Ask a CHOC Doc: How do I properly use a spacer with my handheld inhaler?

Question: I suffer from asthma, and recently got a spacer for my handheld inhaler. How can I make sure I am using it properly? ­-Anonymous


A spacer is a small device that can attach onto the mouthpiece of a handheld inhaler device via the inhaler adaptor that allows you to receive the correct dose of medication with each puff. The medication fills the inside of the spacer chamber (body) and allows you to have ease of inhaling the medication through the mouthpiece.

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Once the inhaler dose has been administered, simply replace the cap over the mouthpiece and remove the oral handheld inhaler device from the inhaler adaptor port. Replace the cap over the mouthpiece of the inhaler device and store both at room temperature (68 – 77 degrees F or 20-25 degrees C) in a clean, dry area. To protect from moisture, store the handheld inhaler in a plastic zip-sealed bag.

Proper techniques to rinse mouth after using certain oral inhalers to prevent thrush:

There are certain oral handheld inhalers, referred to as inhaled corticosteroids or steroid inhalers, that can increase the risk of developing oral thrush, a fungal infection in the mouth. Thrush looks like a white, patchy rash inside the mouth and on the tongue, which can be painful and requires an anti-fungal medication to treat it. If you are prescribed a steroid oral inhaler, it’s recommended that you rinse your mouth with water and spit after each dose of the inhaler. After rinsing your mouth with water, it is best to also brush your teeth. By following these easy steps, the risk of developing this is significantly reduced.

Image: Oropharyngeal / oesophageal candidiasis (oral thrush). (2019)

If you have specific questions about your inhaler, consult your primary care doctor.


-Dr. Violet Valencia, clinical pharmacy resident at CHOC Hospital

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Ask a CHOC Doc: How can I safely gain weight?

Question: I am underweight, and don’t feel like eating sometimes. I am tired of not being able to gain weight. I tried talking to my doctor about it, but she didn’t give me a chance to explain; all she said was to eat more. When I was diagnosed with depression I wouldn’t eat as much and a part of that stayed with me I suppose. I don’t get hungry even when I want to eat. There is this supplement called Apetemin that helps people gain weight by making you feel hungry and slowing down your metabolism. Would you recommend it? -Anonymous


Identifying and maintaining a healthy weight is an important discussion, and a common one I have with teen patients. Here’s what I usually discuss with my patients:

  1. How to determine a healthy weight

To determine whether someone is medically underweight, doctors use a tool called Body Mass Index, or BMI. This is a calculation that uses height and weight to estimate how much body fat someone has. Doctors use it to determine how appropriate a someone’s weight is for a certain height and age. There are online tools to help you calculate your BMI at home.

BMI is the most common measure about what weight is appropriate for someone’s height—but there are exceptions to this guideline. BMI is not always the best measurement for everyone. To determine a healthy weight for you, have a conservation with your doctor. Work with them to identify a healthy weight.

  1. How to know when skipping meals is a cause for concern

It’s ok if you skip a meal every now and then because you’re stressed or sick. That’s normal. Some days our bodies are hungrier than others, and that’s ok. If skipping meals becomes a regular thing, or if you’re unable to complete meals on a regular basis, talk to your doctor. If you’re also experiencing stomach problems like vomiting or diarrhea, see your doctor.

  1. How appetite plays into mental health

If this feeling of not being able to eat accompanies sadness, worry or sadness, speak to your doctor. You can also speak to a trusted adult like a school counselor who can help you find a psychologist or other mental health professional. Depression and anxiety are common problems that can cause changes in appetite and eating. These are chronic problems that can have times where they’re pretty severe, and other times where symptoms are not present, but they can still affect your appetite or mood. It’s important to have an ongoing conversation with your physician about your mental health. They can help you find the resources you need, including a psychologist.

  1. Be cautious with supplements

If you are underweight and having trouble eating, your doctor may recommend seeing a nutritionist for recommendations on food and supplements. Always discuss supplements with a provider, as they are not well regulated and need to be taken under the supervision of a doctor or nutritionist.

Appetite stimulants may be prescribed, but can come with adverse effects, including abnormal changes to the immune system, nausea, stomach problems and fatigue.


-Dr. Terez Yonan, adolescent medicine specialist at CHOC Children’s

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Ask a CHOC Doc: Do I Have Endometriosis?

Question: My periods are heavier and more painful than my friends’ periods. I’ve seen a lot in the news recently about endometriosis. Is that what I have?  -Anonymous


Any time you have questions about your body, ask a trusted adult or your doctor. What you’re describing may be endometriosis, but it could be something else. It could also just mean that you have heavier periods and more cramping than your friends do (everyone’s body is different) and you don’t have a diagnosable medical condition.

If you decide you need to see your doctor, here’s more information about endometriosis, so you can be prepared for your appointment.

 What is endometriosis?

Endometriosis is a condition where the tissue that makes up the inner lining of the uterus is present outside of the uterus, or n other organs in other parts of your body. It most often occurs in the ovaries and pelvis.

What are the symptoms of endometriosis?

The symptoms from endometriosis can vary significantly from woman to woman. Some people who have endometriosis actually have no symptoms, and others suffer from debilitating and chronic pain in the lower abdomen and pelvis. It can also cause pain with periods or during sexual intercourse and may even lead to infertility.

Since this condition occurs when tissue from the inner lining of the uterus is present outside that area, symptoms can vary depending on where the tissue is. For example, with bladder endometriosis, someone can have urinary symptoms such as frequency, urgency and pain. With bowel endometriosis, you can have diarrhea, constipation and bowel cramping. If the endometriosis is in the abdominal wall, there could be a painful abdominal wall mass.

Women who suffer from endometriosis are usually diagnosed between ages 25 to 35. However, teens may suffer from endometriosis as well. It’s rarely diagnosed in premenstrual and postmenopausal women.

During a menstrual cycle, the bleeding occurs not only from inside the uterus, which is typical, but also from areas with uterine tissue outside the uterus. The blood irritates these areas in the abdomen, and the irritation causes inflammation, pain and scar tissue.

 How do I know if I have endometriosis? 

In order to definitively diagnose endometriosis, a doctor will perform a laparoscopy, where they’ll make a small incision in the abdominal wall and insert a small camera in order to view the organs in the abdomen. They will remove a small sample of tissue and review it under a microscope to confirm that it is uterine tissue that’s been growing outside the uterus.

During the procedure, endometriosis can be assigned a stage of severity, based on the location and how much uterine tissue is growing outside of the uterus.

This procedure can make a diagnosis and also treat the pain from endometriosis by removing the uterine tissues found outside the uterus as well as removing scar tissue that may be affecting the pelvic organs. Surgery can help lessen the impact on fertility.

If your doctor suspects you might be suffering from endometriosis, they may choose to first explore non-surgical examinations before considering a laparoscopy. Your doctor may order an ultrasound to evaluate your anatomy and look for ovarian endometrioma (large, fluid-filled cysts), in addition to reviewing your medical history and conducting a physical examination. An assumed diagnosis might be made without surgery, but response or lack of response to treatments cannot confirm or exclude the diagnosis.

What is the treatment for endometriosis?

The most commonly prescribed medication is a non-steroidal anti-inflammatory drug (NSAID) such as ibuprofen. It is important to take the right dose as prescribed by your medical provider for adequate treatment of inflammation and pain relief. The use of cyclic hormonal therapy can be used for pain management. This includes using oral hormonal pills, commonly called “birth control,” or injection Depo-Provera to suppress menstruation and changes in uterine tissue, thereby decreasing pain. Another treatment option is the use of gonadotropin releasing hormone (GnRH) agonists, which can help stop the bleeding by decreasing estrogen production. Some side effects of GnRH agonists include menopause-like symptoms like hot flashes, mood changes, vaginal dryness and bone thinning, among others.

Medication should be trialed for at least three months. If there is no improvement to medical therapy within this trial period, your doctor may refer you to a gynecologist, and a laparoscopy surgery should be considered.

If there is any concern regarding a chronic pelvic pain, painful periods or other symptoms that are affecting your life, make a doctor’s appointment to get it evaluated!

By Dr. Janice Koh, pediatric resident at CHOC Children’s and Dr. Terez Yonan, adolescent medicine specialist at CHOC Children’s

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Ask a CHOC Doc: Can I Use a Kitchen Spoon to Measure Medicine?

Question: Is it okay to use a kitchen spoon to give my child their medicine?  -Anonymous


No! Household spoons are not accurate for measuring the correct dose. Always ask the pharmacist for a syringe or dosing cup. Have the pharmacist show you which line to draw up the volume to make sure your child receives the exact dose prescribed.

 If you’re ever unsure about something regarding your child’s medication, ask your pharmacist! You can call a 24-hour pharmacy any time you need more information about a side effect, how to give your child their medication, or to ask if it should be taken with food.

-Whitney Pittman, clinical pharmacy resident at CHOC

Whitney Pittman, clinical pharmacy resident at CHOC

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Ask a CHOC Doc: Are Heart Palpitations Dangerous?

Question: Sometimes I experience heart palpitations. I want more information on what exactly causes them and if I can do anything to reduce their frequency. At what point should I mention this to my doctor?  –Anonymous


A heart palpitation is the feeling of your heart beating too fast, skipping a beat, or fluttering in your throat, chest or neck.

Palpitations, also known as irregular heartbeats, are most likely caused by non-heart-related triggers. Strenuous exercises as well as strong emotions of anxiety or stress, most common among the younger generation, are frequent causes. Consuming caffeine, nicotine, alcohol, certain herbal supplements, cold and cough medication, or asthma medication, which all contain stimulants, as well as illegal drugs such as cocaine are common triggers. Some people report having palpitations after certain heavy meals that contain large doses of carbohydrates, sugars or fat. Sometimes, eating foods with excessive amounts of sodium can bring them on as well. However, some palpitations are caused by actual medical conditions including cardiac arrhythmias, thyroid disease, anemia, low blood pressure, fevers, and dehydration. If palpitations ever occur with chest pain, exercise, or fainting, this could represent a cardiac arrhythmia, and you should notify a physician.

Changing your diet is another key factor in reducing heart irregularities. Cutting back on caffeine intake such as tea, coffee, sodas, and energy drinks can be quite effective.  As a replacement, drink more water. Dehydration can lead to decreased blood pressure which triggers the body’s compensatory response of adrenaline which makes your heart race. Staying hydrated throughout the day can keep your heart rate normal.

If your heart is racing unexpectedly, there are also several things you can try at home to reduce your heart rate. Vagal maneuvers are ways to send anti-adrenaline signals to your heart and blood vessels. These maneuvers include “bearing down,” blowing through a straw, forceful coughing, and placing ice or cold water on your forehead or neck, among others. Sometimes even headstands accomplish the vagal maneuver! These actions stimulate the vagus nerve, which is the nerve that connects your brain to your heart and helps control the rate at which your heart beats. If these maneuvers make your palpitations stop abruptly, that is a good thing, but it also means that you are likely to have a primary cardiac arrhythmia, like supraventricular tachycardia which requires further evaluation and treatment. If palpitations continue despite vagal manuevers, contact your physician or seek medical care.

Palpitations are most likely harmless; however, it is important to know when it is time to see your doctor. When palpitations are accompanied by severe shortness of breath, fainting, chest pain or discomfort, or dizziness seek immediate medical attention. When your heart is beating too fast, it causes your blood pressure to drop which could potentially lead to fainting. Fainting due to low blood pressure can be a possible sign of a heart problem such as a cardiac arrhythmia, congenital heart disease or a heart valve defect. Palpitations accompanied by these other symptoms are also known to have been related to cardiac arrest, strokes, coronary artery disease, heart muscle problems and heart failure.

Here are some helpful questions to keep in mind before seeing your doctor:

  • Is the onset abrupt or gradual?
  • Check your pulse once your heart starts palpitating. Is your heart beating fast or slow? Is it beating at regular intervals or irregularly?
  • During palpitations do you feel dizzy, short of breath, or experience chest pains?
  • How often do your palpitations occur and for how long?
  • What are you doing when they start? Exercise? Calm and relaxed?

Is there anything else unusual about when your palpitations start? Are you sick with fevers, vomiting or diarrhea? Have you consumed less water that day? Are there other stressful and/or unusual events occurring in your life?

Dr. Anthony McCanta

-Dr. Anthony McCanta, a pediatric cardiac electrophysiology specialist at CHOC

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