Treating Hard To Control Constipation in Kids

Learn how to treat kids with hard to control constipation.

Constipation is very common for kids.

Since your kids will almost certainly become constipated, at least briefly, at some point in their lives, it is important to understand how to recognize the symptoms of constipation.

Symptoms of Constipation

How do you know if your child is constipated?

In addition to grunting and stomach pain, more traditional signs and symptoms of constipation include having:

  • fewer than two bowel movements in a week
  • bowel movements that are small, hard, and like little balls
  • bowel movements that are very big and hard and which may frequently clog the toilet

Most importantly, your constipated child will have bowel movements that are painful and difficult to pass. Very big bowel movements might also lead to small rectal tears and bleeding (usually some bright red blood on the toilet paper when wiping, not blood that fills the toilet bowl).

Not surprisingly, large painful bowel movements commonly lead kids to avoid going to the bathroom, creating a viscous cycle of worsening constipation that can become chronic. Your child with chronic constipation may eventually develop encopresis, having soiling accidents that you mistake for diarrhea. Or because they are holding their stool, they might also hold their urine and develop multiple urinary tract infections or just have urine accidents.

What about grunting and straining? If your baby grunts, strains and even cries briefly, but then passes a soft bowel movement each day, then she probably isn’t constipated (Infant Dyschezia).

Young Children with Constipation

It is often most obvious when young children get constipated, as you are still changing diapers or helping them use the potty.

Keep in mind that:

  • you should talk to your pediatrician if you think that your newborn baby is constipated (not pooping can be a sign that newborn babies aren’t eating enough) or if your child has had constipation problems since he was born (sign of Hirschsprung disease) or is constipated and isn’t gaining weight (Celiac disease)
  • exclusively breastfeeding infants, especially before they start solid foods, once they are gaining weight well, are unlikely to get constipated, but they may only have their soft bowel movements every few days or weeks
  • infants sometimes get constipated when they start rice cereal or other baby foods
  • toddlers sometimes get constipated when they start potty training – this is an especially important time to make sure your child doesn’t get or stay constipated, or it will interfere with potty training

Again, be aggressive if your child becomes constipated when potty training. It is easy to imagine that your toddler is not going to want to have regular bowel movements on the potty if he associated them with pain.

Children with Constipation

Although it is typically harder to recognize, because you likely don’t know how often they are going to the bathroom, constipation is common in older children too.

Common times to develop constipation might include:

  • when they start kindergarten, especially if they don’t feel comfortable going to the bathroom at school
  • after going to camp, on a trip, or any other situation where their diet and routine might have changed
  • after a brief illness, especially if they took or are taking a medication that might have constipation as a side effect
  • during a period of stress, such as starting a new school, moving to a new house, bullying, or social changes (divorce, death in the family, etc.) at home

It is so common, you might even want to watch for constipation at those times, especially if your child has had issues with constipation in the past.

Hard To Control Constipation

Most parents know how to treat simple constipation – more fluids, more fiber, stool softeners, and the occasional glycerin suppository or pediatric enema (the last treatments should likely only be used when nothing else is working and your child is uncomfortable).

But what do you do when that’s not enough?

To help treat kids with hard to control constipation, it usually helps to:

  • make long term changes to your child’s diet, including more fluids (especially water), less fat,  and more fiber, as kids with constipation may have a diet high in fat and low in fluids and fiber
  • make long term changes to your child’s behavior, encouraging him to sit and try to go to the bathroom after breakfast and dinner, but not making him sit until he goes
  • encourage your child to be physically active
  • continue your child’s daily maintenance constipation medicine (usually polyethylene glycol (PEG), lactulose, Milk of Magnesia (magnesium hydroxide), or mineral oil) until he is having a soft stool each day for several months and continues having a daily soft stool as you gradually decrease (over several months) and then stop the medicine (stopping a laxative as soon as kids begin having regular bowel movements is the biggest mistake that parents typically make when their kids are constipated)
  • consider a clean out regimen over a few days if your child is very constipated, using high dose polyethylene glycol or magnesium citrate, which unfortunately might cause some diarrhea as a side effect of getting a lot of hard stool out

What do you do if your child relapses? You usually just start over, especially if the relapse is because you stopped one or more of your child’s constipation treatments.

If your child relapses even though you had been consistent and had been continuing all of his previous treatments that had been working well, you might consider:

  • switching to an alternative to cow’s milk, like almond or soy milk, as some people think constipation can be due to a cow’s milk protein allergy, plus they will likely be lower in fat than cow’s milk
  • increasing the dose of stool softeners and make sure that you don’t stop them too soon
  • avoiding treatments that have not been found to be helpful, including very high fiber diets, prebiotics or probiotics, biofeedback and other alternative treatments
  • avoiding suppositories and enemas, as oral constipation medicines are just as effective and will be better tolerated by your child

Your pediatrician and/or a pediatric gastroenterologist can be helpful if your child has hard to control constipation. In fact, up to 25% of the visits to a pediatric gastroenterologist are for constipation.

For More Information on Constipation

The Numbers Behind Keeping Food Safe

Learn the numbers behind food safety to help keep your kids safe from poisoning.

Learn the four basic steps to keep your food safe from germs.
Learn the four basic steps to keep your food safe from germs.

There is no safe food when it comes to food poisoning. Eggs, fruits, meats, vegetables and even organic sprouts can all become contaminated.

That makes it important to learn how to keep your food safe.

Although many things are being done to reduce contamination before food gets to us, it is just as important to prepare, cook and store food properly so that our kids don’t get sick.

Food Safety Numbers

There are some numbers related to food safety that you might be all too familiar with – about 48 million people get sick from food poisoning each year, sending 100,000 people to the hospital, and causing about 3,000 deaths

Reducing food poisoning is a “winnable battle” though, according to the federal Centers for Disease Control and Prevention. But of course, safe food doesn’t just happen. It takes a little work, starting with understanding some of the other numbers associated with food safety, such as:

  • 4 – the number of steps to proper food safety – clean, separate, cook, chill
  • 0˚F – the temperature to set your freezer (0˚F or below)
  • 40˚F – the temperature to set your refrigerator (between 40˚F and 32˚F)
  • 140˚F – the temperature you should keep food after cooking
  • 145˚F – the minimum internal temperature to cook pork, fresh ham, steaks, roasts, chops and other whole meats (cook to the right temperature)
  • 160˚F – the minimum internal temperature to cook egg dishes and ground meat (cook to the right temperature)
  • 165˚F – the minimum internal temperature to cook poultry and reheat leftovers (cook to the right temperature)
  • 3 minutes – the amount of “rest time” you should wait to make sure harmful germs are killed after cooking food, which is especially important after cooking steaks, roasts, chops, fresh pork and fresh ham. Don’t just heat and eat your food.
  • 2 hours – the maximum about of time that perishable food should be left out before you put it in the refrigerator
  • 90˚F – the outside temperature that should alert you that you need to refrigerate perishable food after just one hour, instead of the usual two hours
  • 20 seconds – how long you should wash your hands before, during and after preparing food and before eating.
  • 4 hours – the amount of time that a refrigerator will usually keep food cold if the power goes out and the refrigerator door is not opened. After that time, throw out perishable food that has been above 40˚F for two hours or more.
  • 3 to 4 days – how long most leftovers can be safely stored in the refrigerator
  • 15 to 20 – the number of Salmonella cells in undercooked food that can cause food poisoning
  • Less than 5 minutes – how long it takes to report a case of food poisoning to your local health department so that you can help to prevent a larger outbreak.

How can you tell the internal temperature of foods that you are cooking? Use a food thermometer, as you can’t tell when foods are safely cooked by simply looking at them.

And be on the alert for food recalls, to make sure that you don’t have contaminated foods in your home.

What To Know About Keeping Food Safe

Do all of these numbers sound too hard to do or keep up with, especially when you are trying to have fun at a cook out or family dinner?

Remember, it is better than the alternative, 2 to 10 days of vomiting and diarrhea because your family developed symptoms of food poisoning…

For More Information on Food Safety Numbers:

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Fire Ant Bites

Learn how to treat and avoid fire ant bites and stings.

A classic fire ant mound popping out of a nice green lawn.
A classic fire ant mound popping out of a nice green lawn. Photo by Bart Drees.

Are you worried about your kids getting bit by fire ants?

If not, then you don’t live in Alabama, Florida, Georgia, Louisiana, Mississippi, or Texas, where they have been around for a while.

Fire Ants

Fire ants are thought to have been imported on ships into Mobile, Alabama from South America. They have continued to spread ever since, lately making it as far as eastern New Mexico, the southern half of Oklahoma, and parts of California.

Like imported killer bees, fire ants are more aggressive than native ants.

Many of us get annoyed when we see large fire ant mounds pop up in our yards after it rains, but it can be really concerning one or more fire ants bite or sting your child.

Symptoms of Fire Ant Bites

While many insects bite, it is the classic behavior of fire ants that can make their bites so much worse.

When disturbed, fire ants emerge aggressively, crawling up vertical surfaces, biting and stinging “all at once”.

Texas Imported Fire Ant Research and Management Project

In a typical situation, a toddler or preschooler steps on a fire ant mound in the yard, and before you know it, dozens of fire ants are covering their feet and legs. Or they fall onto the mound, with the fire ants all over their hands and arms.

As you scramble to move your child and get the ants off (quickly rub them off with a cloth or your own hand), they will likely all start stinging.

Multiple fire ant bites on a child's hand.
Multiple fire ant bites on a child’s hand. Photo by the Texas Department of Agriculture.

Fortunately, very few people are allergic to fire ant stings, which might trigger a whole body reaction, with dizziness, shortness of breath, and hives, etc.. The redness, swelling, and white-yellow pustule at the site of the bite are usually the normal symptoms of a local reaction to the fire ant venom.

The pustules go away over a few days to weeks. There is no need to pop or try to drain them. In fact, popping them might lead to their getting infected. It’s better to leave them alone.

After you are bit, it is going to hurt or burn for a few minutes too – that’s why they are called fire ants.

How do you treat fire ant bites?

After you remove the ants, basic first aid and treatment for fire ant bites might include washing the area with soap and then using a cool compress, oral antihistamines, and topical steroids to treat itching.

And of course, seek immediate medical attention if your child is having an allergic reaction to the bites or if it appears that the bites are later getting infected, with increased pain and swelling when you would think that they should be improving.

What To Know About Fire Ant Bites

Although fire ant bites are rarely dangerous or life-threatening, your best bet in protecting your kids is to get rid of any fire ants in your yard and in other places that they play. You might also encourage your kids to wear shoes (not sandals or Crocs) and socks when walking or playing outside.

For More Information on Fire Ant Bites

Roseola

Roseola is a common viral infection that most kids get in early childhood.

Roseola is a very common childhood infection.

It was first described in the journal Pediatrics in 1910 by J. Zahorsky.

Also called roseola infantum or exanthem subitum (sixth disease), it is caused by human herpes virus type 6 and 7. That fact wasn’t discovered until 1986 though.

Roseola is best known for causing a high fever for about three to five days, but even more characteristically, roseola often causes a rose-pink or red rash on your child’s trunk once the fever breaks.

Infections can also be asymptomatic.

There are no treatments and it rarely causes complications. Even febrile seizures that can be triggered by roseola, which happens commonly, are not thought to be serious.

Roseola, even reactivation of an old infection, can be a serious for children or adults with immune system problems though, especially those who have had a stem cell transplant.

What To Know About Roseola

Roseola is a common viral infection that most kids get in early childhood. The biggest problem when having roseola is that by the time you get diagnosed, because the fever is gone and your child has a rash, it is basically over.

For more information:

Vaccine Preventable Diseases

Kids routinely get 13 vaccines that protect them against 16 vaccine preventable diseases.

There are over 25 vaccine-preventable diseases, including:

  • Anthrax – military use only
  • Adenovirus – military use only
  • Cervical Cancer (HPV)
  • Cholera
  • Diphtheria (DTaP)
  • Hepatitis A
  • Hepatitis B
  • Hepatitis E
  • Haemophilus influenzae type b (Hib)
  • Influenza (Seasonal Flu)
  • Japanese Encephalitis (JE) – travel
  • Measles (MMR)
  • Meningococcal disease (MCV4 and MenB)
  • Mumps (MMR)
  • Pertussis (DTaP)
  • Pneumococcal disease (Prevnar 13 and Pneumovax 23)
  • Poliomyelitis (IPV)
  • Rabies – after bites
  • Rotavirus
  • Rubella (MMR)
  • Shingles (Herpes Zoster) – for seniors only
  • Smallpox – eradicated
  • Tetanus (Tdap)
  • Tick-borne encephalitis
  • Tuberculosis (BCG)
  • Typhoid Fever – travel
  • Varicella (Chickenpox)
  • Yellow Fever – travel

Of course, kids don’t actually get vaccinated against all of these diseases.

They do routinely get 13 vaccines (bolded above) that protect them against 16 vaccine preventable diseases.

For more information:

Breastfeeding Recommendations

The AAP recommends exclusive breastfeeding for about six months and to continue for at least the first year.

Parents often have a lot of questions about breastfeeding.

One thing that they shouldn’t question is that breastfeeding provides a number of “short- and long-term medical and neurodevelopmental advantages” for their baby.

That’s why the American Academy of Pediatrics, in their 2012 policy statement on Breastfeeding and the Use of Human Milk recommended:

“Exclusive breastfeeding for about six months…”

And for breastfeeding “to continue for at least the first year and beyond for as long as mutually desired by mother and child…”

Since the AAP has concluded that “breastfeeding and the use of human milk confer unique nutritional and nonnutritional benefits to the infant and the mother and, in turn, optimize infant, child, and adult health as well as child growth and development,” be sure you get all the help you need to effectively breastfeed your child.

And remember, if breastfeeding was easy, we wouldn’t need lactation consultants. So don’t be afraid to ask for help.

For more information:

Circumcision

The American Academy of Pediatrics policy statement has shifted over the years.

They still don’t recommend that boys routinely get circumcised though.

Instead, the latest recommendation, which was published in a 2012 policy statement, states that:

…the benefits of circumcision are sufficient to justify access to this procedure for families choosing it and to warrant third-party payment for circumcision of male newborns.

While the health benefits of getting circumcised, including prevention of UTIs, penile cancer, and transmitting some STIs, outweigh the small risks of the procedure, the AAP states that parents still need to decide if circumcision is in the best interest of their male child, thinking about their own “religious, ethical, and cultural beliefs and practices.”

Don’t get your child circumcised because you think it will be too hard to clean his intact penis and don’t get your child circumcised because you think everyone else is doing it and he will have problems in the locker room. Those aren’t good reasons.

It is also important to keep in mind that if your child is circumcised, the AAP also states that babies should be given “adaquate analgesia,” (that’s pain control) including:

  • penile nerve block techniques
  • nonpharmacologic techniques, like positioning and sucrose pacifier, can be used as an adjunct to a penile nerve block

And of course, the AAP came out with a policy statement in 2010 against the “traditional custom of ritual cutting and alteration of the genitalia of female infants, children, and adolescents, referred to as female genital mutilation or female genital cutting (FGC).”

For more information:

Helping Kids Cope With Stress

Get help recognizing signs and symptoms of stress in your kids and helping them cope when stress gets to be too much to handle.

Children, especially teens, often have stress in their lives.

Whether caused by the loss of a friend or loved one, a recent move, being teased or bullied, difficulties at home, or problems at school, childhood stress can lead to behavioral problems, anxiety, depression, headaches, drug use, and insomnia, among many other symptoms and medical problems.

Other symptoms of stress can include mood swings or temper tantrums in a younger child, withdrawing from friends and family, and aggression.

What Causes Kids to Have Stress?

Unfortunately, the source of stress for a child is frequently not so easy to recognize and parents are not always very good at noticing things that could be stressors, which can include things like:

  • a change at daycare for preschool age children, including attending daycare for the first time, moving to a new room, having a new teacher, or changing to a new daycare, etc.
  • having too much homework
  • being over-scheduled with sports and other extracurricular activities
  • having expectations for his performance that are unrealistic and too high or a fear of failure, despite of having good grades, having a lot of friends, etc.
  • a divorce or death in a friend’s family, which can raise fears that the same thing could happen to his own parents
  • poor self esteem
  • watching something stressful on the news, such as a school shooting, terrorist attack, or natural disaster
  • a chronic medical problem, like asthma or diabetes, or an acute medical problem, like a burn or broken leg
  • a medical problem in a family member
  • a traffic accident
  • financial problems at home

Keep in mind that common childhood transitions, such as moving to a toddler bed, starting kindergarten, going to camp, starting puberty, beginning high school, and going off to college, etc., can be very stressful for some children.

The other confusing thing about stress is that the symptoms of being stressed do not always immediately follow whatever is causing the stress and the same situations don’t cause stress in all children or even for the same child at different stages in their life.

Helping Kids Cope With Stress

Although overlooked as many parents and children look for a quick fix for their problems with stress, it is important not to overlook the importance of regular exercise, a healthy diet, and a good night’s sleep to help them cope with any problems with any stress they are having.

Other ways to help your child cope with stress can include:

  • scheduling more free time for your child, especially if being too busy is the source of her stress
  • spending quality time with your child and give them plenty of opportunities to talk about their worries and problems
  • eating dinner together each night as a family and having other routines or rituals that you stick to on a regular basis
  • helping your child set realistic expectations for himself
  • be prepared for stressful situations that you can anticipate, such as the birth of a new sibling, a move to a new city, or a parent who is going to have surgery
  • giving your child age appropriate responsibilities and allowing him to overcome simple challenges on his own without always bailing him out, which can help teach them basic problem solving skills that he will need throughout his life
  • teaching your child ways to relax, including diaphragmatic breathing, progressive muscle relaxation, visual imagery, listening to music, reading, keeping a journal, and drawing, etc.

Your pediatrician can be a good resource if your need help managing your child’s level of stress, especially if your child’s symptoms from the stress are not temporary. A mental health professional, such as a counselor, child psychologist, and/or child psychiatrist, can also be very helpful for the overly stressed child or even for a child who does not routinely handle stress well.

Sources:

American Academy of Child and Adolescent Psychiatry. Facts for Families. No. 66; Updated Feb 2013. Stress Management and Teens. Accessed May 2016.

Rotavirus Vaccines and Infections

Rotavirus is a life-threatening disease that was once very common in childhood but can now be easily prevented with either the RotaTeq or Rotarix vaccines.

Rotavirus is a now vaccine-preventable disease that can cause vomiting and diarrhea in young children.

While rotavirus isn’t the only cause of diarrhea in children, it was once the most common cause of severe diarrhea in young children.

Norovirus, several bacteria (Salmonella and Shigella), parasites, and other organisms still cause gastroenteritis (stomach flu) in children, but we don’t see rotavirus as much anymore. The National Respiratory and Enteric Virus Surveillance System (NREVSS) now reports low levels of rotavirus infection each year, with only about 5% of rotavirus tests now being positive during the peak of rotavirus season vs over 25% in the pre-vaccine era.

Rotavirus Infections

Children can develop symptoms of rotavirus symptoms about 1 to 3 days after being exposed to someone else who is sick with a rotavirus infections (the incubation period). These symptoms could include vomiting, watery diarrhea (without blood or mucus), fever, and abdominal pain. Although the fever and vomiting typically only last a few days, the diarrhea can often last at least 3 to 8 days or longer.

A rapid antigen stool test is available to test for rotavirus, but the diagnosis a typically made clinically, which means without testing and based on your child’s symptoms, especially if rotavirus infections are going around in your community.

Of course getting diagnosed with rotavirus is much less likely these days, now that we have a safe and effective vaccine.

While rotavirus was once the most common cause of severe diarrhea in children, leading to about 3 million cases of diarrhea, 55,000 hospitalizations, and 20 to 40 deaths in the United States each year, that has been greatly reduced in the post-vaccine era.

During the 2007-2008 rotavirus season, rotavirus activity decreased by more than 50% as compared to the 15 previous rotavirus seasons from 1991 to 2006. And during the 2010 to 2012 seasons, “the number of positive rotavirus tests declined 74%-90% compared with the pre-vaccine baseline and the total number of tests performed annually declined 28%-36%.”

Rotavirus Vaccines

The first rotavirus vaccine, Rotashield was quickly taken off the market in 1999 after it was found to be associated with an increased risk of intussusception, a type of bowel obstruction.

Newer rotavirus vaccines include:

  • RotaTeq – approved in 2006 and given to infants as a 3 dose vaccine series, it provides protection against five common strains of rotavirus, including serotypes G1, G2, G3, G4 and P1
  • Rotarix – approved in 2008 and given to infants as a 2 dose vaccine series, it provides protection against the most strain of rotavirus that most commonly gets kids sick

Both are live vaccines that are given orally and are thought to provide protection for at least two to three rotavirus seasons.

How good is that protection?

Completing either series of vaccines has been found to provide up to 98% protection against severe rotavirus gastroenteritis and up to 87% against any rotavirus gastroenteritis.

Infants should not get a rotavirus vaccine if they have had a severe allergic to a previous dose of the vaccine, to latex, if they have a history of intussusception, or if they have severe combined immunodeficiency (SCID).

They can usually get the rotavirus vaccine if they simply have some chronic stomach issues, like acid reflux or a milk intolerance, or if someone in the house has a problem with their immune system (just wash your hands after diaper changes). An immune system problem that is not SCID, an episode of acute, moderate or severe gastroenteritis, or other acute illness would be considered precautions to getting the rotavirus vaccine.

What To Know About Rotavirus

Rotavirus is a life-threatening disease that was once very common in childhood but can now be easily prevented with either the RotaTeq or Rotarix vaccines.

 

Sources:

American Academy of Pediatrics. Rotavirus infections. In:Pickering LK, Baker CJ, Long SS, eds. RedBook: 2015 Report of the Committee on Infectious Diseases. 30th ed. Elk Grove Village, IL: American Academy of Pediatrics, 2015

Gershon: Krugman’s Infectious Diseases of Children, 11th ed.

Live attenuated human rotavirus vaccine, Rotarix. Bernstein DI – Semin Pediatr Infect Dis – 01-OCT-2006; 17(4): 188-94.

Outbreaks of Acute Gastroenteritis Transmitted by Person-to-Person Contact, Environmental Contamination, and Unknown Modes of Transmission — United States, 2009–2013. MMWR. December 11, 2015 / 64(SS12);1-16

Tate JE et al. Trends in national rotavirus activity before and after introduction of rotavirus vaccine into the national immunization program in the United States, 2000 to 2012. Pediatr Infect Dis J. 2013;32(7):741-744.

Are Drug Coupons Behind the Jump in the Cost of an EpiPen?

The high price of Mylan’s EpiPens is getting a lot of attention lately.

In a way that’s good. Not just so that something will finally be done about high drug prices, but because more people need to know about food allergies and about the importance of having and using EpiPens. That is one thing Mylan got right. Their education and awareness campaigns not only encouraged parents to get EpiPens for their kids, but they strongly encouraged them to use them.

Just a ploy to sell more EpiPens? Not when you realize that many people are afraid to use their EpiPens, even when they are having a severe allergic reaction.

Still, they certainly got greedy with the continued price hikes.

Although we are getting used to hearing about high drug prices, they typically aren’t for drugs that your pediatrician prescribes everyday.

You were likely outraged when Martin Shkreli raised the price of Darapim to $750 a pill, but you probably still have no idea what it is used for. On the other hand, you may have or almost certainly know someone with an EpiPen.

An epinephrine autoinjector is traditionally the only treatment for people having anaphylactic reactions to peanuts, insect bites and stings, or other serious allergic reactions.

Why fuss about the cost of a life-saving drug or device? A product that can save your child’s life in a manner of seconds would be priceless to most people.

Much of the issue is that they went from costing about $100 in 2006 to over $600 today. Even last year, a set of two EpiPens (one dose) cost up to $450. So it would be nice to have that option to save lives and save money. Afterall, the very same EpiPens are much cheaper in most other countries.

Surprisingly, it has been the media and not parents or patients who are doing most of the complaining about the high cost of EpiPens. Most of us have insurance and can use a coupon to waive their copay and effectively get their EpiPens free. Those without insurance may not be able to see a doctor to get a prescription, but if they can, may be eligible for Mylan’s patient assistance program.

So who is paying full price?

Mostly people with high deductible insurance plans, at least until they realize that they might save money going with a more costly insurance plan without a deductible, especially if family members have other medical problems, like asthma.

Why asthma?

Have you priced an asthma inhaler lately? Those that you use to prevent asthma can easily cost $300 to $400 each month. A rescue inhaler can cost another $100.

Competition hasn’t helped us get less expensive asthma inhalers. You will need a coupon for that.

Drug coupon use by patients could “come at the cost of higher long-term expenses for themselves and society.” That was a warning in the New England Journal of Medicine editorial “Prescription-Drug Coupons — No Such Thing as a Free Lunch.”

Unfortunately, instead of heeding the warning back in 2013, some companies adopted it as a business model.

Martin Shkreli didn’t do anything original when he bought the rights to the antiparasitic drug pyrimethamine and rebranded it as Darapim, raising the price 5,000%.

For example, although Lupin Pharmaceuticals makes many generic medications, they chose to license Suprax, an expensive antibiotic with a coupon, as a branded generic. So while a similar generic antibiotic, such as cefdinir, might cost about $50, Suprax costs about $250 to $400 for a 10 day course. It will also likely be on the highest and most expensive tier of your insurance, which is why they offer a coupon.

Impax Laboratories, another big maker of generic drugs, takes the cake though. They are selling Emverm for $596 a pill. A chewable pill that is used to treat pinworms, with two doses over two weeks, that means one treatment to stop your child’s butt from itching can cost almost $1200 – unless you use their coupon. An inexpensive generic version of the very same medicine, Vermox, was discontinued in 2011.

It was discontinued by Teva Pharmaceuticals, who then sold the rights to the drug to Amedra Pharmaceuticals, which was then acquired by Impax.

An off-patent, generic drug, Vermox should have been getting cheaper, not having its price soar. The fact that they offer consumers free coupons, meaning they won’t actually pay for the drug, likely explains how they get away with it.

Of course, we all end up paying. There is no free lunch, except maybe when the drug reps for these companies drop off those coupons at your doctor’s office.