms can be similar, flu symptoms are usually more severe and come on more suddenly.

Can’t you just get a flu test?

While rapid flu tests are fast and easy to do, they are likely not as accurate as you think.

“This variation in ability to detect viruses can result in some people who are infected with the flu having a negative rapid test result. (This situation is called a false negative test result.) Despite a negative rapid test result, your health care provider may diagnose you with flu based on your symptoms and their clinical judgment.”

CDC on Diagnosing Flu

If your pediatrician is going to diagnose your child with the flu because of their symptoms, even if they have a negative flu test, then why do the test?

Rapid flu tests are usually invalid if they are positive for A and B, but many folks are told that they have both.
Rapid flu tests are usually invalid if they are positive for A and B, but many folks are told that they have both flu virus strains.

Can you test for all of the other viruses that are going around during cold and flu season?

Tests can be done to detect most cold and flu viruses.
Tests can be done to detect most cold and flu viruses.

Sure.

The real question is should you.

Like the rapid flu test, many pediatricians can do an RSV test in their office. But like many other viruses, there is no treatment for RSV and the American Academy of Pediatrics actually recommends against routine RSV testing. Whether your child’s test is positive or negative, it is not going to change how he or she is treated.

And the other viruses? Not surprisingly, there are respiratory panels that can test for most or all of these viruses. They also usually include flu and RSV.

The problem with these tests is cost. They are not inexpensive, and again, in most cases, the results aren’t going to change how your pediatrician treats your child.

And they all involve sticking a nasal swab far up your child’s nose…

What About Strep?

While strep throat can occur year round, it does seem to be more common in the winter and spring.

And while you can certainly have two different infections at the same time, such as strep throat and the flu, it is important to remember that the rate of strep throat carriers is fairly high. These are kids who regularly test positive for strep, even though they don’t have an active group A strep infection.

During cold and flu season, if kids routinely get a “strep/flu” combo test, it is possible, or even likely, that many of the positive strep tests are simply catching these carriers.

Remember that a cough, runny nose, hoarse voice, and pink eye are not typical symptoms of strep throat and are more commonly caused by cold viruses. Adenovirus is especially notorious for causing a sore throat, fever, pink eye, runny nose, with swollen lymph nodes = pharyngoconjunctival fever.

Kids who are likely to have strep throat usually have a sore throat, with red and swollen tonsils, and may have swollen lymph nodes, fever, stomach pain, and vomiting, but won’t have typical cold symptoms.

Why does it matter?

Viral causes of a sore throat don’t need antibiotics, while a true strep infection does.

And remember that none of the other cold and flu viruses need antibiotics either, unless your child gets worse and develops a secondary bacterial infection.

What to Know About Cold and Flu Season Viruses

Flu isn’t the only virus that is going around during cold and flu season. Many others can cause flu-like illnesses, croup, bronchiolitis, or just a cold.

More on Cold and Flu Season Viruses

What to Do About the Quillivant XR Shortage?

Does your child with ADHD take Quillivant XR?

quillivant-xr-shortage

Then you likely hopefully aware that there is a shortage of Quillivant XR because of a manufacturing delay.

What Is Quillivant XR?

Quillivant XR is another stimulant that is used to treat kids with ADHD.

Like many other ADHD medications, the main ingredient in Quillivant XR is methylphenidate – the main ingredient in Ritalin.

The big difference is that Quillivant XR is an oral suspension or liquid form of methylphenidate.

What to Do About the Quillivant XR Shortage?

So what do you do if you can’t get Quillivant XR for your child?

There are plenty of other ADHD medications

You will likely want to stay on something similar though, which will mean another long acting stimulant with methylphenidate, such as Aptensio XR, Concerta (Methylphenidate ER), Cotempla XR-ODT, Daytrana (patch), or Quillichew ER (chewable tablet). Metadate CD, Metadate ER, and Ritalin LA are other forms of methylphenidate, but they only last about 8 to 10 hours vs the 10 to 12 hours of all of those other long acting ADHD medications. Focalin XR (dexmethylphenidate) would likely be another alternative.

Unfortunately, there are no other liquid forms of methylphenidate. Except for Concerta and Metadate CD, you can open and sprinkle the contents of these capsules on applesauce if your child can’t/won’t swallow pills though.

You can also try and teach your child to swallow pills…

Best Alternatives To Quillivant XR

In reality, you probably don’t have that many options.

Your child is likely taking Quillivant XR because he couldn’t learn how to swallow pills, won’t take medications if you open and sprinkle them on things, and didn’t tolerate Daytrana (the methylphenidate patch).

That still leaves you with a couple of good options, including:

  • Quillichew ER – a chewable form of methylphenidate available in 20mg, 30mg, and 40mg chewable tablets (was under backorder, but that seems to have been resolved)
  • Cotempla XR-ODT – an oral disintegrating tablet form of methylphenidate available in 8.6mg, 17.3mg, and 25.9mg tablets

The main difference between all of the different forms of methylphenidate?

Surprisingly, it’s not only if it is a liquid, capsule, or pill. They all have different time release mechanisms that affect how your kids get the medication.

Quillivant XR, for example, uses a 20/80 time release delivery system. That means that your child gets 20% of the dose immediately and then 80% throughout the rest of the day. Ironically, because it is only available in a pill that can’t be crushed or opened, the closest medicine to that delivery system is Concerta, with its 22/78 system.

Cotempla XR-ODT is close, with a 25/75 delivery system.

Quillichew ER uses a 30/70 delivery system.

Aptensio XR uses a 40/60 system and some others, like Focalin XR use a 50/50 system.

Why does any of this matter?

If your child was doing great on Quillivant XR and you switched to another medicine using an equivalent dose of methylphenidate, they will be getting that dose delivered to them differently throughout the day. While that might be okay, it could also mean that your child is now starting the day off with either too much medicine (watch for side effects) or is getting too little medicine later (watch for decreased effectiveness). And that will mean some extra fine tuning of your child’s medication until Quillivant XR is available again.

Is your child due for a refill of his Quillivant XR? It’s probably time to look at your alternatives until the shortage is fixed.

What to Know About the Quillivant XR Shortage

Quillivant XR is a long acting form of methylphenidate that is available in a suspension form, so is easy for kids with ADHD to take if they can’t swallow pills, at least it is when there isn’t a shortage.

More About the Quillivant XR Shortage

How Long Are You Contagious When You Have the Flu?

Do your kids have the flu?

When their kids have the flu, one of the first questions most parents have, after all of the ones about how they can get them better as quickly as possible, is how long will they be contagious?

How Long Is the Flu Contagious?

Technically, when you have the flu, you are contagious for about a week after becoming sick.

And you become sick about one to four days after being exposed to someone else with the flu – that’s the incubation period.

“Most experts believe that flu viruses spread mainly by droplets made when people with flu cough, sneeze or talk. These droplets can land in the mouths or noses of people who are nearby. Less often, a person might also get flu by touching a surface or object that has flu virus on it and then touching their own mouth, eyes or possibly their nose.”

CDC on Information for Schools

That’s why the flu spreads so easily and it is hard to control flu outbreaks and epidemics once they begin.

Most school closures are not to prevent the spread of the flu and clean the school, but simply because so many kids and staff are already out sick.
Most school closures are not to prevent the spread of the flu and clean the school, but simply because so many kids and staff are already out sick.

Another reason it spreads so easily is that most people are contagious the day before they even begin to develop flu symptoms!

And again, they then remain contagious for another five to seven days.

When Can You Return to School with the Flu?

Does that mean kids with the flu have to stay home for at least seven days?

Not usually, unless they have a fever for that long, or severe flu symptoms, which is definitely a possibility for some kids with the flu.

“Those who get flu-like symptoms at school should go home and stay home until at least 24 hours after they no longer have a fever or signs of a fever without the use of fever-reducing medicine.”

CDC on Information for Schools

In general, as with many other childhood illnesses, you can return to school or daycare once your child is feeling better and is fever free for at least 24 hours.

Keep in mind that even if they don’t have a fever, if your child still isn’t feeling well and isn’t going to be able to participate in typical activities, then they should probably still stay home.

But Are They Still Contagious?

Many childhood diseases have contagious periods that are far longer than most folks imagine. That’s because we continue to shed viral particles even as we are getting better, and sometimes, even once we no longer have symptoms.

Teach your kids proper cough etiquette to help keep cold and flu germs from spreading.
Teach your kids proper cough etiquette to help keep cold and flu germs from spreading.

For example, some infants with rotavirus are contagious for up to 10 days and some with RSV are contagious for as long as 4 weeks!

Like the child with flu that doesn’t have a fever, that doesn’t mean that these kids have to stay out of school or daycare for that whole time. But since they are still contagious, it does raise the issue of what to do about non-essential activities.

Should you keep going to playdates after your child had the flu? How about the daycare at church or the gym?

In general, you should probably avoid non-essential activities while your kids are still recovering from an illness, even if they feel better, because they are likely still contagious.

Most parents have the expectation that their own kids won’t be exposed to someone who is sick in these settings.

So you probably don’t want to bring your sick kid to a playdate or birthday party, etc., even if he is already back in school or daycare.

And whether they have a cold or the flu or another illness, teach your kids to decrease their chances of getting sick by washing their hands properly, not sharing drinks (bring a water bottle to school), and properly covering their own coughs and sneezes. They should also learn to avoid putting things in the mouth (fingers or their pencil, etc.) or rubbing their eyes, as that helps germs that could have made their way onto their hands get into their body and make them sick.

What to Know About Staying Home When You Have the Flu

Although your child may be contagious with the flu for up to a week, your child only has to stay home from school or day care until they are feeling better and are fever free for at least 24 hours.

More About Staying Home When You Have the Flu

 

Warning Signs of a Severe Case of the Flu

We all know the classic signs and symptoms of the flu.

They can include the sudden onset of:

  • fever
  • chills
  • cough and chest discomfort
  • headaches
  • fatigue
  • body aches
  • runny nose
  • sore throat

And these symptoms usually last a few days to a few weeks, with the worst of them lasting about five to seven days.

Warning Signs of a Severe Case of the Flu

But what if you don’t just have a classic case of the flu.

While many of the stories of this being the worst flu season are media hype, the flu is always dangerous and this is a severe flu season.

That makes it important to be able to recognize severe flu symptoms or signs that someone with the flu needs immediate medical attention, including:

  • having trouble breathing or fast breathing
  • being unable to eat and drink and getting dehydrated (dry mouth, urinating less, or fewer wet diapers, etc.)
  • not waking up easily
  • being inconsolable or so irritable that your child does not even want to be held
  • having chest pain
  • is suddenly dizzy
  • being confused
  • having seizures
  • having severe vomiting

You should also seek medical attention if your child was getting better, but then got worse again, especially if they again develop a fever and a worsening cough. Or if your child has a chronic health problem, like asthma or diabetes, and the flu is making it hard to control.

How will your child be treated? It depends, on treatments might include oxygen, IV fluids, antiviral medications, and antibiotics (if there is a secondary bacterial infection), etc.

And remember that children under the age of two to five years and those with chronic health conditions, such as asthma, diabetes, neurologic and neuromuscular conditions, and heart disease, etc., are most at risk for severe flu complications.

In four of the last deadliest flu seasons, at least half of the kids had no underlying medical conditions.
In four of the last deadliest flu seasons, at least half of the kids had no underlying medical conditions.

But you don’t have to be at high risk to develop flu complications.

Many of the kids who die with the flu each year don’t have any underlying health problems.

PedFluDeath_Characteristics-ages
And at least half of the kids who die with flu complications are school age children and teens.

Anyone, even previously healthy kids, can develop pneumonia, myocarditis, encephalitis, or septic shock, etc., so get help if you see any of the above signs and symptoms that your child with the flu is getting worse.

And get your kids vaccinated. Tragically, most kids who die with the flu each year didn’t have a flu shot.

What to Know About the Warning Signs of a Severe Case of the Flu

Seek medical attention if your child’s flu symptoms are getting worse, especially if it seemed they were getting better, but then got worse again, which can all be signs of complications of a severe flu case.

More on the Warning Signs of a Severe Case of the Flu

Sugar and Added Sugar

What do you think about when you think of sugar?

Candy and junk food?

It is important to remember that sugar is also naturally present in milk, including breastmilk and baby formula, and in fruits, and vegetables, etc.

That means that not all sugar is bad sugar.

Types of Sugar

Most of us have learned to limit or avoid certain types of sugar, like high fructose corn syrup, but you don’t have to avoid all sugar. In fact, if you eat fruits and vegetables, it would be awfully hard to avoid sugar.

You probably thought that sugar was sugar, right?

Nope.

There are many different types of sugar, with the most common types including:

  • glucose – found in many fruits and in corn syrup
  • fructose – fruit sugar
  • sucrose – sugar cane, sugar beets (a combination of glucose + fructose)
  • maltose – barley or malt sugar (a combination of two glucose molecules)
  • lactose – milk sugar (a combination of galactose + glucose)

Honey, a sweetener like sugar, is also made up of glucose and fructose, but they are not combined together. In general, honey contains much more fructose than glucose, which is why it is so sweet.

What about table sugar? That’s sucrose.

Still, like most other types of sugar, table sugar is broken down by enzymes in our body to glucose, with each gram of glucose providing four calories of energy. If you don’t need that energy at the time, that glucose gets converted into fat and is stored away.

Good Sugar vs Bad Sugar

While it’s become popular to worry about how bad sugar is for us, that’s not really what you should focus on. Instead,  learn more about the the differences between naturally occurring sugar and added sugars.

A large strawberry contains about 1 gram of natural sugar. They are low in sugar, unless you dip them in sugar before giving them to your kids.
A large strawberry contains about 1 gram of natural sugar. They are low in sugar, unless you dip them in sugar before giving them to your kids. Photo by Ken Hammond

If there is a bad sugar, it is the added sugars in foods that help us get too much sugar in our diets.

Also, when you eat or drink something with naturally occurring sugar, even though you are getting some sugar, you are also getting many other vitamins and minerals in your diet. For example, when you drink milk or eat an orange,  you get other nutritional benefits, unlike drinking a soda or eating a piece of candy.

So while you do get sugar from all of them, that’s all you get from the soda and candy.

That’s why it is often said that junk food is filled with empty calories.

Has someone got you shocked about the sugar content of your child’s lunch consisting of a PB&J sandwich, applesauce, and fruit punch? Then swap the applesauce for an apple and the fruit punch for low-fat milk or water.

Identifying Added Sugars

A new food label with added sugars is coming - by January 2020...
A new food label with added sugars is coming – by January 2020…

How do you know if the foods you are eating are high in sugar?

Just check the Nutrition Facts label and look at the amount of Sugars listed under Total Carbohydrates.

That can be misleading though, as it doesn’t differentiate between natural sugars and added sugars. At least not yet.

For that, we have to check the ingredients list and look for clues that the food item contains added sugars, including that it contains things like:

Hidden Sugar on Ingredients List
agave nectar invert sugar
anhydrous dextrose lactose
beet sugar malt syrup
brown sugar maltose
confectioner’s powdered sugar maple syrup
corn syrup molasses
corn syrup solids nectars (e.g., peach nectar, pear nectar)
dextrose pancake syrup
fructose raw sugar
fruit juice concentrate sucrose
high-fructose corn syrup (HFCS) sugar
honey white granulated sugar

New rules from the FDA will hopefully soon make it easier to recognize added sugars on food labels, as they add information about the amounts of added sugars in foods.

Limiting Sugar in Your Diet

Although some people are concerned that sugar is an actual poison – it isn’t – the most common reason to avoid added sugar is to simply avoid extra calories.

Sugar itself doesn’t cause diabetes or ADHD or any number of other things it gets blamed for, except maybe getting cavities.

If you get too much sugar in your diet and you become overweight, then you could develop type II diabetes. Getting too much fat in your diet is also an easy way to become overweight though, especially if you don’t exercise everyday.

How much sugar is too much?

“Free sugars include monosaccharides and disaccharides added to foods and beverages by the manufacturer, cook or consumer, and sugars naturally present in honey, syrups, fruit juices and fruit juice concentrates”

WHO on Sugars intake for adults and children

In general, you don’t usually want to get more than 10% of your daily calories from free sugars. Unfortunately, most people get too many calories in their diet, and too many of those calories are from free sugars.

Other recommendations are a little more restrictive.

“The committee found that it is reasonable to recommend that children consume ≤25 g (100 cal or ≈6 teaspoons) of added sugars per day and to avoid added sugars for children <2 years of age.”

AHA on Added Sugars and Cardiovascular Disease Risk in Children

But remember, this is the sugar that you get from candy, cakes, fruit drinks, donuts, and soft drinks, etc.

A teaspoonful of sugar is equal to 4g of sugar or 16 calories.
A teaspoonful of sugar is equal to 4g of sugar or 16 calories. Photo by Samantha Celera (CC BY-ND 2.0)

In general, it is not the sugar that they get from whole fruits, plain yogurt, or milk.

For example, don’t be mislead by scary claims, like yogurt might have more sugar than a Twinkie. Unless it is a kid’s brand, with a lot of added flavorings, the sugar in yogurt is mostly from naturally occurring milk sugar and sugar from added whole fruit, while a Twinkie is almost all added sugars.

Once you start being more mindful of how much sugar your kids are getting and you limit sugary drinks and candy every day, it becomes easy to get under about 25g of added sugar each day.

Avoiding Added Sugars

To help your kids avoid added sugar, it can help to:

  • drink water
  • limit or avoid soda, fruit drinks, and other sugar-sweetened drinks, including sports drinks
  • drink low-fat white milk without extra flavorings
  • avoid sugary cereals
  • choose canned fruits with water over syrup when not eating fresh whole fruit
  • limit candy, cakes, cookies, ice cream, and other junk foods
  • choose plain yogurt without added sugars instead of a flavored yogurt and then add fresh fruit to it

Even 100% fruit juice should be limited, and avoided all together if your infant is under 12 months old.

And don’t make the mistake of limiting added sugar, but then turning to high fat foods!

Healthier alternatives can include more nutrient dense foods, including beans and peas, eggs, fat-free and low-fat milk and cheese, fruits, lean meats and poultry, seafood, unsalted nuts and seeds, vegetables, and whole grain foods.

Most importantly, learn to read food labels to look for added sugar in the foods your kids eat and then avoid those food and watch their portion sizes. When you do allow your kids to have a treat, don’t go overboard with a 24 ounce soda or letting them eat a pint of ice cream.

Learn to eat healthy.

Remember that it’s not all about sugar, fat, carbs, or any other one thing. A registered dietician can be helpful if you need more help planning what your family eats.

What to Know About Sugar and Added Sugar

Learn to avoid added sugar in your child’s diet as part of an overall healthy eating plan.

More About Sugar and Added Sugar