Quest for Health

Why all the paperwork?

2012-03-02T06:47:00.000-06:00

Every doctor's visit involves so many things-- many of which are behind the scenes. All patients want is good, timely care, but there are other things that are important too. Much of what our front office and billing staff do is never really noticed by patients. Yes, they check you in and collect your co pay. They schedule your follow up appointment. They make small talk.

You might not realize that between checking in patients they have many other tasks to keep them busy. One such task is to look ahead to the following week's schedule to check for incomplete information in charts to flag them for the upcoming visit.

We have always required that patients have a current patient information form filled out at least once a year. (Please complete one sooner if your information has changed.) This is actually required to comply with many insurance company contracts. In my opinion it is irresponsible of us to provide care without correct up to date contact information. We typically ask all new patients to fill out a form and for a new form with each well visit after 1 year of age. Those who have not had a well visit in the previous 12 months are at the highest risk for having an out of date form due to the complexity of checking patients in and checking their chart for up to date paperwork. Please keep up with your child's well checks!

While the information doesn't change often and it seems you shouldn't need to fill out another form, it is very important that everyone has an updated form yearly. It is not uncommon for us to try to reach a patient's family and we have the wrong information. In recent years many families have dropped their land line, yet the main contact number we have on file is that number. This means you miss your appointment reminder call. We have a hard time calling with lab results. We cannot reach you in case of an important question or result. We give referral practices the wrong contact information and they cannot call to schedule your appointment.

I know when you are checking in your baby's crying, your toddler's trying to eat the books, and your oldest kids are fighting, but it is still important that we have your updated patient information. Too often parents omit parts of the form and we are left with incomplete forms, or they simply never turn them back into the front staff.

This has become such an issue that we are now enforcing that you will not be checked in unless we have a form that has been completely filled in within the past 12 months. So even if you arrive on time, if it takes you 15 minutes to fill out your form, you will be checked in 15 minutes late. This might mean you are put behind the person who checks in with a completed form for the next appointment.

This was not an easy decision for us to make because we know that it will cause some backlog in our waiting room, which will make the providers wait to be able to see patients. That means patients will wait longer to be seen. The way we have done it for years (allowing parents to finish the forms after the nurse brings the patient to the room) simply isn't working and we need to do something different.

This new policy does not mean you must wait to be checked in. All you need to do is fill out a form in advance. They are available on our website. If you cannot print it at home, come in a few minutes before your appointment and fill yours out if it is due. We send this link to all patients prior to their well visit if they are registered on our website. (Note: each child must be registered. We do not send Johnny an email if Jenny is the one registered.) You can easily register by clicking on "Create An Account" on our Home page. Tips to create an account and add family members (additional children) are available here.

We hope that once everyone becomes accustomed to this procedure the forms will be filled out prior to appointment times so check in can proceed on time and your child will be seen in a timely fashion. Thank you for your patience and understanding and your help completing forms before your visit.

Help us find our STARS!

2012-02-23T08:56:00.003-06:00

Help us recognize staff who go above and beyond!

Did a nurse make your visit wonderful?

Did our front office staff member go the extra mile to help?

Nominate any staff members to help us show our appreciation when our staff does a GREAT JOB!

We know the biggest reward of doing a job well done is the satisfaction of doing it, but we want to give extra recognition to our staff for special efforts.

If you're in the office, fill out a STAR Reward Form. You can also post kudos on our Facebook wall for all to see and we will take care of the rest!

Thank you for helping us support outstanding service!

Play it Safe!

2012-02-22T22:07:00.002-06:00

As the Spring sport season approaches, it is a good time to review the importance of playing safe to prevent injuries. Parentswant their children to grow up to be well rounded academically andphysically. A great way to be physicallyfit is to participate in sports, but often kids do too much too soon or playwith an injury- which can lead to worsening the injury and removal from the game. Unfortunately by 13 years of age many kids leave sports due to feelings of inadequacy or burnout. They lose the many benefits of athletics, including physical exercise, mental well being, drug abuse prevention, and more. Most young kids should not play at an elite level. Not all will be natural athletes, but all can and should participate in life long sports to varying degrees. Emphasizing having fun while improving performance can help kids feel less pressure to win and be the star athlete, but even the star should emphasize fun at younger ages!

In generalthere are two types of injuries: acute and overuse. Overtraining syndrome is a mental as well as physical issue that can lead to decreased performance and sports burnout. Acute injuries are commonlyrecognized, and include things such as sprained ankle, wrist fracture, orconcussion. Overuse injuries are lessoften identified and are more difficult to diagnose. They occur subtly over time from repetitivetrauma to the bones, joints, and tendons. Examples include little league elbow, gymnast wrist, or stress fractures.

Acute Injuries: Although not all injuries can be prevented, you can decrease the risk of acute injuries by adhering to the rules of the sport and the sport-specific safety measures recommended. If injury is suspected, removal from the sport until injury is healed is important to prevent further injury.

OveruseInjuries: Inthe child and adolescent, overuse is the cause of up to half of all pediatricsports injuries. It is bone, muscle or tendon microtrauma caused byrepetitive stress without adequate healing time. It begins with painafter activity, then pain during activity without affecting performance,followed by pain during activity that affects performance, and finally paineven at rest. Children are at increased risk because of their growingbones and inability to recognize or describe symptoms.  

OvertrainingSyndrome (“burnout”) is the psychologic, physiologic and hormonal changesthat lead to decreased performance. Symptoms include chronic muscle orjoint pain, personality changes, increased heart rate at rest, decreased sportsperformance, fatigue, lack of enthusiasm, and inability to complete usualroutines. Prevention includes encouraging a variety of sports throughoutthe year, making workouts interesting and fun and having athletes take 1-2 daysoff per week, plus 2-3 months off per year for other activities. Overtraining can lead to burnout in the early years, which can cause a child toend participation in sports altogether, which may cause inactivity andcontribute to the obesity epidemic in our country.

In general, injury prevention begins with making sure your child is playing in a safe environment with a knowledgeable coach and well fitted safety gear. My favorite tips:

Remember that many coaches are volunteers with little (or no) specific training. Don't assume the coach knows how to prevent or treat injuries... you should ask what their experience is! Be sure there are always at least 2 adults around (this is abuse prevention... another topic entirely, but important!)
Encourage athletes to take the time to warm up and cool down.
Make sure athletes drink plenty of water, especially in warm weather.
Be sure they are playing at a level that meets their skills.
Let them know that they should enjoy playing for the fun of the game, not to win.
Be sure to remind them that you enjoy watching them play ~ not watching them win!
Have kids take time off a favorite sport to try something different for a season. This not only keeps the game fun, but it works different muscle groups and improves overall fitness.
I am also a firm believer in sleep for kids of all ages! Sports practices and games can interfere with an appropriate bedtime and adequate sleep, so make sure your child doesn't suffer from sleep deprivation.

American Academy of Pediatrics Guidelinesand Recommendations Include:

Athletes should take 1-2 days offper week from competitive athletics and competitive practice to allow physicaland psychological recovery.
Athletes should be a member of onlyone sport per season.
Athletes should take at least 2-3months away from a specific sport during the year. During this timeanother fun activity can be done to prevent loss of skills or conditioning.
The focus of participation should befun, skill acquisition, safety, and sportsmanship.
Weekly training time, number ofrepetitions or total distance should not increase by more than 10% per week.
Watch for possible burnout if theathlete complains of nonspecific muscle or joint problems, fatigue or pooracademic performance. Consider time off at that time to allow physicaland psychological recovery.
Use caution for younger athletes whoparticipate in multiple games during a short time period.
Children should participate in a sport at a level consistent with their ability and interest.
Single sport specialization should be avoided before puberty. Young athletes who participate in different sports at various seasons have less burnout and fewer overuse injuries.
Parents should be aware of the coach’s knowledge of proper training techniques, equipment and training of a particular age group. Parents should encourage organizations to mandate coach training in these areas.
Never allow an injured athlete to participate in activities until completely healed or cleared by a physician.
Children are more at risk for heat injury. Proper hydration should be encouraged. Avoidance of prolonged activity in moderate temperatures or any activity in extreme temperatures should be enforced.
Ensure proper nutrition:

Propercaloric intake is based on body size and growth rate in addition to caloriesburned. Monitor for signs that the athlete is trying to lose weight tobenefit performance (to the detriment of overall growth).
Balancenutritional elements based on the Food Guide Pyramid.
Adequateiron is needed. The amount of iron needed in the diet is highest duringthe growing years and sports may contribute to iron losses. Athletes needadequate iron to bring oxygen to tissues in the body.
Calciumintake is important for normal bone growth and possibly to help prevent andheal stress fractures.

Resources and References:

 PEDIATRICS Vol. 106 No. 1 July 2000, pp. 154-157, AMERICAN ACADEMY OFPEDIATRICS: “Intensive Training and Sports Specialization in YoungAthletes.” Committee on Sports Medicine and Fitness. 

PEDIATRICS Vol. 119No. 6 June 2007, pp. 1242-1245, “Overuse Injuries, Overtraining and Burnout inChild and Adolescent Athletes.” Joel S. Brenner, MD, MPH and the Councilon Sports Medicine and Fitness.

Stop Sports Injuries

Teen Dating Violence Awareness Month

2012-02-14T14:19:00.000-06:00

February is Teen Dating Violence Awareness Month, so it is a great time to learn about this all too common problem.

Teen Dating Violence is a very difficult and complex topic. Teens might share friends with their abusive partner. Their friends might think the abuser is wonderful, lending to peer pressure to stay together. They typically go to school together, so it is difficult to avoid each other entirely. Teens might fear trying to leave the relationship safely. If teens have lived with domestic abuse at home, they might even think the abuse is normal. The abusive behaviors tend to lower the victim's self esteem, making leaving feel less desirable since they feel no one else will ever care about them and a bad relationship is preferable to being alone. They often have feelings of love and attachment to the abuser, and hope that behaviors will change. Online teens can experience cyberbullying even when not with their (ex-) partner. There are often no physical signs, but the emotional scars can last a lifetime. Learning about abuse characteristics can help save someone you love from a dangerous relationship!

Nearly 1 in 10 high school students report being physically hurt by their boyfriend or girlfriend in the previous year. (CDC 2009 Youth Risk Behavior Survey)

1 in 10 = TEN PERCENT of high school kids in the past year were hit, slapped, or otherwise physically hurt by their date!

The Liz Claiborne Inc.'s Love is Not Abuse 2011 College Dating Violence and Abuse Poll showed that 43% of dating college women have experienced violent and abusive dating behaviors.

That's nearly HALF of college dating women who have been victims!

I remember as a medical student working ER shifts or in the STD clinic and seeing several college girls come in for suspected sex while drunk (they never called it rape) or after unplanned/undesired sex with a "boyfriend". They typically just wanted testing for disease, but what they really needed was much more! They had mixed emotions and were confused about who was at fault. They had a lot of guilt that really was misplaced (in my opinion).

Though females are more likely to be the victims (1 in 4 women have been assaulted by a partner), 1 in 14 men report being victims. Regardless of sex, it is likely that abusive relationships are underreported due to the nature of the problem.

We see news stories of abusive relationships but it doesn't always seem real. A new bride murdered. A teen raped. A sports figure accused. Unfortunately we don't even know about most abusive relationships. People suffer silently. How is a parent to know? Can a teen see risk factors before becoming involved with a risky personality?

Parents might look for the "type" of teen that they want their child to steer away from, but unfortunately, the abusers are not easily identified.

They typically are very smart, personable, likable people.

They manipulate others.

They gain trust.

They weave deception.

What it might look like:

The relationship typically starts out well. A lot of laughs, good times. If it didn't, people would leave. Abusers have a power and control cycle that builds over time. They gain a little trust, then test with a little control.

Bit by bit they become more controlling and abusive. It builds so slowly many people miss the early warning signs and then are so swept by the cycle that it is hard to leave.

Abusers want to know your every move, which at first might even seem flattering, but it is a control tactic. They might chose what you wear or where you go. They monitor your phone calls to see who you talk to. They isolate you from your friends and even family so you lose your support group. They put you down so you feel no one else would like you or want you. They make you feel less of a person and they are "good" to put up with you.

They get jealous (again, flattering on the outset because they "care"). They often apologize for hurting you, but then claim it is your fault that they behave that way. In truth, they blame others for most of their behaviors and only take credit when things make them look good.

What to do?

There are many levels that need to be addressed to prevent and recognize abusive relationships, starting with how we raise our children from infancy and continuing throughout their lives.

Children who are raised in homes with abusive behaviors are much more likely to grow up to be in an abusive relationship. If your home is not safe make every attempt to make it so. Stop the cycle!

Abusers often monitor your computer and phone use, so use caution.

From a safe computer, click here if you are in the KC area. From a safe phone call 913-262-2868 (phones answered 24/7 confidentially at SafeHome).

We need children to feel loved and secure. Children who feel unloved might look for love in all the wrong places, trying to please others and end up being taken advantage of. Love unconditionally!

Kids need defined limits, but an ability to learn and grow into independence with experience. Being firm and setting boundaries is an important part of being a loving parent. You are NOT their friend. You don't need to be a friend to be an effective, loving, parent who is well loved and respected.

Kids need help learning to stand up for themselves and to deal with anger and disappointment in a healthy way. Set an example for this. Life typically presents many opportunities to model these behavior. If you have not learned to control your temper, learn. Ensure enough sleep for everyone at home, as we are all more short tempered when tired. Choose words carefully. Remain calm. Of course you can't be a pushover either. There is a way to stand firm in your position without yelling and losing your temper. There are many self-help books on this topic and counseling is available. It is that important!

Kids need to learn to accept responsibility. Responsibility should grow as kids grow. They should have appropriate consequences that teach lessons along the way.

Remind teens that they are never to blame if someone forces them to do something sexually they don't want to do. They need to feel open to share this pain with you or another trusted adult so they can get the help and support they need.

Kids need respect. Do unto others as you would have done unto you. These words of wisdom have passed through the generations, and are needed as much now as they were generations ago.

They should be taught to respect themselves in all they do: eat nutritionally, exercise, get enough sleep, wear helmets, buckle up, stay away from drugs, etc.

They should be taught to respect others: say nice things, don't ask others to do things that might cause them harm, respect their personal space and things, etc.

They should enforce that others treat them with respect. If a friend does not treat them with respect, they can try first to talk with the friend about it if they feel safe doing so. If the friend does not change behaviors, they should leave the friendship.

How can parents and teens recognize signs of potential abuse? Use your instincts. If you suspect something is not right, act on your hunch and take action to address issues and leave the relationship early if problem behaviors persist. Get help from local resources as needed.

Things to watch for with an abusive relationship:

Relationship moves quickly to "serious"
Jealousy in the relationship
Frequent calls, texts, and other contacts
Control issues in the relationship
Isolation from family and friends
Mood swings, anxiety, or depression
Physical signs: bruises, cuts, scrapes, showering immediately when coming home
Verbal criticisms are overheard: stupid, fat, ugly, no one else would put up with you, etc
Abused feels guilty and "at fault" and makes excuses for their partner
Personality changes in the abused
Drug or alcohol use
Multiple sexual partners

What are signs of an abusive personality or one who is likely to abuse? Abusers do not look like drug dealing, tattoo covered, pierced people in tattered clothing. They are difficult to recognize on first glance because they tend to be popular, good looking, and personable. They are often *good at reading people and responding to other's desires, making them seem "perfect" initially.

Traits to watch for in an abuser:

One who blames others for all problems
One who wants to move quickly into a relationship
One who does not respect personal boundaries
One who is easily jealous
One who is insulting (you're fat, you're stupid, no one else would love you like I do)
One who has a history of hitting or hurting others
One who criticizes others
One who takes little personal responsibility for actions
One who tries to monopolize your time and life
One who seems perfect initially (no one's perfect!)
One who has mood swings or can't manage anger or frustration well
One who takes big risks and is impulsive
One who wants to control what you wear, who you are with, and what you do

Where to go for more help:

Be Smart. Be Well

Centers for Disease Control and Prevention

Love Is Not Abuse

National Network to End Domestic Violence

Safe Home

Teen Dating Violence

Recurrent Strep Throat

2012-02-10T06:49:00.001-06:00

Rapid Strep testing

Recurrent strep throat is a problem for many families. Some kids seem to catch strep the minute it enters their classroom or neighborhood. Their parents recognize the symptoms and bring the child in immediately for diagnosis and treatment so they can get the child back to school in 24 hours (and parents can get back to work).

The problem with this rapid treatment approach is it doesn't allow the child's immune system to rev up against Strep. The antibiotic kills it off, and doesn't leave "memory" of the Strep bacteria. If given a few days, the body's immune system builds fighter cells to kill off the Strep bacteria. Some of these cells hang around as "memory" cells so that with the next exposure, they round up the troops and kill off the Strep before it becomes a big infection.

It's a matter of short term versus long term solutions. The short term solution is to quickly treat so everyone can get back to their routine lives, but leaves opportunity for recurrence. The long term solution is to treat symptoms to maintain hydration and comfort for a couple of days and then to treat with antibiotic. This requires more time at home and delays return to school. Which option is better for your child depends on your current needs and long term goals.

Parents chime in: Knowing the short term/long term issues with rapid treatment of Strep throat, will you take your kid to their doctor or walk in clinic at the first sign of sore throat or wait?

Remembering Vitamins and Medications

2012-02-06T21:33:00.000-06:00

Compliance taking a daily medication (or vitamin) can be troublesome for many. I find myself counseling parents and kids how to remember medicines often. Here are my favorite tips:

Use a pill box for pills. They come in various sizes and either single daily dosing or am/pm dosing, depending on your needs. Pill boxes allow you to:

be sure you have enough for the upcoming week,
remember if they were taken today,
keep several types of pills for each day together if taking more than one pill.

Liquid medicines: Wash the syringe after each use. Empty the dish drain of all contents daily so you find the syringe and remember to use it. Or put a clean syringe in visible sight where you often look (tape it to the milk jug, in a glass next to the kitchen sink, in a glass near your coffee pot). Remember the medicine needs to be out of reach from kids... not necessarily the syringe!
Refrigerated medicines: Put the medicine on a shelf that is eye-level, right in front. Don't let it get pushed to the back. Return the bottle to the fridge before giving the medicine to lessen the chance you leave it on the counter. Remind older children that can access the refrigerator that the bottle is off limits!
Keep medicine next to something you do daily (coffee, toothbrush). *Always keep out of reach of young children.*
Use a specific glass that is unique that goes from table to dishwasher to table and never is put away. Every time you empty the dishwasher, put water in the glass and set it on the table for medicine.
Refill the medicine 1 week before you run out. This allows you flexibility in case you forget to pick it up. It also allows recognition that there are no refills if that was missed, giving one week to see your doctor. You can have enough for vacations if you routinely do this, since you can only fill one week earlier than the last fill... plan ahead if travelling!
Keep tabs on number of refills left. The pharmacist should let you know with each refill how many are left. If there are none, call right then to set your next appointment if you haven't already.
Set your phone or watch to alarm at the times the medicine is due. Change the tone to one that is unique to remind you.
Put a reminder on your calendar to call for refills and/or schedule appointments before the last minute.
Leave sticky notes around the house or in your bathroom and kitchen if necessary!
Keep some medication in your purse (or at the school nurse) to take if forgotten in the morning if this might still be a problem. Remember to not leave your purse in the car or other places the medicine will get too hot or cold. If the school nurse will keep some, be sure to ask for a nurse's note when getting the prescription.
If you travel often, it helps to keep an empty pill box in your toiletry bag, so when packing it you see the empty box that needs to be filled. Or you could put a sticky note in the toiletry bag reminding you to pack them.

Regular prescription medications goes hand in hand with regular follow up with your doctor to manage the medication dosing. This is important for many reasons, so I try to give as many refills that will be needed until the next visit. Ask your doctor how they handle refills before the medicine runs out so there are no delays in treatment. Remember to schedule your next visit!

If able, schedule the next visit before you leave the doctor's office. Bring your calendar to each visit!
Call as soon as you can to schedule if you don't have your calendar available at the doctor's office or you were unable to schedule for any reason.
If you notice no more refills on the bottle when picking up your medicine, call that day to schedule an appointment. The later you wait, the fewer appointment times will be available. Early morning and later in the day fill first!
If you are filling the prescription at a time that your doctor's office is closed, look for options for them to call you. Some offer online appointment requests. You can request appointments from our website at any time day or night. Leave the best numbers for us to call during business hours. Many offices have a voice mail that allows leaving a message for them to call you to schedule an appointment.

Once habits form, it is easier to remember, but until then be sure to set reminders-- especially if the medication must be taken at a certain time each day or if missed doses can be dangerous. Learn what to do if you forget a dose by talking with your doctor or pharmacist. Some medicines are fine to skip a dose, others are not so forgiving and must be taken as soon as remembered.

I hope this helps! What tricks have you learned to remember your medicines?

Walk In Clinic Etiquette

2012-02-01T06:46:00.003-06:00

Cold and flu season always brings more people to the doctor or health clinic. The pure volume can be overwhelming for any clinic, scheduled or walk in, but the nature of walk in clinics makes the volume unpredictable. Sometimes no one in walks in, other times several come at once. Walk in clinics are wonderful for the overall rapidness at which one can be seen, but how can you help streamline the process?

1. Write down symptoms. It sounds crazy to write down things since you know your child better than anyone, but if your child is sick you are probably sleep deprived and might forget important details. Writing things down helps everyone summarize what is going on and get facts straight. Very often the diagnosis lies in the history, and if the person bringing the child in does not know symptoms well, it is difficult to make a proper diagnosis.

2. Expect to be seen for one acute problem. Illnesses typically have more than one symptom, but they are a single illness. It is appropriate to bring a child in for multiple symptoms, such as cough, fever, and sore throat. It is not appropriate to bring them in for those issues as well as a wart and headache of 3 months off and on.

The nature of walk in clinics is that they move rapidly. The number of patients checking in at any given time can be large, so each visit must be quick. If you need more time with a provider, schedule an appointment.

3. Do not attempt to get care for a chronic issue. Chronic issues are always best managed by your Primary Care Provider (PCP). This does not include sudden changes to a condition, such as wheezing in an asthmatic. You child can go to the walk in for the wheezing, but should follow up with the PCP with a scheduled appointment to discuss any changes needed to the daily medication regimen (Action Plan) to prevent further wheezing. This is especially important if you went to another urgent care or ER for initial treatment so that your doctor knows about the recent exacerbation of a chronic issue.

4. Do not add additional children to the visit. Many parents bring additional kids to the visit and ask if we can "just take a peek" in their ears. If you want them seen, check them in too. Again, walk in clinics move quickly and the "quick" peek takes longer because the child is running around the room or fighting the exam. The quick peek also does not allow for documentation of findings in the medical record, which might be helpful in the future.

5. Have your insurance card and copayment ready at check in. Streamline checking in by having everything ready. It is amazing to me how many people must return to their car for their wallet.

6. Try to bring only the child who is being seen. It is difficult to focus on one sick child when another is running around the room, falling off the exam table, or constantly asking questions. This applies to scheduled as well as walk in visits. I know this becomes a childcare issue, but it can really help focus on the child being seen.

7. Bring medications your child has recently taken. Often parents have tried treatments at home, but are not sure what was in the bottle. Bringing all medications (prescription and over the counter) and supplements helps us advise on correct dosage and use of the medications.

8. Go to a walk in clinic at your regular doctor's office if available. I know not all doctor's offices have walk in hours and most are not open all night long, but most walk in type visits are not emergent, they can wait until the next business day. Treating symptoms with home remedies is quite acceptable for most illnesses for a couple days. This might even be beneficial to improve the immune system's ability to fight illnesses and to see how the symptoms change over time. Some kids are brought in at the first sign of fever, and look normal on exam, only to develop cough and earache over the next few days. When the symptoms change, so might the exam and treatments!

The benefits to going to your regular doctor's office to see your PCP or another provider with access to your child's medical record are many. The record has your child's immunization history, previous drug reactions, any underlying illnesses or frequency of illnesses (as long as you use them exclusively), as well as any other pertinent information. Primary Care Providers and their staff also know your family and that alone can help!

Some walk in centers limit services or ages of patients. The provider at the clinic may or may not have adequate training in pediatrics, and they often do not have others around who can help if a problem arises that is out of their comfort zone. If a baby is crying, the eardrum gets red, but isn't necessarily infected. A provider without a lot of experience will often err on calling it an ear infection. Giving a prescription for an antibiotic makes parents happy, regardless if it is necessary. Better satisfaction scores for the clinic. Faster turn around time since it takes longer to explain how to treat a cold than it does to write a quick script. Everyone's happy, but antibiotics are overused. They also do not offer follow up of issues to see if there is improvement. They do not take phone calls if there is a followup related question. You must call your PCP, but if we haven't seen the child for the issue, we are unable to give appropriate advice.

There are gaps in care even at urgent cares where there is a pediatrician or midlevel provider with extensive pediatric training (there is more than one option in this area). They do not know your child's full medical background and do not update your child's health record in the medical home. Following in one office allows us to see the chronicity or recurrence risk of an issue. If your child goes multiple places for every sore throat, the PCP only sees him for well visits and no one recognizes that a tonsillectomy might be beneficial.

9. Please don't use walk in clinics to have health forms filled out. I know it is tempting to get a quick physical just to have the sports form or work physical signed, but this breaks the concept of a medical home. Your regular doctor doesn't get to see you for a comprehensive visit, reviewing growth, development, safety, immunization status, and more. We lose the opportunity to share what has happened in the past year and continue our relationship. If the medical home does all the well visits and vaccines, we have up to date records and can update as needed. Some kids have missed school because vaccines were missed and they can't return until they get them. Others have gotten extra doses of vaccines because a record of a shot was missing and parents can't remember where they got the vaccine. We request a well visit yearly (after age 2) within the medical home. If in need of a well visit, please call the office to schedule!

When To See Your PCP?

2012-01-21T10:11:00.002-06:00

We have many kids who come in for what I consider "band aid" medicine. We only see them when they have a problem. They never come in when well so we can know more about them: what they enjoy doing, what good (and bad) habits they have, if they are growing properly... you get the idea.

I understand that it is time and money to visit the doctor's office, but it is time and money well spent. Sometimes it isn't obvious that this is an investment that benefits in the long run, but preventative care has been shown to be worthwhile! I typically feel that I give inferior care to kids I rarely see because I only see them when they are sick, and can only focus on the current problem, not the overall health. You can't use a band aid to fix a broken bone or high cholesterol. Without proper evaluation, you don't even know you have some health problems. Even our cars get better care: people do routine maintenance checks on their car every 3-5 thousand miles, they don't just call the service station when it won't start.

Many problems have few or no signs or symptoms until they become severe. Anemia, elevated lead levels, high blood pressure, growth problems, and behavior concerns are some that we typically only see when critical if kids don't come in for recommended visits or do recommended testing. Some parents fail to bring kids to the lab or other facility for recommended evaluations. This can delay diagnosis and puts kids at risk.

There are kids who visit urgent cares often, yet never come in for routine care. It may be years between visits with the primary care provider (PCP). "PCP" is used broadly here, since the primary care isn't done. I understand that sometimes it is because kids wake in the middle of the night and the parent wants a quick fix, parents don't want to take off work so go on weekends, or the drugstore with a clinic is on the way home, but this isn't good care on many levels.

I don't always trust an outsider's assessment of certain physical signs. Studies show parents are much happier with a diagnosis of "ear infection" and a prescription than an accurate assessment of a viral respiratory infection and instructions on home remedies. Many ear infections are over diagnosed, leading to inappropriate antibiotic use, despite better parental satisfaction. It benefits a practitioner who will be evaluated with patient/parent surveys to provide a prescription rather than an accurate assessment and instructions. It also takes less time to write a quick script than to discuss the diagnosis, when to follow up if worsening, what to do to help symptoms, etc. Less work and more satisfaction, sounds good, but...

I don't know if the provider has enough experience with infants/young children to recognize what is really going on. I'm sure some of the people working urgent cares are really good at what they do, but many have little experience when they start working without supervision. They have no one to ask for a second opinion, so even after years of working they haven't developed the same skills as a practitioner working with more experienced providers who are able to help when needed. Bad habits can be reinforced because they simply have no way to learn better skills.

Quick treatment of some infections that really do need treatment leads to poor immune memory, increasing the reinfection rate. Strep throat recurrences have been shown to happen more when kids start treatment with less than 2 days of symptoms. There is benefit to waiting! Strep should be treated within a week to prevent complications, but allowing the body a couple days to fight it off first builds the immune system! It is okay to wait until office hours for many (if not most) problems.

Difficulty breathing, dehydration, altered mental status, many injuries, and other things do require emergent care. If your parent alert system is telling you your child needs to be seen, then an ER visit is appropriate.

Keeping a good timeline of infections helps the PCP know when it is time for more intervention, such as ear tubes or prevention medications. If quick fixes are always at another location, we might not recognize the frequency. Even when parents bring kids in with a history of frequent infections we can't make appropriate recommendations because we might not trust the diagnoses. Parents might not ever be told that their child has asthma that needs a prevention medication, so they simply keep using the quick relief inhaler, which puts the child at risk for serious complications. Asthmatics who have regularly scheduled asthma visits when they feel well have fewer wheezing episodes requiring emergent visits and admissions. Improve management of frequent or chronic illnesses by visiting with the primary care provider for illnesses and when your child feels well to optimize medication use, make appropriate referrals, improve safety, and spend overall less time and money.

Recommended routine maintenance is spelled out clearly in a book that comes with every car, yet a maintenance book doesn't come with kids. Yearly exams for those over 3 years (more for infants and toddlers) are recommended at a minimum. Routine care also means regular visits to check on chronic conditions, such as asthma or obesity.

Preventative Care Guidelines are developed by people smarter than me by reviewing statistics including risk/benefit ratios, cost analysis, and more. These aren't perfect and are regularly reviewed and often change. Some recommendations are simply not followed because insurance companies don't cover the cost. Pediatricians and many others are fighting for better coverage. Examples of things recommended at various visits (depending on age):

height/weight measurements
blood pressure screenings
lab screenings (anemia, lead, cholesterol)
vision and hearing screenings
development assessments
mental health screens
more...

I'd like to think that I can make a difference with healthy lifestyles by providing regular routine care. Sleep habits, screen time, exercise, safety, and more are discussed at various well visits. This might uncover issues that need additional visits to be properly addressed, but early recognition helps improve outcomes.

I know my own kids take what others at the office (other doctors, the midlevels, even the nurses) say about safety, nutrition, and sleep more seriously than when I say it. (Never mind that I have qualifications to discuss and advise on this topic, I am just Mom to my kids!) I also recognize that I see my kids daily, but don't know their growth parameters, blood pressure, heart sounds, etc from day to day living. I bring my own children in for routine well care and follow up of health issues so that they can be the healthiest they can be. It has become routine for me to schedule their summer physicals every Spring Break. This routine helps because:

it gives plenty of time to find a time/date that fits our busy family calendar and the provider's schedule.
it is a routine, which helps me remember... yes, I forget to make appointments just like everyone else! (Others use birth dates to remember, but I prefer summer visits for many reasons.)

It is not uncommon to uncover a problem during a well visit that needs to be addressed more completely but wasn't recognized ... even by smart, educated, attentive parents. Please join me in healthy parenting and schedule routine checks for your kids! Do the tests, treatments, and follow up recommended by your provider or speak up during your visit if you don't plan on doing them, which allows for open discussion about why they should or should not be done.

Use band aides when appropriate, but treat overall health with routine visits!

Red Dye #40

2012-01-16T08:57:00.001-06:00

Image: meepoohfoto/FreeDigitalPhotos.net

A recent facebook post asked about the link between red 40 dye and hyperactivity.

Nicole Rousset Williams Pediatric Partners, PA. Overland Park, Kansas

Would love to see an article on red 40 dye and thoughts from a professional medical standpoint. As the mom of a very strong-willed child, I've gotten advice from other moms who swear this is the "poison" that creates so much difficulty in kids. Wondering how you feel..... So"What's up, doc?"

Tolerability and safety of food additives and their influence on behavior have been questioned since the 1970s after a pediatric allergist alleged that there was risk of hyperactivity due to food additives. This allergist, Dr Feingold, supported the Feingold Diet. Scientists reviewing his studies found he had no control group, limiting the validity of his study. Several other well designed studies have not found a risk except to those allergic to the food dye (FD&C Yellow No.5 leads to hives in 1 out of 10,000).

Studies attempting to show a link between food additives (including Red dye #40) have been inconclusive, inconsistent, or inadequate.

In 1982, a Consensus Development Panel of the National Institutes of Health concluded that for some children with ADHD and confirmed food allergy, dietary modification provided some benefit to behavior. They did not recommend all children alter their diet since there was no proof that it helped anyone but the small group with ADHD and food allergy.

In 1997, a review of several studies on this topic showed minimal evidence of benefit and extreme difficulty getting children and adolescents to adhere to a restricted diet.

In 2007, color additives specifically were questioned in relation to hyperactivity in a study by the UK Food Standards Agency. Both the FDA and the European Food Safety Authority independently reviewed the results and concluded that there is no substantial link between color additives and behavioral effects.

Parents could argue that simply omitting foods with additives wouldn't hurt their child, and on many levels they are correct. But...

We should all attempt to eat a nutritious diet rich in fruits and vegetables and minimize processed foods. Unfortunately, that becomes very difficult in our society. Many foods, including dairy, breads and cereals, and more have food additives. It is difficult to eliminate these entirely and continue to get a balanced diet.

Kids with true food allergies who must avoid certain foods often feel singled out and "different" or "fragile". While this is very important for kids who have direct health risks to foods, it is psychologically difficult and if not a real risk/benefit, do we really want our kids suffering psychologically?

Avoiding these foods also might allow the child to place blame on an external factor, leaving less responsibility for their action. "I ate jelly beans, that is why I am out of control today. It's not my fault."

Trying an elimination diet also might delay the initiation of seeking professional help to try things that have been shown to work, such as behavioral modification, improved sleep, routines, and sometimes medication.

I believe in recognizing real risks, looking at the risk benefit ratio, and then making a decision. If you have not noticed a difference with your child's behavior when eating only real whole foods (not from a package) then food additives likely aren't the culprit.

Behavior is very complex and is related to the child's temperament, sleep effectiveness, environment, hunger, emotional support, and more. If there was one easy solution (ie removing food dyes) parents would all be doing it!

Sources:

FDA: food ingredients and colors

FDA: Import Alert

Food Insight

Red40

New Look! New Title!

2012-01-06T21:20:00.003-06:00

My blog has a new look!

And a new title... Quest for Health

I have changed the title of my blog to further identify my mission to spread information, offer my reflections on news related to child health, and to tell of personal experiences relating to the practice of medicine.

This blog was started over the summer as a collaborative effort of the pediatricians at Pediatric Partners. Busy lives and writer's block have kept all the physicians from contributing. As a previous medical school yearbook editor and current family historian / scrapbooker, I have found a new voice and love in blogging, so will continue the endeavor on my own. Though I still plan to ask for guest bloggers... hint hint, wink wink. You know who you are!

The new format allows readers to see previous post titles at a glance and open any interesting topics easily. The background is clean and sharp, allowing an easier view on the eyes.

I am still accepting topic ideas and feedback! Post to the Pediatric Partners Facebook page if you have suggestions!

Here's to your health!

DrS

New Year's Reflection

2012-01-03T15:07:00.002-06:00

I was fortunate to be able to spend New Years with my extended family in the St Louis area. Conversation led to my mother remembering old family videos in the basement. After a little digging around, my brother found the never before seen footage!

We had a blast watching videos of past holidays and vacations.

Some things were fun to compare. My daughter is better at ballet than I was at her age.

Other things were simply laughable. Although I was impressed at my grandmother looking fit and trim in short shorts, most clothing choices of the 70s should never be repeated. What will they think of our current clothes in 30 years?

One thing that struck me sadly was the average weight of people at all ages in the 70s seemed to be less than the average weight of people the same age today. I'm not saying my friends and family have gained weight ~ I would get into trouble for that! It was simply noticeable that people of today are heavier when comparing large groups.

I've read the statistics before...

Self Reported Weight up Nearly 20 Pounds Since 1990
Mean Body Weight, Height, and Body Mass Index, US 1960-2002

... but it was interesting to see large groups of people from my past vacations and comparing to what I see daily when out and about. It made it real.

If the US is such a great nation, how have our individuals as a group gained weight in this unhealthy manner?

Is it the convenience of pre-packaged foods, many of which are processed and/or high in fat? More women work now than previously. Does this contribute to less home-cooking and more fast foods?

Is it that the meal size increasing? Large sodas of my childhood are now the smallest size available. Who needs 64 ounces of acidic bubbly sugar? We eat larger servings both at home and at restaurants.

Are we less active than we used to be? I can easily see how today's kids are tempted with tv, video games, and other sedentary activities. As a child, I only had one tv channel, and most often it had adult programming. (There were no recordings available!) I had many other things to do both in the house and outside. We didn't have many structured activities, so we just made it up as we went along. And we had a blast! What about adults? Are they less active? Do we work more hours than our parents? Do we spend more free time in front of the tv/computer than our parent's generation? What did they do for fun? Was it out of a chair?

Do we sleep enough? With many tasks to do and distractions, such as tv programming and internet available all night, do people stay up too late to get a good night's rest? More and more research supports that sleep is needed for concentration, endurance, immune functions, as well as weight control and more. How often do we feel tired?

I suspect that there are many reasons for our generalized weight gain, which means that there are many potential fixes, and not one alone will help. I have tried to limit processed foods at home, but they are convenient and easy, so I sometimes splurge. We try to eat as a family at home most nights, though activities sometimes interfere. Portion control is relatively easy for my kids: they eat minimally by nature. My husband and I need to check ourselves. My kids are much better at exercise than I am, mostly because they have time and they love to move! I don't want to forego sleep to fit in exercise. No one gave me time for Christmas... but I'm working on finding some free time!

What do you find helps keep your family healthy?

Homework Battle Plan

2011-12-27T09:04:00.000-06:00

Any parent with school aged children knows that homework can be a battle. Even good students can procrastinate, prefer to play, or have practice after school leaving little time for homework. Then there are the kids who struggle...

I think I threw my son's middle school homeroom teacher for a loop on back to school night. She mentioned that I can always look on line to see the assignments, and I replied something to the effect of, "I don't have homework, so I'll never look. It is his responsibility to know what is due." I am not an absent parent. I do ask about his day, what he's doing in class, and what his plans are with friends. He knows I care because I show interest in him, but I don't micro-manage his day. I do not want to be the parent responsible for the college kid who fails because Mommy can't manage his schedule. Of course, I know my son and he's self motivated and capable of keeping track of assignments. Another child might need more help, but at this age I would recommend covertly looking at the assignments and guiding with questions and looking for the student to offer solutions and plans to get the work done.

How can you help your kids with homework without letting it become your problem? I am a firm believer that kids are the students, not the parents. Kids need to take ownership of their homework and all other aspects of school. Of course, for many kids this is easier said than done, but I hear all too often of college kids who have Mommy call the Professor to question a grade. That is totally unacceptable. Kids need to practice ownership from early on. Parents need to guide always, but manage less and less as the kids grow.

Not every solution comes from a cookie cutter mold. Kids have different personalities and abilities. You know your kids best. Think how they work and what makes them tick.

Many parents underestimate the problem with missing out on basics: sleep, nutrition, and exercise. If kids don't get the amount of sleep they need, healthy foods, and regular exercise, they will not be as successful academically. I have blogged on this previously, and really feel that finding balance is important for everyone.

Kids have different problems with homework at different times, and they each deserve their own solutions. Not one of these "types" fits every child perfectly. Most kids have more than one of these qualities, but tend to fit into one type best.

Procrastination: There is always something more fun to do than work. Kids will put off overwhelming tasks or big projects because, well, there's a lot to do.

Ask not only what homework they have for tomorrow, but if there are any big projects due in the future. See if they can estimate how much time it will take to do the project and help them plan how much to do each night to get it done on time.

Breaking big assignments or long worksheets into small pieces with short breaks in between can help kids focus. Use a timer for breaks or do a fun quick activity, like silly dance to one song.

Allow kids to have some "down" time after school for a healthy snack (brain food) and to run off energy. Limit this time with a timer to 30 minutes or so. The timer helps kids know there is an end point to the fun, and then it's time for work. Play can resume when work is done correctly.

Poor Self Confidence: Kids who are afraid they won't understand their homework might fear even starting. They blame the teacher for not teaching it correctly. They might complain that they are stupid or everyone else is smarter. They blame the class for being too loud, causing distraction and therefore more homework. They might complain of chronic headaches or belly aches.

Be sure to praise when kids do things right and when they give a good try. Be honest, but try to think of something positive to tell them each day. When they don't meet expectations, first see if they can see the mistake and find a solution themselves. Guide without giving the solution. Then praise the effort!

Find their strengths and allow them to follow those. If they are poor in math but love art, keep art materials at home and display their projects with pride. Consider an art class. Remember to budget time. Over scheduling can result in anxiety, contributing to the problems.

Perfectionist: While the desire to do everything right has it's benefits, it can cause a lot of anxiety in kids. These kids think through things so much that they can't complete the task. See also the "poor self confidence" section above, because these kids are at risk for feeling they are failures if they don't get a 100% on everything. They can have melt downs if the directions don't make sense or if they have a lot of work to do.

Help your child learn organizational techniques, such as write down assignments and estimate time to do each project. Plan how much time to spend each day on big projects and limit to that time. Help them review their progress in the middle of big projects to see if they are on track. If not, have them establish another calendar and learn to review why they are behind. (No self-blame. Is it because one step took longer than projected, they were invited to a movie and skipped a day, they got sick and were not able to work... This helps plan the next project and builds on planning skills.)

Remember to give attention and praise for just being your kid. These kids feel pressure to succeed, but they need to remember that they are loved unconditionally.

If you notice they have an incorrect answer, state "that isn't quite right. Is there another way to approach the problem?"

Not everything is about the grade. Praise the effort they put into all they do, not the end point. Make positive comments on other attributes: a funny thing they said, how they helped a younger child, how they showed concern for someone who was hurt.

Encourage them to try something new that is outside their talent. Not only are they exploring life, but they are developing new skills, and learning to be humble if they aren't the best at this activity. Help them praise others. Model this behavior in your own life.

Co-dependence: Helicopter parenting is a term often used to describe the parent hovering over the child in everything they do. This does not allow a child to learn from failing. It does not allow a child to grow into independence. It allows the parent to "own" the problem of homework. These kids call home when they leave the homework or lunch on the kitchen table for Mommy to bring it to school. These kids grow up blaming everyone when things don't go their way and Mommy can't fix it. They don't learn to stand up for themselves. They seem constantly immature with life situations.

Young children need more guidance, but gradually decrease this as they get older. Teachers can help guide you on age appropriate needs. Most parents must sign a planner of younger kids, but as kids get older the kids become more responsible for knowing what the homework is. Many schools now have websites that parents can check homework assignments, but be sure the kids own the task of knowing what is due too.

Have a place that children can work on homework without distraction (tv, kids playing, etc).

Be available to answer questions, but don't do the work for them. If they need help, find another way to ask the question that might help them see the solution. Get a piece of scrap paper that they can try to work through the problem. If they have problems with reading comprehension, have them read a few lines then summarize to you what they read. They can take notes on their summary, then read the notes after the entire chapter to get a full summary.

Busy, busy, busy: Some kids are really busy with after school activities, others just rush through homework to get it done so they can play.

Set limits on how much screen time (tv, video games, computer time) kids can have each week day and week end. A maximum of 10 hours per week of screen time is recommended by experts. If they know they can't watch more than 30 minutes of tv, they are less likely to rush through homework to get to the tv.

Ask kids to double check their work and then give to you to double check if you know they make careless mistakes. Don't correct the mistakes, but kindly point them out and ask if they can find a better answer. Once they learn that they have to sit at the homework station until all the work is done correctly, they might not be so quick to rush.

If kids have after school activities the time allowed for home work and down time are affected. Avoid over scheduling, especially in elementary school. Be sure they have time for homework, sleep, healthy meals, and free time in addition to their activities. Are the activities really so important that they should interfere with the basic needs of the child? Is the child mature enough to handle the work load?

Kids who are in constant motion can't seem to sit still long enough to do homework. Be sure they have the proper balance of sleep, nutrition, and exercise or all else will fail. Praise their efforts when they are successful. Set a timer after school to let them play hard for 30 minutes, but then make them sit. Help little ones organize what needs to be done and break homework into several smaller jobs. Set regular 5 minute breaks every 30 minutes so they can release energy. Set a timer to remind them to get back to work and compliment them when they get back on task.

Struggling despite help: There are many reasons kids struggle academically. Reasons vary, such as behavior problems, anxiety, illness, learning disabilities, bullying, and more.

If they are struggling academically, talk with the teacher to see if there are any areas that can be worked on in class or with extra help at school. Can the teacher offer suggestions for what to work on at home?

If kids have chronic pains or school avoidance, ask what is going on. Depression and anxiety aren't obvious and can have vague symptoms that are different than adult symptoms. Bullying can lead to many consequences, and many kids suffer in silence. If your child won't talk to you, consider a trained counselor.

Talk with your pediatrician if your child is struggling academically despite resource help at school or if he suffers from chronic headaches or tummy aches. Treating the underlying illness and ruling out medical causes of pain is important. Depression, anxiety, ADHD, and other learning disorders can be difficult to identify, but with proper diagnosis and treatment, these kids can really succeed and improve their self confidence!

Help us help you!

2011-12-09T06:42:00.001-06:00

Hello. This is Dr. Stuppy. I'm returning your call about...

That is how my phone calls start, then they take various turns. Some are easy, some not so easy. I'd like to discuss what makes a phone call to the doctor's office more productive, so we can help you better. All examples are entirely fictitious, made up of 12 + years of phone call experiences.

Many calls start off like this:

Hi. This is Mary Sue. My son has a rash and I want to know what to do.

Me: ????? I must ask many questions for more information.

Some callers don't seem to know what to say, so they only answer direct questions. How old is your son? When did the rash start? What does it look like? Has it changed? Does it itch or hurt? Any other symptoms? What have you used to treat it? Did that help? Has he had any new ingestions, lotions, or creams? Does he have a history of allergies? Anyone else with a rash that looks like this? On and on...

Or like this:

Hi. Thanks for calling back. My son Jack is 3 years old. Well, really his birthday isn't until next month, but he's almost 3. He has had a fever for 2 days, maybe 3 days because he felt warm but he wasn't acting funny or sick that first day he felt warm. He actually was fussy last week, but I don't think he ever had a fever then. I was thinking maybe he didn't sleep well last week, but I don't know why. I took his temperature and it was 100.3, that was on Tuesday around 7am. I gave Tylenol, and it went down to 97.9, but then 4 hours later it was back up to 99.7....

My thoughts so far: Get to the point.

Sorry, but that's true. I care about my patients, but so far this phone call has taken me quite a bit of time and I really know nothing except this almost 3 year old has an elevated temperature (not even a true fever).

When parents call, they need to summarize with pertinent facts. While they shouldn't leave out important helpful information, they don't need to mention every time they took a temperature.

Much like the evening news: they can't do a play by play of every football game. There's no time and it serves no purpose. A few highlights of the game and the score. That works well. People get a pretty good idea of how the game went.

It's the same thing with phone calls to your doctor's office or on call provider. We have thousands of patients. Not all call the same day, but during peak cold and flu season last year our office we took 50-90 calls/day (the highest numbers on Mondays). One phone nurse has 8 hours to answer up to 90 calls in addition to filling out insurance forms and other tasks. (We have great nurses that help out if they have time, but if the phones are busy, I guarantee the office is busy too!) They simply can't spend 15 minutes chatting about every detail. That's for your friend and you to discuss over coffee.

After hour phone calls during the winter are also more frequent. It is not uncommon for me to be on the phone with one parent and another call comes in. This is at the same time I am trying to watch my son's game or go to the grocery store. I really don't want to sit and chat. I don't have time for play by play action. Again, I really care about my patients, but I can do a better job at answering your questions if you are clear and concise.

Things that help us help you over the phone:

Know what is going on. When a parent calls and the child is at daycare or grandma's so the caller doesn't know details, we can't really help. Write down the pertinent facts to get them straight if you need to.
Start with your child's full name and birth date. Include any significant past history, such as your infant was born at 28 weeks gestation, or your coughing 3 year old has a history of wheezing.
Give pertinent facts related to the concern.

If your child has a fever, give the number of days of fever, the maximum temperature, and how it was taken. If you have given a fever reducer, share that.
Briefly describe symptoms and what you have done to help them as well as if your child responded or not to the treatment. Remember treatments are not only medicines, but if you use a vaporizer or saline for a cold, or have stopped dairy and used G2 for vomiting, let us know.
If your child has a rash, it is typically best for us to see the rash, but if you call about a rash describe it in terms of location, color, and size (many find it helpful to relate to common objects, such as quarter-sized).
Note if there is a pattern to the symptoms, such as headache every day after school or barky cough only at night.

Let us know any medications your child typically takes in addition to ones you have tried for the current symptoms.
Leave out details that don't help. Trends and generalizations work well. If we want more details, we can always ask.

Examples of good call starters:

I am calling about Joe Smith, birth date 9.12.08. He has had a fever for 3 days, up to 101.3 under the arm. It comes down with ibuprofen, but is right back up in 6 hours. He also has sore throat and headache. He's drinking well but not eating much for 3 days.

Sally Smith, birth date 9.12.11, has vomited 6 times in the past 12 hours. If I give formula it immediately comes up. She is now dry heaving and hasn't had a wet diaper in 12 hours. She doesn't have a fever but looks tired and it is hard to wake her to drink. She doesn't have diarrhea. Her older brother had the stomach flu a few days ago but is now better.

John Smith, birth date 9.12.11, was in the NICU for 2 months due to prematurity. He has been fussy all day and is now breathing fast and hard and is not able to drink more than a few sucks at a time. He doesn't have a fever, but I'm really worried.

Remember: Our website has many pearls of wisdom. Often when we give advice it is already stated on our site. Parents sometimes call multiple times because they can't remember what we said. This is frustrating on both ends of the phone. We wrote it down for a reason. Use our site!

Things that cannot be done by our on call providers:

Prior authorization for an ER or urgent care visit. These must be done during office hours, and most of the time our office is not involved. These are typically done by the location at which your child is seen.
"Allow" you to leave a busy ER. It sounds silly, but I have had many calls from the waiting room at ER/Urgent Cares with parents asking if I think it okay that they leave due to a long wait. If you thought it necessary to go in the first place, I would be open to a malpractice lawsuit if I told you to go home without being seen. You should ask their triage nurse who can make that assessment.
Refill medications. We typically expect that your child is seen prior to most prescription refills for best medical care. If it is urgent that your child have a refill, such as an inhaler, they should be seen to evaluate the concern. There are exceptions to every rule, but don't be upset if the on call provider refuses to call out a prescription.
Make a diagnosis. We cannot see the ear, listen to the lungs, or feel the belly over the phone. A physical exam (and sometimes labs or radiology studies) are needed to make a diagnosis. If your doctor claims to be able to diagnose by phone to call out prescriptions, I would suggest that they are not doing the best of care.

Some things are best done with a visit for further evaluation.

Difficulty breathing. If a child is having difficulty breathing and you don't have treatments at home that work, he needs to be seen as soon as possible.
Dehydration. An infant hasn't urinated in 6-8 hours or an older child hasn't urinated in 12 hours might be dehydrated and should be seen as soon as possible.
Some fevers. Temperature above 100.4F under the arm in an infant under 3 months or under immunized child can be serious and should be seen as soon as possible. Fevers lasting more than 3-5 days or with other concerning symptoms require an evaluation.
Uncontrollable pain. If you have used standard pain relievers and your child is still hurting, we cannot do anything by phone that will improve the situation. A careful exam might find a treatable cause of pain.
Most rashes. Though these don't necessarily need to be seen emergently unless there are other concerns, rashes cannot be evaluated on the phone and a physical exam is needed.
Chronic problems. If your child has been dealing with anything for more than a few days, it might help to schedule a visit with your usual provider.
Diagnosis vs information. If you want a diagnosis, we need to see your child. We cannot tell if the ear is infected or if your child has Strep based on symptoms alone. If you want advice of what to do with symptoms, we can generally give advice. Remember that our website also has most of this information too!
Behavior problems. These are best discussed with your usual provider, not an on-call provider who doesn't know your child. Most of these build up over time and are not emergent issues.
Injuries. If your child has a moderate or severe head injury, possible broken bone, laceration, or other injury symptoms they require evaluation. Lacerations must be repaired as soon as possible, so don't wait until office hours the next day!

Help me help you! Let me know what else you need to know to be an educated caller. I'd be happy to answer questions about when to call, what to ask, and what to expect. If I left any questions unanswered, please ask!

Dr S

How to get kids to take medicine

2011-12-05T21:02:00.001-06:00

A recent facebook post discussed how to give medicine to children, but left out how to give liquid medicine. A reader asked for advice, and I wanted to expand my original answer.

The article: Medical Mom: A spoon full of sugar helps the medicine go down

The facebook question: She gives great advice on pills, but what about liquid medications that kids just WON'T swallow? I've tried putting it in his cheeks, but the flavor they mixed it with he hates :(

Of course, there is so much to giving medicine to kids. They already feel sick for most of the medicines we give, and anything is distasteful when you feel sick, regardless of the flavor the pharmacist adds. Some medicines have a horrible aftertaste that is difficult to mask. Some upset the stomach.

If medicine is vomited within 30 minutes, it generally can be given again. If your child vomits more than 30 minutes after the medicine is swallowed, do not offer it again.

I don't miss the days of liquid medicines! My son (who suffered from many ear infections) spit out most medicine (and often vomited what he swallowed). My daughter didn't need as many medicines as him, but as the expert vomiter (she would vomit whenever she didn't get her way as an infant) and expert manipulator, she had unique issues to get the medicine down.

Needless to say, I learned a lot of tricks trying to get them to keep medicines down.

Most liquids taste better cold, so check with your pharmacist if the medicine can (or should) be refrigerated. Also ask if it can be mixed with juice or foods. Some should be given on an empty stomach without food and only sips of water.

Be sure you have a properly sized medicine syringe or medicine cup for all liquid medicines. Shake the bottle well before dispensing.

If it can be mixed into juice, jelly, or yogurt, be sure to mix in a small enough volume that you can ensure your child will take the entire amount. You can measure the amount of medicine in a syringe, then fill the remainder of the syringe with drinkable yogurt, juice, or whatever liquid is okay to mix with the medicine. (Always ask your pharmacist first!)

Sometimes using a medicine that comes in a capsule that can be sprinkled onto a spoon of yogurt, jelly, or applesauce works well. Yogurt tubes are especially great for this if your child eats these. Put the contents from the capsule on the top of the open tube, and they suck it down as they enjoy the yogurt. Ask your pharmacist if you can mix the medicine with foods first!

For infants: Try squirting it in the inner cheek and blowing on the face. I don't know why, but it seems to make infants swallow. You can also put it in a nipple and allow them to drink from the nipple, which bypasses most of the taste buds on the tongue! After the medicine is swallowed, use the nipple for water or formula/milk to rinse all the medicine down as long as it does not need to be given on an empty stomach.

Preschoolers: This age might feel "big" if allowed to hold the medicine cup themselves. Supervise closely so they don't spill it. Praise when they did it!

Preschool and up: Offer a chocolate syrup chaser. Syrup is thick and masks a lot! Another trick is to offer a popsicle (or ice) first. This numbs the taste buds, making the medicine taste less noticeable.

Holding the child's cheeks to make them pucker their lips until swallowed sometimes works (though I found kids can still spit it out that way!)

You can also have the pharmacist flavor most medicines, and if you pick the right flavor, it can help. Ask for suggestions, since the flavor added might not be the best for the particular medicine.

Bribery works with preschoolers and up. (A thing I promised myself I would NEVER do... but once I had kids and realized bribery works, I reserve it for the really important things.)

As for most of my behavioral advice: praise a job well done! If they took the medicine, tell them you are happy they did.

When you think your child is able to swallow pills without choking, teach with small candies, such as Tic Tacs or mini M&Ms. I always suggest using a cup with a straw, since when you drink out of a cup you tilt your head back, narrowing the throat. A straw allows you to keep your neck neutral. Once swallowing a small candy is mastered, you can use real medicine capsules or tablets, as long as the dose is correct for the child's weight.

Sometimes making a game of it works. My husband came up with this trick for our daughter when she was 5-6 years old. Remember she was the expert manipulator. She threw a fit about taking a medicine and made getting out of the house for school on time difficult a couple of days. He suggested that if she was ready for school by 7:15, she could throw a fit for 10 minutes. If she wasn't ready until after 7:20, she could only throw a fit for 30 seconds. Either way we would set the timer for her fit, then she would take the medicine. Of course we knew she'd never be ready early (and she really couldn't tell time well in kindergarten) so when it was time for medicine, we set the timer for 30 seconds and told her to throw a good fit. She threw a great fit, then took the medicine without a problem. It was as if owning it worked for her, and she then took the medicine each day for the rest of the week after setting the timer for a fit. By the end of the week she could hardly throw a fit she was giggling so much!

The most important thing is to remember why you are giving the medicine. If it is an antibiotic or other medicine that is important to completely take, then it is more important than if you are simply trying to give a fever reducer. A fever reducer might make your child feel better, but it really isn't required. If it is required, then you need to play hard ball and do whatever it takes to get the medicine down.

What has worked for your kids to take medicine? Please share your tips!

Fever is...

2011-12-03T17:21:00.000-06:00

Fever is scary to parents.

Parents hear about fever seizures and are afraid the temperature will get so high that it will cause permanent brain damage. In reality the way a child is acting is more important than the temperature. If they are dehydrated, having difficulty breathing, or are in extreme pain, you don't need a thermometer to know they are sick.

Fever is uncomfortable.

Fever can make the body ache. It is often associated with other pains, such as headache or earache. Kids look miserable when they have a fever. They might appear more tired than normal. They breathe faster. Their heart pounds. They whine. Their face is flushed. They are sweaty. They might have chills.

Fever is often feared as something bad.

Parents often fear the worst with a fever: Is it pneumonia? Leukemia? Ear infection?

Fever is good in most cases.

In most instances, fever in children is good. It is a sign of a working immune system.

Fever is often associated with decreased appetite.

This decreased food intake worries parents, but if the child is drinking enough to stay hydrated, they can survive a few days without food. Kids typically increase their intake when feeling well again. Don't force them to eat when sick, but do encourage fluids to maintain hydration.

Fever is serious in infants under 3 months, immune compromised people, and in under immunized kids.

These kids do not have very effective immune systems and are more at risk from diseases their bodies can't fight. Any abnormal temperature (both too high and too low) should be completely evaluated in these at risk children.

Fever is inconvenient.

I hate to say it, but for many parents it is just not convenient for their kids to be sick. A big meeting at work. A child's class party. A recital. A big game or tournament. Whatever it is, our lives are busy and we don't want to stop for illness. Unfortunately, there is no treatment for fever that makes it become non-infectious immediately, so it is best to stay home. Don't expose others by giving your child ibuprofen and hoping the school nurse won't call.

Fever is a normal response to illness in most cases.

Most fevers in kids are due to viruses and run their course in 3-5 days. Parents usually want to know what temperature is too high, but that number is really unknown (probably above 106F). The height of a fever does not tell us how serious the infection is. The higher the temperature, the more miserable a person feels. That is why it is recommended to use a fever reducer after 102F. The temperature does not need to come back to normal, it just needs to come down enough for comfort.

Fever is most common at night.

Unfortunately most illnesses are more severe at night. This has to do with the complex system of hormones in our body. It means that kids who seem "okay" during the day have more discomfort over night. This decreases everyone's sleep and is frustrating to parents, but is common.

Fever is a time that illnesses are considered most contagious.

During a fever viral shedding is highest. It is important to keep anyone with fever away from others as much as practical (in a home, confining kids to a bedroom can help). Wash hands and surfaces that person touches often during any illness. Continue these precautions until the child is fever free for 24 hours without fever reducers. (Remember that temperatures fluctuate, so a few hours without fever doesn't prove that the infection is resolved.)

Fever is an elevation of normal temperature.

Normal temperature varies throughout the day, and depends on the location the temperature was taken and the type of thermometer used. Digital thermometers have replaced glass mercury thermometers due to safety concerns with mercury. Ear thermometers are not accurate in young infants or those with wax in the ear canal. Plastic strip thermometers and pacifier thermometers give a general idea of a temperature, but are not accurate.

To identify a true fever, it is important to note the degree temperature as well as location taken. (A kiss on the forehead can let most parents know if the child is warm or hot, but doesn't identify a true fever and therefore the need to isolate to prevent spreading illness.) I never recommend adding or subtracting degrees to decide if it is a fever. In reality, you can look at a child to know if they are sick. The degree of temperature helps guide if they can go to school or daycare, not how you should treat the child. Fevers in children are temperatures above

100.4 F (38 C) rectally

99.5 F (37.5 C) in the mouth

99 F (37.2 C) under the arm

Fever is rarely dangerous, though parents often fear the worst.

This is the time of year kids will be sick more than normal. With each illness there can be fever (though not always.)

What you can do:

Be prepared at home with a fever reducer and know your child's proper dosage (especially with the recent dosing changes to acetaminophen!)
Use fever reducers to make kids comfortable, not to bring the temperature to normal.
Have an electrolyte solution at home in case of vomiting.
Teach kids to wash their hands and cover coughs and sneezes with their elbows.
Stay home when sick to keep from spreading germs. It is generally okay to return to work/school when fever - free 24 hours without the use of fever reducers.
Help kids rest when sick.
If the fever lasts more than 3-5 days, your child looks dehydrated, is having trouble breathing, is in extreme pain, or you are concerned, your child should be seen. A physical exam (and sometimes labs or xray) is needed to identify the source of illness in these cases. A phone call cannot diagnose a source of fever.
Any infant under 3 months or immune compromised child should be seen to rule out serious disease if the temperature is more than 100.5.

Excessive milk can cause anemia? How?

2011-12-03T08:04:00.001-06:00

A recent facebook posting recommending limiting milk intake prompted questions from followers about iron deficiency anemia from milk. Nutrition and iron balance is actually a relatively lengthy discussion, so I will try to explain it here.

Short answer: Cow's milk has little iron. When kids drink a lot of milk, they don't eat iron-containing foods in sufficient volumes. Cow's milk also has big proteins that can cause microscopic bleeding in the gut. The more milk consumed, the more bleeding (though usually still not seen in the stools).

More milk = more blood loss from the gut

but less blood produced because less iron in the diet

= anemia

Iron is used to build healthy red blood cells that carry oxygen throughout our bodies. Too few red blood cells in the body is called anemia. Red blood cells are made in our bone marrow and they live for about 3 months. It is important for the body to continually make new red blood cells as it breaks down and removes old ones.

In general anemia can be caused from several factors:

too little blood produced (iron deficiency being a major risk for this)
increased blood loss (ie excessive bleeding)
increased destruction of blood cells in the body (typically from abnormal blood cells or infection)

Iron deficiency can be due to several factors:

poor iron absorption due to disease (some studies show milk inhibits iron absorption)
poor iron in the diet (the most common cause)
long term slow blood losses (such as heavy monthly periods or GI bleeding)
increased iron need (such as a growth spurt or pregnancy)

Why does preventing iron deficiency anemia matter? Because the most common symptom of anemia is no symptoms. It can go unnoticed for quite a while in some kids, yet cause long term problems with growth and development. Symptoms develop when the anemia becomes more severe and include tiredness, looking pale, irritability, decreased appetite, slowed development, weakness, immune dysfunction, and pica (eating non food substances- such as dirt).

Newborns are designed to drink their mother's milk. Humans have learned to make formulas that can nourish babies if they aren't able to drink their mother's milk for whatever reason. Cow's milk, soy milk, and goat's milk are not acceptable for infants due to the nutritional voids they have (not just iron). After about 1 year of age babies tend to wean from mother's milk and/or formula onto whole milk. (Newer recommendations allow weaning onto low fat milk--another topic entirely.) Unfortified non-human milks contain very little iron. The iron in human milk is better absorbed and iron is supplemented into formula. If toddlers and children drink too much milk, they fill up on it and don't eat a variety of other food groups that include iron and other important nutrients missing in their milk.

Foods that are good sources of iron:

meats and poultry (especially organ meats, such as liver)
lentils, peas, and dried beans
eggs
oysters, clams, and fish
molasses
peanut butter
soy
pumpkin or sesame seeds
fruits such as prunes, apricots, and raisins
vegetables such as spinach, kale, broccoli, and other greens
whole grain fortified breads and cereals

Vitamin C increases iron absorption, so eat foods with iron and Vitamin C at the same meal!

Sexual abuse

2011-11-26T09:28:00.000-06:00

Recent news about a well known person repeatedly sexually abusing children over many years has many parents angry, confused, and simply aghast.

Many of us feel like we do all we can to protect our kids and our kids aren't at risk, yet statistics show that any child could be a victim. Studies reveal that about 20% of women and 10% of men experienced sexual abuse as children. Sexual abuse crosses all socioeconomic groups, all racial groups, all ethnicities, and all neighborhoods. Often the perpetrators are the least suspected: a family member, a coach, a neighbor.

Signs of abuse in kids can be subtle. They are often attributed to something else.

If kids do try to talk about feeling scared or not safe with someone: LISTEN. They don't make this stuff up!

I appreciate the organizations that require background checks on all adults around kids. I have had my background checked on many occasions: job related, coaching my daughter's cheerleading squad, volunteering at my children's school, and volunteering at a local children's theater. I was never offended by these requests and always supported these checks, but some parents grumble. I suspect they just don't understand. Many schools, sports organizations, and scouting organizations require teachers and volunteers to have routine background checks. Does yours?

Do you ask if the adults supervising your children have had background checks?

Most do not.

I am not even sure how I feel about this. I suspect it gives a false sense of security, knowing that many abusers have many victims before being caught. They would have normal background checks. They are often personable, friendly, someone who grooms victims and their families to gain trust.

If background checks aren't full proof protection, what should a parent do? I believe that the best protection about abuse is to show love to your children, educate yourself and them about abuse, and frequently talk with them.

Knowledge is Power!

Teaching kids about proper boundaries is important. Let them know that their swim suit area is private, and no one should be able to look or touch there without permission from mom or dad.
Young children should learn their full address, phone number, first and last name (and first/last names of parents).
Remind kids that there are no secrets between kids and their parents. They can tell you anything. They can keep your birthday gift a surprise though! Secrets that scare them are especially important to tell! They will NEVER get in trouble for telling about a scary secret.
Know your children's friends, their friend's parents, teachers, coaches, piano teachers, etc. Offer to help as much as possible at school and activities.
Be sure there are no secluded areas in the places your child goes. Kids should always remain in a group with adults. A minimum of two adults is safest.
For your protection, if you must take other kids to a public restroom, stand in the main door with it open and let the kids go into stalls alone.
Teach kids that adults will never need help from kids to find a missing puppy. Adults can ask other adults, not kids, for directions if lost. Give examples and role play.
Caution kids when they wear shirts with their name clearly posted on the outside that strangers will "know" their name. Stay especially close when your kids have their name displayed. It is easier for a stranger to trick them: "Johnny, your mom told me to come get you. She is hurt. Come with me." What kid wouldn't question that???
Question about new toys or gifts. Kids might earn token gifts from coaches or teachers as a reward system, but if your child is getting bigger, more expensive gifts, that is a cause for alarm.
If kids are lost, have them find another child to ask for help. Usually the other child has a safe adult with them that can help. (Plus kids are less intimidated talking to other kids when they are already scared and lost.)
Parents of today need to learn about protecting kids on line. Bullying now does not stop in the safety of one's home. On line threats, photos, and comments follow kids everywhere and are very dangerous. Keep computers in public areas, monitor cell phone use, teach kids to never give identifying information on line, and use a computer monitoring system.
Abusers often target kids who are feeling unloved. They groom those kids (and their families) by befriending them, making them feel special, and giving them gifts. The kids start to deeply care for that person, and then the confusion of feelings does not allow the child to easily tell on the person. Show your kids love in many ways: time spent one on one talking and playing (not watching tv), show interest in your children's activities, give good touches (ruffling hair, pat on the back, hugs), and build your child's self confidence.

Building confidence in kids is tricky. Be careful in how you word things... it is always okay to say "I enjoyed watching your game," whether your child was the star player or had a horrible game. You can say something about how proud you are of the effort they put into something even if the outcome wasn't good. Try to avoid saying "better next time," since that means they didn't do well this time. Praise frequently and honestly from the heart.

Create a safe environment at home. If kids witness fighting among parents, or parents don't treat others with respect, the children will learn that this is acceptable behavior. They have a strong potential to get seriously injured at home or to enter abusive relationships as adults. Seek help if your home is not safe! Use a public computer if yours might be monitored and click here or call 1.800.422.4453 (1.800.4.A.Child) from a safe phone.
Learn more about protecting against abuse and what to do if you suspect it. There are on line resources, such as TheSafeSide or PreventChildAbuse, and locally The Sunflower House to learn about abuse. GetNetWise and NetSmartz411 have information about keeping kids safe on line.

Chores for kids become chores for parents?

2011-11-14T07:01:00.000-06:00

As a parent I see the great value of chores for kids.

Anyone can learn the satisfication of completing a task, improving self confidence.
Young children can improve self care competence such as with bathing and dental hygiene.
Older kids can learn money appreciation and management if they are paid and expected to save some and share some of their well-earned money. Learning to save for a large ticket-item and not spend frivolously is a great life lesson many adults missed.
Older kids can establish a great attitude about work and learn real-world skills such as laundry, cooking, and cleaning.
Kids might even gain self esteem by the positive intrinsic reward of a job well done.
They learn responsibility.

The downside?

Chores for the kids often make work on the parents harder. (Who said parenting is easy?)

Parents must decide what tasks are able to be done by children at various stages of maturity. There are on-line resources available to help guide parents. This is one place I disagree with the WebMD list because they say a 10 year old can mow the lawn--not recommended by the AAP until 12 years!

Some good lists: Workingmom.com, Focus on the Family, Chores-Help-Kids

Parents must make sure the chores are completed or set a means of monitoring what is done. Ideally chores would be accomplished without fighting and whining, but how? Verbal praise and acknowledgment is always a winner. If parents choose to reward chores with stickers, gifts, or money, there must be a way to track when a task is complete.

Consistency is key in any form of discipline, and this includes the tracking of chores. The biggest reason chores fail in my house is we (the parents) forget to check the lists to be sure the kids did them. Having a consequence for not doing the expected chores versus getting a reward for doing the list... behavior experts disagree on these points.

Many behavior experts recommend to not remind kids to do chores. They feel that the negative consequences of not doing the chores will teach the lesson better than the constant nagging to do the chores. I have found that without reminders the chores are simply not done, but this does not mean I must always directly remind. Praising the initiation ("I'm glad you are getting your homework done early tonight!" "I see you remembered to sort your laundry, that's the hardest part!") is often an effective way to get kids to complete the task. There is a fine line between nagging the kids to do the expected things and letting the chores slip by without being completed.

Over the years we have had many means of keeping track of chores in my family.

When the kids were young, we first tried a dry erase board, but that got erased too easily.
We then found a simple paper chart each week that had lists that could earn stickers. I liked the format because it separated tasks into the general categories below, but we often forgot to mark things off at the end of a busy day, so there was little reinforcement for the kids to do the chores. The categories of chores:

Self: included things such as brush teeth, bathe, get dressed
Home: included things such as pick up toys in living room
Room: included things such as pick up room, make bed
School: included things such as help a friend, homework, pack backpack

One of my favorites was a system called 10-20-30Go! that friends developed. It was wonderful because it is based on the kids taking full responsibility for marking down what they did. It is simple and includes a strong family and faith base. It was one of the longest running systems that worked for us, but as all systems, it also faded in follow through. A big reason was that we often had activities that interfered with the family meeting night, no matter what night of the week we tried to do it. (Family meeting nights are still a great thing, but difficult in a busy house!) We also found that the kids didn't look forward to their allowance, so it was little reinforcement to do the tasks. They might have been too young at the time.
Another favorite system of mine due to ease of use, cost (free), and kid -centered responsibility is MyJobChart. It works well for kids who can use the internet fairly independently. My kids can log in to their account and mark the chores as they do them, or once a day. They earn points, which they can choose to share (with pre-determined charities), spend (on items I help pick), or save (for the future!) I like many features of this system, but it still has periods that my kids forget about it for weeks, then periods that we all remember again. They still do their chores (or they have no clean clothes the following week... or whatever natural consequence follows the forgotten chore) but they don't always mark them down for credit.

What do you find helps to keep your kids up to date on their chore list?

New SIDS Prevention Guidelines

2011-11-05T10:43:00.000-05:00

As pediatricians we practice a lot of preventative medicine. Our patients are generally young and healthy... and we want them to stay that way! One way we do this is to discuss safety at well visits. We try to share safety tips on our facebook page, website, and here.

A big safety issue is the sleep position of babies. Most parents by now have heard that it is safer to put babies to sleep on their back, not belly. Occasionally we hear of young babies sleeping on their stomachs because parents have realized they sleep longer that way, and they do. But this is dangerous. Babies don't wake up as much when on their stomach, this is true. Some babies simply don't wake up. Please put your babies on their back to sleep!

Parents often want to sleep with their babies because it also is associated with longer sleep time for the baby and more convenience for the parent (especially the breastfeeding mother). Despite ease and convenience, this is not a safe sleeping arrangement for babies. Arguments that this is safe because world wide many families share beds is not often a valid argument. Americans tend to sleep on a bed with a headboard and bedding. Babies can get their head stuck between the mattress and headboard (or wall). They can suffocate from the bedding. Parents can roll over in their sleep and smother the baby. There are simply safer options for all to sleep better.

Recently the American Academy of Pediatrics (AAP) released new Sudden Infant Death Syndrome (SIDS) prevention guidelines. AAP SIDS prevention Guidelines that are based on strong evidence:

Back to sleep every time.
Use a firm sleep surface covered with a fitted sheet.
Room share without bed share (put the baby in a crib or bassinet near the parent bed).
Keep soft objects and loose bedding out of the crib.
Pregnant women should receive routine prenatal care.
Avoid smoke exposure during pregnancy and after birth.
Breastfeed.
Consider a pacifier at nap and bed times, but do not attach it to the infant or infant's clothing or stuffed toys.
Avoid overheating.
Do not use home cardiorespiratory monitors as a strategy to reduce SIDS.

Other recommendations based on limited evidence:

Immunize in accordance with the AAP and CDC guidelines.
Avoid commercial devices marketed to reduce the risk of SIDS (postitioners, co-sleepers, wedges).
Supervised, awake tummy time is recommended to help development and reduce the risk of positional plagiocephaly (a misshapen head from laying on one side routinely).

Other issues addressed:

Co-sleepers are not recommended.
Absolutely no bed sharing the first 3 months.
No bed sharing at any age if a person in the bed is a smoker.
No bed sharing with anyone who is excessively tired.
No bed sharing with someone who is using medications that increases drowsiness or impairs alertness (pain medicications, alcohol, illicit drugs, certain antidepressants).
No bed sharing with anyone who isn't a parent. This includes no bed sharing with siblings or other children.
No bed sharing with multiple persons.
No bed sharing on a soft surface (waterbed, old mattress, sofa, armchair)
No bed sharing on a surface with soft bedding, including pillows, heavy blankets, quilts, comforters.
Because of the high correlation with SIDS and suffocation on couches and armchairs, infants should not be fed on these when the parent is extremely tired and at risk of falling asleep.
When choosing a crib, be sure it has not been recalled and all the parts are put together properly.
Use only mattresses designed for infants. Do not add any comforters, quilts, pillows, or other soft bedding to the sleep area.
Bumper pads are not recommended.
Infants should wear clothing that will keep them warm (not excessively hot) and that will not cover the head/face.
Keep dangling cords or window coverings away from the sleep area.
If infant slings are used, it is important to keep the infant's head up and above the fabric so the face is visible (unless currently breastfeeding).
Infants should not routinely sleep in car seats or other sitting devices (strollers, carriers, or backpacks/slings).

NOT safe!!!!!!
Picture actually taken to show the person who gave the comforter and bumper pad set, then it was put away.

Keep your baby safe by placing her in a safe place at all times. It only takes one accident to have life-ending consequences. To say that you've always slept with your babies and they are fine, so it's not a problem for babies to sleep with their parents is like saying you never wear a seatbelt and haven't had any problems. Just wait until that first crash...

Complimentary and Alternative Medicine

2011-11-03T21:17:00.002-05:00

Complimentary and Alternative Medicine (CAM) means many things to many people, but the truth is that many people use it to try to help a broad range of ailments without much guidance from their physicians.

Why? Reasons vary. Some feel that "natural is better." Others feel that mainstream medicine is not working. Many people see CAM as a lifestyle choice. Some don't have access to (or money for) a doctor visit, and CAM is readily available at many locations. There are many other reasons that people use CAM.

Is it safe? Is it reliable? Depends on the CAM.

What is CAM?

CAM includes any form of medical treatment that is not a part of mainstream medicine. It has gained popularity because it is holistic, and people like the idea of treating the whole person and not simply one condition. It includes many categories of treatments, including natural products (vitamin supplements, herbal medicines, minerals, and probiotics), homeopathy (diluted substances that would typically cause symptoms used to treat those symptoms), acupuncture and manipulative treatments, Oriental medicine (energy fields), and mind-body medicine.

What are potential problems with CAM?

Homeopathic medicines and natural products are not regulated by the FDA.

Some therapies have been shown to be contaminated with heavy metals (such as lead)
Products have been shown to be inconsistent in the amount of active ingredient from bottle to bottle
Studies to show the appropriate dose have not been done in most instances

Studies to show effectiveness have not been done in many cases

Many don't share CAM use with their physicians. Why?

Don't want to admit in case doc disagrees

Don't think about it and aren't asked specifically

Don't think it will make a difference

Many docs don't know how to advise about CAM.

If parents ask about herbs, spinal manipulation, or other CAM treatments, physicians often don't have the answers.
Physicians are taught to advise based on an evidenced based platform. If studies haven't shown a treatment to benefit, we are less likely to recommend it. For many complementary and alternative medicines studies have not been done to show safety and efficacy.
Studies that have been done typically were done in adults, not children. Children handle medicines and therapies differently than adults, but research is often not done on them.

CAM information does not often make news in medical journals and is not typically discussed at conferences, the places at which your physicians learn.

Do I recommend CAM?

While there are many CAM treatments that I am not comfortable recommending, I often recommend things that are CAM.

The first and foremost form of alternative medicine I recommend to everyone is healthy diet and lifestyle. This is widely accepted among mainstream medical doctors. Healthy diet and exercise helps prevent many health problems, treat some health problems, and even helps mental focus and overall mental health.

I believe there is solid research supporting fish oil, probiotics, and other vitamin supplements. The American Academy of Pediatrics recommends Vitamin D for all children.

I think that relaxation techniques, biofeedback, yoga, prayer, and meditation can all be beneficial and I cannot see how they would be detrimental if used properly.

In the category of manipulative medicine, I have not been trained specifically, but I refer to physical therapists and sometimes chiropractors. Massage therapy is a growing field, and has been recommended for children with muscle tightness affecting gait and for those with sports injuries.

Other CAM therapies are difficult for me to recommend.

Herbal therapies might be beneficial, but there is also potential risk of interactions with other therapies. They are not regulated by the FDA and have been known to be contaminated with things such as lead. There also have been reports of the strength of the supplement to vary widely from what is listed on the bottle and non-listed ingredients to be in the supplement. This can lead to unknown interactions and consequences.

Most studies of CAM therapies have been done on adults. Children are not little adults. Therapies such as lifestyle changes are safe, but those with herbal or homeopathic medications might not be. There simply is not enough scientific data to support the use of these in children.

Studies do show that about 50% of children have used complementary or alternative medicine (higher numbers if you include vitamin supplements). Unfortunately most of the time the physician is unaware of these treatments. Many of the kids using these therapies are those with chronic conditions for which there is no traditional medical therapy that manages the condition well. This means that more research is needed to show if they are safe or effective. Are they worth the cost? Is there something better? Should physicians recommend them because they do work?

Why would parents use a treatment that isn't proven? They just want to help. Many parents think "natural" is better.

My answer to that: I would never give my kids organic marijuana to stimulate their appetite. It is natural. Organic even. And it does stimulate the appetite, so it might work. But I know there are risks to marijuana. We've all heard those because it is a well known (and unfortunately misused) substance. Many herbs and other treatments aren't as well known.

How to improve the safety of CAM use in your children:

Discuss any therapy you are using with your health care provider. If you have more than one provider, be sure all know each treatment you are using.
If you use a CAM provider, be sure to check the education and training of that person. Are they licensed to practice? Be sure they have experience with the age group of your child. (This actually goes for any health care provider you choose!)
Ask your pharmacist if there are any known interactions with the supplements and medications you are giving your child. Be sure to list all prescription, over the counter, and supplements given.
Store all medications, supplements, and vitamins out of reach of children.
If you notice any ill effects that might be related to CAM or other treatments, be sure to discuss with your provider!

Resources:

AAP News 2008; 29;1
PEDIATRICS Volume 120:1, July 2007
PEDIATRICS Volume 125:2, February 2010
National Center for Complementary and Alternative Medicine (NCCAM)

Cold and Flu Season is Upon Us!

2011-10-20T12:48:00.000-05:00

As cold and flu season approaches, I have been thinking about how our kids are managed when they become sick. Not only what we do to treat symptoms, but how, when, and where patients get medical advice and care.

We are a busy society. We want things done now. Quickly. Cheaply. Correctly. Resolution so we can get back to life.

Illness doesn't work that way. Most childhood illnesses are viruses and they take a few weeks to resolve. There's no magic medicine that will make it better.

Please don't ask for an antibiotic to prevent the runny nose from developing into a cough or ear infection.

Don't ask for an antibiotic because your child has had a fever for 3 days and you need to go back to work.

Don't ask for an antibiotic because your teen has a big test or tournament coming up and has an awful cough.

Antibiotics simply don't work for viruses. They also carry risks, which are not worth taking when the antibiotic isn't needed in the first place.

Many parents in this community have grown accustomed to using after hour urgent cares because they are convenient.

Convenient isn't always the best choice. Many times kids go to an urgent care after hours for issues that could wait and be managed during normal business hours. I know some of this is due to parents trying to avoid missing work or kids missing school, but is this needed? Can it hurt?

Some kids will get unnecessary tests, xrays, and treatments at urgent cares that don't have a reliable means of follow up. They attempt to decrease risk often by erring with over treating. Our office does have the ability to follow up with you in the near future, so we don't have to over treat.

Urgent cares don't have a child's history available. They might choose an inappropriate antibiotic due to allergy or recent use (making that antibiotic more likely less effective). They might not recognize if your child doesn't have certain immunizations or if they do have a chronic condition, therefore leaving your child open to illnesses not expected at their age. We know that parents can and should tell all providers these things, but our own new patient information sheets are often erroneous when compared to the transferred records from the previous physician... parents don't think about the wheezing history or the surgery 5 years ago every visit. It is so important to have old records!

There is some evidence that treating things too soon does not allow our bodies to make immunity against the germ. A great example of this is Strep throat. Years ago we would go to a doctor when our sore throat didn't get better after a few days. They would swab our throat and send the swab for culture, which took 2 days. We would treat only after that culture was positive. That delay in treatment allowed our bodies to recognize the Strep and begin making antibodies against it. Now kids are brought in the day they have symptoms, and if the rapid test is positive, they immediately start antibiotics. The benefit? They are less likely to spread Strep to others and they can return to school 24 hrs after starting the antibiotic. The negative? They might be more susceptible to recurrent illness with Strep, so in the end are potentially sick more often and end up missing more school.

Receiving care at multiple locations makes it difficult for the medical home to keep track of how often your child is sick. Is it time for further evaluation of immune issues? Is it time to consider ear tubes or a tonsillectomy? If we don't have proper documentation, these issues might have a delay of recognition.

Urgent cares and ERs are not always designed for kids. I'm not talking about cute pictures or smaller exam tables. I'm talking about the experience of the provider. If they are trained mostly to treat adults, they might be less comfortable with kids. They often order more tests, xrays, and inappropriate treatments due to their inexperience. This increases cost as well as risk to your child. We have been fortunate to have many urgent cares available after hours that are designed specifically for kids, which does help. But this is sometimes for convenience, not for the best medical care.

Cost. As previously mentioned, cost is a factor. I hate to bring money into the equation when it comes to the health of your child, but it is important. Healthcare spending is spiraling out of control. Urgent cares and ERs charge more. This cost is increasingly being passed on to consumers. Your co pay is probably higher outside the medical home. The percentage of the visit you must pay is often higher. If you pay out of pocket until your deductible is met, this can be a substantial difference in cost. (Not to mention they tend to order more tests and treatments, each with additional costs.)

What about our urgent care in our office? We offer a walk in urgent care as a convenience for parents who are worried about their acutely ill child. It is within the medical home, which allows us access to your child's chart. We can keep all treatments within this medical record so it is complete. Our staff follow the same protocols and treatment plans as scheduled patients, so your child will be managed with the protocols our physicians and midlevel providers have agreed upon. Essentially we have a high standard of care and want your child to receive that great care.

So what kinds of issues are appropriate for various types of visits?
(note: I can't list every medical problem, parental decisions must be made for individual situations)

After hours urgent care or ER:

Difficulty breathing (not just noisy congestion or cough)
Dehydration
Injury
Pain that is not controlled with over the counter medicines
Severe abdominal pain
Fever >100.4 rectally if under 3 months of age

Pediatric Partner's Urgent Care:

Fever
Ear ache
Fussiness
Cough
Sore throat
Vomiting and/or diarrhea
Any new illness

Issues better addressed with an Appointment in the Medical Home:

Follow up of any issue (ear infection, asthma, constipation) unless suddenly worse, then see above
Chronic (long term) concerns (growth, constipation, acne, headaches)
Behavioral issues
Well visits and sports physicals (insurance counts these as the same, and limits to once/year)
Immunizations - ideally done at medical home so records remain complete

If your child gets a vaccine at any other location, please send us documentation (including the date, brand, lot number, and place administered) so we can keep the records complete.

Remember our website offers answers to questions and many treatments to try at home for various illnesses and conditions!

Starting Solids-- The Old and the New and the Myths

2011-10-19T06:44:00.000-05:00

Many parents are excited yet apprehensive to start foods with their infants. So many questions, so many fears. So much food introduction guidance has changed in recent years, that what you did with your older kids might not be current. Change takes time, so not everyone agrees on the "new" rules. Talk to your own pediatrician to see their take on it all!

The older "rules" for starting foods were so confusing... different sources will vary on these rules.

don't feed before 6 months is now ok to feed at 4 months if baby's ready

don't give nuts, eggs, and other "allergy" foods until ____ (2/3/5 years, varying by expert) is now it is okay to give allergy foods unless there is a family history of food allergy

don't start more than one food every 3-5 days is now introducing multiple foods at one time is ok

start with rice, then add vegetables, then meat., wait until last for fruit is now begin with any foods, but try to make nutritious choices, such as meat which is high in iron and protein

Variations of this were plenty, depending on the provider's preferences.

No wonder there is so much confusion!!!!

New rules are much easier. I like easier.

Start new foods between 4 and 6 months, when your baby shows interest and is able to sit with minimal support and hold the head up.
Don't give honey until 1 year of age.
Don't give any textures your baby will choke on.

Done.

That's it. Nothing fancy. Any foods in any order. Multiple new foods on the same day are okay. Common sense will hopefully guide types of foods. Nothing too salted. Try nutritious foods, not junk.

These minimal rules can make parents weary.

What about food allergies if foods are given too early?

Research does not support the thought that starting foods earlier lead to allergies. In fact, there is research to support that starting foods earlier might prevent food allergies. A full 180 degree change! Pregnant women and breastfeeding mothers no longer have to avoid nuts or other allergy foods in most cases. If there is a close family member with a food allergy, it might still be beneficial to wait to introduce that food. Talk with your pediatrician in that case.

I admit that I was initially nervous about telling parents it was okay to give nut products in infancy. Not just the allergy aspect, but also choking risks. ~ Back to the no textures your baby will choke on... nuts are hard and round-- two no-nos, peanut butter is thick and sticky-- another choking risk.

Any of the more allergy prone foods should first be offered in small amounts at home. These foods include nuts, egg, and fish. Do this only if there is no one in your house who is allergic to that food. Have diphenhydramine allergy syrup around just in case, but remember most kids are NOT allergic, and starting younger seems to prevent (not cause) allergy. In the case of nuts, since there is also a choking risk, you can try a food cooked with nuts or nut oil.

What about saving the fruit for last so they don't get a sweet tooth?

Babies who have had breast milk have had sweet all along! Breast milk is very sweet, yet babies who are graduating to foods often love the new flavors and textures with foods. Formula babies haven't had the sweet milk, but they can still develop a healthy appreciation of flavors with addition of new foods. Saving fruit for last simply doesn't seem to make a difference. Adding fruits alone is not very nutritious though, so fruits should be added along with other more nutritious foods. The more colors on our plates, the healthier the meal probably is!

I thought they couldn't have cow's milk until after a year?

Cow's milk is not a meal in itself (like breast milk or formula). It is missing many vitamins and minerals, so babies need to continue breast milk or formula until at least a year. Cow's milk may lead to allergies or eczema, including formulas made with cow's milk. Milk products, such as cheese and yogurt can be given to babies as part of an otherwise well rounded diet as long as they don't show any allergy risks to milk. Regardless of dairy intake, it is recommended for infants under 6 months to have 400 IU Vitamin D/day and those over 6 months to take 600 IU Vitamin D/day as a supplement.

I thought they should have cereal first...

Rice cereal has been the first food for generations, probably because grandma said so. There has never been any research supporting giving it first. With white rice and other "white" carbohydrates under attack now, it is no wonder the "rice first" rule is being debated. Despite being fortified with vitamins and iron, it is relatively nutrient poor, so choosing a meat or vegetable as first foods will offer more nutrition.

Shouldn't we wait on meat?

Waiting on meat due to protein load was once recommended, but no longer felt to be needed. Pureed meats (preferably from your refrigerator... baby food meats are not very palatable!) are a great source of nutrition for baby! Some experts recommend meat as the first food due to its high nutritional value and low allergy risk.

How do we know what they're allergic to if we start several new things at once?

First, most kids are not allergic.

Second, if they are allergic to a food, it is often days/weeks/months before the allergy is recognized. Waiting 3 days between food introduction simply doesn't allow recognition unless it is hives or anaphylaxis, and there are a small number of foods that account for most of these reactions. If your child has one of these reactions we can test to see what the offender was. This is recommended with severe allergies since people with one allergy might have other allergies, and identification for avoidance is important.

Allergy symptoms can be broad and often are not specific: dry skin (eczema), runny nose, hives, swelling of lips, difficulty breathing, vomiting, diarrhea, or blood in the stool. If you think your child is allergic to a food, discuss with your doctor. Severe symptoms (anaphylaxis) demand immediate attention!

How do we know when to start foods? I wanted to start to help baby sleep through the night, but I heard starting too soon increased obesity and diabetes.

When babies are able to sit with minimal support and hold their head up and when thye show interest in food by reaching for it they might be ready. They can wait until 6 months to start foods, but some studies show poor weight gain and nutritional balance as well as resistance to foods if started after 6 months.

In formula fed babies it has been shown to increase the risk of obesity at 3 years (6x!) if foods are started before 4 months of age. That risk is not seen in exclusively breast fed infants or those who begin foods after 4 months of age.

It is still an old wive's tale that starting solids will help baby sleep through the night. Babies tend to sleep longer stretches at this age, so it is no wonder that this myth perpetuates. Start foods because you see signs that baby is ready, not because you want longer sleep patterns!

How do I know how much to feed my baby?

Babies will let you know when they are full by turning away, pursing their lips, spitting out food, or throwing foods. As they eat more food, they will need less breast milk or formula. In general a baby who is gaining weight normally will self regulate volumes.

What's better: baby foods bought at the store or home made foods?

Marketing and ease of preparation has made pre-prepared foods for us all common place. It does not mean they are any better. They cost more than home made foods. I didn't make baby foods when my kids were babies because I thought it would be too hard, but now I puree foods to put into recipes (my kids are like many who aren't fans of veggies and I want to improve their nutrition). It really isn't hard. You can take whatever you are cooking for your family and put it in a food processor or some blenders and with a little water to get it to a texture baby can eat: voila! Home made food. There are of course many baby food cook books and ideas of how to freeze meal-sized portions so you can make multiple meals at one sitting. There is help for parents who want to safely prepare baby food at home at the USDA website.

My baby only wants table foods. Is that okay? Don't they need pureed foods first? He doesn't have many teeth!

Pureed foods are what most babies start with due to the easy texture, but some babies quickly develop the ability to pick up small pieces of food with the pincher grasp (finger/thumb) and want to feed themselves. If they are able to get the food in their mouth, move it to the back safely with their tongue, and swallow without choking, they are ready to feed table foods... at least with some textures. Beware of chewy or hard foods as well as round foods ~ these all increase the risk of choking.

Most babies will be able to eat table foods between 9 and 12 months. They tend to not have molars until after 12 months, so they grind with their gums and use all their saliva to help break down food. They need foods broken into small enough pieces until they can bite off a safe bite themselves.

Don't put the whole meal on their tray at once... they will shove it all in and choke! Put a few bites down at a time and let them swallow before putting more down. Rotate food groups to give them a balance, or feed the least favorite first when they are most hungry, saving the best for last!

This is a great time for parents, sitters, and other caregivers to take a refresher course on CPR in case baby does choke. Infants and young children are more likely to choke on foods and small objects, so it is always good to be prepared!

How much juice should my baby drink?

In general I think babies don't need juice at all. They can practice drinking from a cup with water. Juice adds little nutritional value and a lot of sugar. Eating fruit and drinking water is preferable. If they do drink juice, it should be 100% fruit or vegetable juice, not a fruit flavored drink! No more than 4 ounces/day of fruit juice is recommended.

What about organic?

There is not enough evidence to recommend organic food, since the nutritional components of the foods are similar regardless of how they were farmed.

Organically grown foods do have lower pesticide residues than conventionally farmed produce, but it is debated if this is significant or not to overall health. Conventionally farmed produce have the pesticide levels monitored, and they fall within levels that are felt to be safe.

Organic farming rules also dictate no food additives or added hormones, which is also an area of study for health risks and benefits, but not enough data is available to give an educated opinion yet.

Organic farming is generally felt to be better for the environment, but the sustainability of that is questioned.

Organic farming might increase the risk of bacterial and fungal contamination or heavy metal content, so it is very important to wash fresh fruits and vegetables well prior to cutting or eating (as you should with all fresh foods).

For more information, see the USDA site.

A backyard garden can be inexpensive, organic, and a great way for your kids to learn about growing and preparing healthy foods!

Food Strike!

2011-10-14T10:15:00.000-05:00

A recent facebook question: Any articles out there about what to do when your child goes on an eating strike? My son, who's five (soon), has these occasionally, and he's already thin as a rail to begin with :)

My answer became much too long, as this is a very common concern and there are so many aspects, so it turned into this blog.

This question (very common) always reminds me of the Judy Blume book, Tales of a Fourth Grade Nothing. (One of my favorite books growing up.) The younger brother in the book, Fudge, refuses to eat. After many failed trials of forcing food, and bribing, his Dad finally loses patience and says "eat it or wear it." Needless to say, Fudge ends up with the bowl of cereal on his head and goes around for days saying "eat it or wear it!"

Food Strike! This is a common concern of parents. But kids are smart, they won't let themselves starve.

Of course there are some instances that are cause for concern. Red Flags include kids who are sick, recurrently vomit or ruminate, seem dehydrated, have problems with food allergies, are very limited in foods over an extended time, experience swallowing problems or choking, or who are not following their growth curve. Red flags are another topic entirely! Work with your physician in these cases.

If hungry, he will eat. Just don't let him fill up on things that aren't giving a nutritious balance. Even just milk all day can be harmful because it lacks many vitamins and minerals, so a little milk with other foods is better!

Offer veggies, fruits, cheese, nuts, etc at scheduled snack times.
Limit pre-packaged foods and snacks.
Limit drinks other than water and low calorie milks. These fill kids up and don't offer balanced nutrition.
Put only a small amount on his plate... it might be overwhelming to have a full plate.
Turn off the tv. Have a dinner conversation with the family. This not only sets up healthy eating habits, but also healthy family dynamics. Teens who eat with their families are less likely to have risky behaviors!
Set a good example! Talk about how much you are enjoying the healthy foods at the table. (Not how healthy they are, but rather how good they taste.)
Keep foods separate on the plate... they might eat one food if not touching another.
Set a time for meals and stick to it. If your child doesn't eat, still clear the table. When they complain of being hungry, don't be condescending. Simply say, "I know how you feel. I'm hungry too when I don't eat. Dinner is coming up soon. I'm sure you'll be ready!" Don't offer filler foods. Don't yell. Don't over-discuss. Kids are smart, they'll pick up on the fact that they need to eat at meal time or be hungry. (They won't starve to death!)
Hide healthy foods in casseroles, sauces, etc. I love my blender... the food processor was too much for me to clean, but my blender works just as well! Many vegetables have little flavor, which makes it easy to "hide" them in things.

I put a can of beets in with the spaghetti sauce --makes a cool color without changing the flavor.

I put carrots, spinach, or cabbage in my smoothies without changing the flavor. Strawberries, bananas, kiwi, and other fruits are much more flavorful than many veggies and kids tend to like their tastes. I just try to match color to hide the vegetable.

Puree onions, carrots, zucchini, spinach, and other vegetables in recipes rather than chopping them... kids won't pick them out! Chances are they won't even know they're there.

Try foods in different forms:

frozen peas are crunchy-- maybe they don't like the squishy texture of cooked peas
raw broccoli is much different in taste and texture than cooked broccoli
many kids love cheese over vegetables or foods dunked in catsup or yogurt
it is fun to eat with fingers for a change... let them get messy!
try cutting things into pieces and serve with toothpicks
make a kabob of fruit and cheese pieces... it's always more fun to eat off a stick!
cut sandwiches with a large cookie cutter for fun shapes
use small cookie cutters for bite sized sandwiches or fruit pieces

Try not to use food as a reward. This can set up unhealthy eating habits.
Don't reward for eating. Most kids will get the intrinsic reward of satiety. They don't need stickers or dessert for eating a meal.
Praise small steps. If kids try a new food (whether they like it or not) praise the fact that they tried!

Set your expectations realistically. Don't expect kids to eat as much as infants/toddlers or teens/adults. Calorie needs go down when not in growth spurts. Just make the nutrition needs balance. Don't worry as much about volume as variety of healthy foods! Most kids don't need supplemental meals in a can (Pediasure and other brands) ~ they are getting the nutrition and calories they need, there is just an imbalance of perception of what they need. I always prefer a healthy, active, thin child over a child who is overweight and not active (and often undernourished due to poor quality foods).

Vitamin supplement use and need is debated (except Vitamin D, which is recommended for all). In general, I think it is a good idea to give a multivitamin with iron if kids aren't eating well. Iron deficiency actually causes anorexia-- increasing the problem! Just be sure to lock up vitamins as if they are medications, so kids don't accidentally ingest too much.

Most kids grow well during their picky eating and food strike phases! Just be patient and aware of any red flags that need to be evaluated. If you are concerned, schedule an appointment to discuss foods, growth, nutrition, and concerns. Bring a typical food log of foods and drinks (with approximate volumes) for at least one week. We can either identify a concern and develop a plan of action, or reassure you that your child is normal!

Middle Man Payment Plan?

2011-10-08T15:41:00.000-05:00

Healthcare billing is a very complex issue, mostly because people are familiar with purchasing things with money or credit in full disclosure of costs, not the complex system of insurance billing.

People pay a lot for insurance, and then expect insurance to cover the cost of care, but they often do not realize the details of their contracts with insurance - AKA the Middle Man.

Patient <--> Insurance <--> Doctor Office

This is a long post, so bear with me... it is such an important but complex issue. I am only touching the surface here. If you can't read the whole thing, at least hit the highlights at the bottom!

Typical purchase: Buying a shirt.

I select my favorite store.
I look through the rack of shirts and pick one that is the right size and color.
I look at the price tag and decide if I want it.
Maybe I have a coupon or it's on sale - I can calculate the discount!
If it is the right cost and meets my needs, I make the purchase. I can choose cash, check, credit card. Maybe I have a gift card!
If it isn't right for any reason, I keep shopping.

Healthcare purchase: Full of Unknown costs... making the decision to "purchase the product" much more difficult.

Product? What product?

"Product" is the expertise and knowledge of the healthcare professionals.
There is nothing to take home to show.
Time spent with the provider may or may not end up with a prescription or other identifiable thing that shows what the money was used for.
You might leave the office with as many (or more) questions because final diagnosis of a problem can be a process that takes time.
You might disagree with the diagnosis or treatment given. You don't have the option to choose another shirt. You already bought this one when you signed in. You could buy another (2nd opinion) but you'd have to pay for both. I hope you talk about these concerns at your visit... don't just worry that we "missed" something or did it wrong!

Costs are becoming more important to the consumer as many insurance companies are putting more financial responsibility on their policy holders and covering less medical costs. So it would be best if we let you know our fees and your payment amount before we see your child, right? Well, there's a catch to that.

The catch? I don't know what your insurance contract requires of you, so it is impossible to accurately tell you what your real cost will be until after my office gets the insurance adjustment. I don't know exactly what the insurance company will pay and what they'll discount ... my billing staff can make an educated guess based on past experience with a company, but it varies from case to case.

In this difficult economic time this places financial stress on families. I understand this and am happy to work with families on payment plans if they let me know their hardships, but often they simply yell that I billed it wrong. Because of contracts between my office and the insurance company and the patient and the insurance company, there are many rules and laws regarding how to bill and collect payment.

Back to Healthcare "purchase":

Patient/consumer uses a service.
Place of business (ie doctor's office) submits a bill based on well defined codes. This bill doesn't go to the patient. It goes to the Middle Man.
Middle Man (insurance company) reviews the bill submitted.
Middle Man discounts each item to what they believe is a reasonable fee.
Middle Man pays the part of the adjusted fee that they are contracted to pay.
Middle Man sends us this information and we write off the discount they applied and bill the patient/consumer the difference.
We have provided a service and it is several weeks to months before any money is collected. Anyone in business knows the consequences of this timeline of money collection.
Payment collected from the doctor's office depends more on what the insurance company adjusts the bill to rather than the original bill itself.
Note: although the bill comes from us and is due to us, it is a result of your insurance plan/contract! In general, the less expensive your plan for monthly health insurance, the more you are responsible to pay with each use.

Let's run through a couple scenarios of this Middle Man payment plan.

First scenario: Well visit plus additional concerns. A child is scheduled for a well visit but woke with a fever and cough. He has an insurance company that requires a copay for each issue seen in the office. We provide the care for a complete well visit (monitoring growth, development, nutrition, safety, reviewing vaccinations, etc) and bill for that service. We also ask further questions regarding this illness and symptoms and discuss management for the fever and cough. Addressing and Documenting these issues (after all, the kid isn't well) is important. When the bill is submitted to the Middle Man, the insurance company sees that the child is sick, so tells us to bill the family for a 2nd copay. Our contract with this insurance company requires this, so we must bill to the family. By law we must follow our legal contract. To fail to do this is insurance fraud. I'm not willing to go to jail to save a family a few bucks. Sorry. I love my patients and want to help, but I don't want to have to go to jail for trying to do a good deed.

Second scenario: Screenings and tests sometimes, but not always covered. Another child is in the office for a 3 year old well visit and is due for a vision screening. We know that most people either don't have vision coverage or their insurance only covers one vision test every 1-2 years. The standard of care (ie what should be done if we want to provide the BEST care) is to do the vision test at this age. This causes many possible scenarios, most of which equates to a headache for pediatricians:

If a patient passes a vision screen done at our office and the insurance pays: great. Rare, but great.
If a patient's parent refuses the vision screen in our office (or fails to take the child to the specialist when we refer) because they feel the eyes are normal and don't want to pay, but later learn there was a problem that should have been addressed earlier for better outcome: parent is upset with us that we didn't insist on screening. The child also suffers from an undiagnosed vision problem.
If a patient passes a vision screen and insurance applies the charge to the deductible: the parent is upset at us for charging something "that wasn't needed. I knew the eyes were fine." (Note: we are the bad guy because the bill comes from us, despite the fact that it is their insurance company that chooses this payment method.)
If a patient fails our vision screen and insurance pays us: parent is upset because we used up the once/year (or every other year) coverage, and now they pay out of pocket for the ophthalmologist.
If patient fails our vision screen and insurance doesn't pay: parent is VERY upset because they must pay twice! (us and ophthalmologist) Why is this? Screenings by nature pick up some normals so they don't miss any abnormals. If a child fails at our office, they need to be seen by a specialist to confirm if there is or is not a problem. Two visits by two providers with two fees. Ugh!

So... how many of these vision screening scenarios ended up with all happy? ONLY ONE RARE CASE!

Please read your policies and ask questions to your insurance company before visiting the doctor so you know your financial responsibility. Plan accordingly to save some money for healthcare needs.

One major issue we are seeing is described in scenario #1 above. We follow the use of CPT codes as published by the American Medical Association. To bill both a sick and well visit on the same date of service, we add a Modifier -25 to identify separate preventive medicine service (well child exam) and a problem-oriented service (ear infection, hurt foot, earwax removal, etc) on the same date of service. This is the national standard, but not all insurance companies cover it the same. Middle Man may tell us to charge the insured family a second co pay. Why? Because they want their members to pay their contracted portion of each visit. Simply saving up multiple issues to be seen on the same visit day does not result in a person being less responsible for their portion of medical costs agreed to in a contract. You are responsible for what your contract states.

Or maybe you simply have a high deductible plan. You will be responsible for payments until you reach the magic number in your contract. You have the benefit of lower monthly premiums, but expect to pay more each time you need medical care.

Another issue is labs. Some insurance companies ONLY pay for labs done at their contracted lab. This means that quick Strep throat test we did gets charged to you. Unfortunately we didn't know this from your insurance card. Is it worth it to you for the convenience of knowing results right away to pay for the rapid strep, or would you prefer to wait for the lab to give culture results in a couple days? If this is important to you, call your insurance company. Tell us before we do the test!

Billing codes separate out parts of services/product. Immunizations are a great example of this. There is the vaccine component, and there is an administration cost to cover costs associated with a vaccine:

vaccine insurance -- they are expensive and need to be covered!
temperature control of the refrigerator--did you know if the temp gets too high or low it alarms so our vaccine doesn't become ineffective? After hours one of us is automatically paged and we have to go in to see what is wrong?
incidental supplies like syringes, needles, bandaids-- all the little costs add up!

Some insurance companies pay only the vaccine component, but not the administration fee. It goes toward the deductible. Do you know how your plan works?

What does this all mean?

We would like to provide the best care to our patients in a timely and economical manner, but we need your help identifying what you want done and not done due to costs before your visit.

If we address well and "not well" issues on the same day, it might mean a 2nd co pay or deductible for you to pay. Some issues deserve a separate visit due to the nature of the concern.

We encourage you to do the recommended follow up labs and tests discussed at visits for the best medical care of your child.

If your insurance company tells us to write off a portion of your bill, we do. It is illegal to balance bill a patient.

If your insurance company tells us to bill you for a service, we do. It is illegal to write this portion off.

If you have a high deductible plan, save the money you save on premiums monthly in a special account for use when needed.

If you have any questions about your bill, please feel free to call our billing department to discuss. Please choose nice words with our staff. They are only the messenger!

Humility: the Anti-Bully

2011-10-02T20:54:00.000-05:00

October is National Bullying Prevention Month, a topic that is important to me because it affects most of us at some point or another. I will post information all month on our facebook page about bullying. I don't want to repeat details of recognizing and stopping bullying -- there will be lots of great information posted, keep watching our wall!

I want to talk more about learning how to prevent bullying from a different perspective. The slippery slope of when friendly banter or bragging turns into hurt feelings. The way kids treat family members can reflect on how they will treat friends and classmates. The way kids are treated by family members also shapes their behaviors.

Bullying varies in severity and type. We all recognize severe verbal bullying and physical bullying, but there are shades of grey. When is it bullying and when is it just kids being kids?

Bullying is when kids hurt other kids on purpose, but what if it isn't on purpose? Kids still feel hurt. How can you tell if it was with intent to hurt or just a blunder?

My team is better than your team. Bullying or just a friendly competitive spirit?
I got an A on my test! Pride or making another feel small without knowing it?
You got your hair cut? (in that voice) Surprise reaction -- or does hurting feelings mean bulling?

Kids don't always recognize when they say something hurtful. They haven't learned to always think before speaking or acting. This doesn't make the action acceptable, but it offers a teaching moment.

Tell them when you hear words that can be hurtful. Ask how they would feel if someone said that to them.
Discuss how the look on the friend's face lets you know something is wrong. Talk to kids about how to understand when another person looks hurt or changes their mood suddenly it might be due to what was said or done. When they see face changes or moods fall or become angry, they need to quickly think back to what was said. They can ask the friend if they said something wrong. They should apologize if the friend's feelings were hurt, whether the friend admits hurt feelings or not.
Teach kids to speak up for themselves when someone says something hurtful. Until their friends learn to recognize what they say is hurtful, they need to be told. A friend will stop. Hopefully the friend will apologize, but maybe they haven't been taught that yet. Teach your kids to accept apologies and offer forgiveness.

A bully will keep doing the same behaviors even after the behavior has been called to their attention. Bullies tend to pick on kids who have less self confidence, so build up your kids. Let them know they are loved. Teach kids that it is okay to ask an adult for help.

I believe that teaching core values and showing a child love can help prevent bullying. This is counter to many of societies goals. It involves a tricky balance between building self esteem with praise without over-inflating the ego or demanding perfection. Love kids for who they are, not what they do.

Bullies are self-indulgent and impatient. They try to feel better or inflate their self esteem by putting others down, but don't feel happiness. They blame others or the system for problems. They often feel unfulfilled and need more out of life but they don't know how to achieve these needs. They probably don't even see that they are unfulfilled.

Kids who know that they shouldn't lie, cheat, and hurt others because it is wrong might think twice before intentionally hurting someone's feelings or spreading lies. Young children must learn this. We need to talk to them about how their words make others feel. How would they feel if someone said that to them?

Don't tell them how they would feel. Ask them, guide them.

I think humility is the anti-bully. Humble people put others first and treat others with respect. They are not weak and they are not step stools. They have self confidence and inner strength, but are happy when others are happy. They don't need to prove themselves to others. Kids who put others first will be less likely to try to put others down to make themselves feel better. A mistake should not break their whole self esteem because they know they are loved for who they are, not what they do. They shouldn't have to defend themselves. They can admit their mistakes and not lie to cover them up.

Do not confuse humility with humiliation. Humiliation is of course bullying and the opposite of being humble and helping others.

The best way to teach humility is to be a humble example. Serve others. Volunteer. Give praise freely and unconditionally. Show caring and respect to all. Give credit where credit is due. Accept responsibilty. Ask for forgiveness when needed. Offer forgiveness to others.

Teach kids to give out praise often to others. Who doesn't love it when others notice them? What can we say to people with genuine heart felt praise? Think of ideas together and praise them when you see them hand out praise! This builds confidence all around. Confidence protects against bullying!

Teach kids how to respond truthfully without making others feel put down and without seeming over-confident. (No one likes the kid who brags...)

"You scored the most goals. Great job!"

Reply: "The whole team was great. I couldn't score if they didn't pass the ball."

or "Coach taught me a great move. I couldn't do it without his help."

"Wow! You got an A on the test. I tried so hard and got a C."

Reply: "The way the teacher explained it really made sense to me. I couldn't do it without good teaching."

or "I had to study really hard too. Maybe we can quiz each other next time."

or "Math might be easier for me, but you are great with music!"

Teach kids to apologize when needed. No one is perfect, and there is always a need to know when and how to apologize. Words must sound sincere. Don't allow kids to work around the situation or lie to get out of trouble. Don't allow them to put blame on anyone or anything else.

Teach kids they can only control what they say and do. No one can control what another says or does. How can they change their words or actions to change the outcome of a situation?

Have you ever read one of those books that have multiple endings? The ones that say things like, "If you want to go into the house, go to page 43. If you want to go to the park, go to page 46."

Have kids pretend that their life is one of those books.

Tell him to pick a time that someone's feelings were hurt, a fight started, or he got in trouble.

Now have him change one thing he did or said. Play out the rest of the situation.

Ask: How would the other person respond to your new action? How does that change the end of the situation?

This takes some practice, but we can all learn from this type of reflection.

Adults need to model these behaviors. Kids can't learn humility just from being told. They must be shown these behaviors daily.

Kids who know what to do if they see bullying behavior or feel bullied can help stop the cycle. Many schools have anti-bullying programs in place.

Does yours?

Do you model anti-bulling values at home?

Too Little Sleep in Athletes

2011-10-01T15:35:00.000-05:00

I am very concerned on many levels about late nights required for local sport programs from a parent perspective and as a pediatrician.

Many physical and emotional problems have been linked to sleep deprivation. I see many kids who struggle in school and at home with behavior and learning problems that are directly related to loss of adequate sleep. Poor sleep is also related to obesity, poor growth, depression, anxiety, poor school performance, and so many other issues. Sleep is needed for release of growth hormone, which is needed for bone and muscle growth, muscle repair, fat burning, and learning. Sleep loss leads to poor attention spans, inconsistent performance, decreased aerobic endurance, delayed response times, and increased illness, and will therefore affect their game! There is increased risk of injury in these tired athletes.

You can argue that one late night a week will not have devastating consequences, but I disagree. We have all heard that consistent bedtimes are important for sound sleep. Ironically sleep deprivation often leads to insomnia and more sleep problems. You cannot sleep "extra" to bank sleep hours. Kids will often sleep in on weekends to attempt to catch up on the sleep hours missed during the week, but that means a week of struggles emotionally and physically. It also gets their sleep routine off balance, which again contributes to poor sleep.

It is recommended to exercise at least 2-3 hours before bedtime because exercise is stimulating, making it difficult to fall asleep after exercise until the body temperature and metabolism return to normal. Yet I find that many school aged kids have practices and games in the late evening into night hours.

School aged kids up to 12 years of age need 9-11 hrs of sleep per night to function adequately. Practices and games late in the evening shortchange their night's rest by far too many hours. Don't forget to consider that the time to settle down after the game is up to 3 hours. The following day they are likely to have problems at school. An overtired child often has MORE problems getting to sleep, which affects the rest of the week. These younger kids tend to have a lot of noticeable behavior and learning problems. Many are misdiagnosed with ADHD and treated with medication, when all they really need is better sleep. It is simply not acceptable to set them up for this failure.

As kids enter middle school they often need extra sleep due to puberty. (Growth hormone is released during sleep.) Unfortunately, school tends to start earlier and their game/practice times are often later, meaning they might be getting up just a few hours after they are falling to sleep. Do we really want to affect their growth during these important years?

No wonder many middle and high schoolers fall to sleep in class and struggle with falling grades, irritability, depression, and more.

Kids shouldn't have a hard time getting up in the morning. If they are, it's a sign of not enough sleep!

I should also include coaches and parents in this, since we will be required to teach and transport these kids. Adults will fall short of their recommended 7-9 hrs of sleep, which affects mood, weight gain, and attentiveness. This affects not only health, but also home and office life. Can you wake up before your alarm? If not, can you get to bed earlier? That is a healthier choice than adding an extra cup of coffee or energy drink to your day.

We as parents and coaches want our kids to succeed in all areas of life. We want to give them the tools they need for this, which must include proper sleep. Practice and game times on school nights must take into consideration the sleep requirements of these kids. I do not want to be responsible for allowing my child to be out late on school nights, therefore contributing to increased risk of poor school performance, behavior issues, immune deficiencies, depression, growth and obesity, and all the other known consequences of poor sleep. Once these issues surface it is too late to prevent them and the snowball effect begins!

The question: What can parents do?????

Got Milk? Cow, Coconut, Soy, or Almond?

2011-09-25T14:17:00.000-05:00

A Facebook follower asked about how to choose a milk substitute recently. There is not a simple answer.

For many years it was easy: The American Academy of Pediatrics recommended whole milk from 1 year to 2 years of age, then 2% until 4 years. At 4 years it was recommended to switch to skim milk. If kids couldn't tolerate cow's milk they were given soy.

Then came questions about the estrogen like effects of soy and the problem that soy allergy is common in milk allergic kids.

The obesity rates climbing in kids has put into question whether whole milk is needed until 2 years and if lower fat milks should be given at younger ages. The answer to this is probably not routinely, but toddlers who are overweight can benefit from a lower fat milk.

Grocery store shelves now offer not only whole, 2%, 1%, and skim cow milks (regular, hormone free and organic of each of these!) and soy milk, but they also sell lactose free milk (in several fat concentrations), rice milk, almond milk, coconut milk, and goat milk.

How do you make the right choice for your child? Below is a nice chart from MyHealthNewsDaily.com comparing calories, fat, protein, and calcium contents of various milks. Taste is a very important consideration for the picky child. If they don't like the taste, they will not drink it. Even the textures of the milks can vary quite a bit and might require acclimation. Food allergies and intolerances drive many of the choices. Note: none of these are appropriate for infants under one year. Breast milk or formula are the only healthy options for infants due to other nutrients needed in an infant's diet!

Historically it has been felt that toddlers need more calories from milk, and should not regularly drink a low fat/low calorie milk. Because of the rising obesity rates (even among toddlers and preschoolers) this recommendation is changing and kids can drink lower calorie products if their caloric intake from foods is sufficient. Beware of high calories in milks like coconut milk, goat milk, rice, or soy milk. They have nearly as many calories (or more!) than whole fat cow's milk.

One cup of coconut milk has over 50 grams of fat and over 460 calories! A special treat: yes. A routine daily drink: no!

(For comparison, a BK vanilla milkshake has 412 calories and 23 grams of fat in 227 grams (just 1/2 oz shy of a full cup).

Calcium levels vary widely in various milks and should be taken into consideration when choosing a milk for your child. Other foods, such as calcium fortified orange juice, yogurt, tofu, leafy greens, cheese, and fortified cereals, can (and should) incorporate calcium into the diet.

Vitamin D is very difficult to get through diet alone and it is recommended that everyone take a Vitamin D supplement. For more information, click here.

There is no consensus that organic milk offers any health benefit. Due to it's high cost, it is prohibitive for many families to buy organic. Hormone free milk is available for a mid-range cost without the potential (yet unproven) risks of hormones given to cows. There isn't any nutritional benefit of the hormone free milk or organic milk compared to conventional milk, but if you are concerned about hormone exposure from milk, hormone free is less expensive than organic.

Lactose free milk: 160 calories, total fat 9g, protein 8 g, calcium 30%
Lactose free reduced fat milk: 130 calories, total fat 5g, protein 8 g, calcium 30%
Lactose free fat free milk: 80 calories, total fat 0g, protein 8g, calcium 30%
(Lactose milk nutrition facts based on one cup, from www.fatsecret.com)

Screen Free Week Reflections

2011-09-25T07:12:00.000-05:00

I have been a fan of Screen Free Week since I heard about it. Even before I heard of the official week, it was a popular negative consequence in our home.

I used to enforce unofficial screen free weeks at our house regularly when I saw my kid's behaviors turn toward selfishness, fighting, and whininess. Turning off the tv and video games help. Maybe it's because the screen activities wind up their brains. Maybe it's because it is "down" time and they need active time. Maybe because I was guilty of using the tv as a babysitter so I could get my own things done, yet the kids needed time with me. There are many more maybes, but all I know is that turning off the tv and video games seems to always help. I get a bunch of complaints at the beginning of the week, but by the end of the week the kids are in a new habit of finding things to do without electronics. It's fun. We all get along better.

This Screen Free Week I realized that it is harder than ever though. Not for the kids, but for me. I can never get off computers completely. We use electronic records at my office. I use the internet to search for information related to my job. Those are allowable uses, since electronics for work and school are exceptions to turning off the screen. Computers are simply a part of our life.

We are all relatively new to all the opportunities for wasting time on tv (remember when there were just a couple channels?) and internet offerings. We are plugged in from our computers and our Smart Phones. We get a lot of work done and learn information on these Screens. When can we unplug? How do we learn to manage our time?

This week I was going to at least stay off Facebook, since that is mostly fun stuff that I share with patient families. Work related, yes. Necessary, no. I feel that by posting to Facebook it encourages others to look at Facebook. Facebook is a huge time waster for many. (And yes, this is from someone who is totally addicted to facebook... I spend quite a bit of time searching around on it to scope great things to share!) A great reason to turn off the screen for a week!

But then I need to reevaluate the "Necessary, no." What is necessary? I still had to look at Facebook to be sure the office page was not being abused with posts that were inappropriate. Most things I post are not timely. There are some recalls that are important, but not really imperative to share NOW.

But there were several things that happened in this one week that Social Media could really benefit. Where do you draw the line of staying off Social Media and when does it become "work" so it is excluded?

We did post two things to our wall that did seem to meet the criteria of important and timely. One was a request from the Health Department to spread the word about an outbreak. Why is this important? Because 8 people in Kansas have been sick and 2 have died. Warn people: good. But then to see it, people are checking their Facebook posts: bad. Such a slippery slope!

The second post was about our own office's access. We were not warned that our parking lot was to be resurfaced. Staff arrived to work and found the whole thing blocked with no access to our main door (until we convinced them it was unacceptable during office hours). Yikes! How to spread the word quickly? Yes, we can call the patients with appointments and tell them where to park, but what about walk ins? Facebook is fast. It can be helpful! But we told people to stay away for the week. Sigh. Just can't win!

A third post that didn't end up getting posted because it is a bit hazier in importance and timeliness. We have promised that when we open flu clinic appointments we will share on our website and Facebook page. Of course we were able to secure a couple dates during this Free Week. We posted to the website, since people always use that for health matters, not "fun". We sent out an email to registered website users. But we didn't post immediately to Facebook, again to encourage people to stay off Social Media for the week. But Facebook isn't purely Social. It is used to share information in a way that wasn't possible years ago. (No worries for those of you who haven't signed up yet... there will be plenty of time to sign up!)

Other posts that aren't timely were easy. Save for later. I am using a scheduling system that schedules posts, so I don't have to post daily. That is helping manage my time on Facebook. I still have to look daily to check on posts, but it does help with time management.

I think that is where the secret lies.
We all need to learn time management with the Screens. What is important? What are time wasters? Time wasters aren't always bad. It can be great to vege in front of the tv after a long day and just relax without any bothers. It is fun to catch up on what friends are up to on Social Media. It can save time if you have exciting news and post once for all your friends and family to see (less personal than a phone call or visit, but faster!)

We need balance.
We need to make time for family, faith, exercise, healthy family meals, and sleep. Cutting out those important things in life to waste more time in front of the screen simply is dangerous.

Kid's Weight is Weighing in my Mind

2011-09-12T10:34:00.002-05:00

Reports of increasing obesity levels have been circulating for years on the news. I see kids in my office regularly who are in the overweight or obese category and we all struggle how to treat this growing problem. Excess weight in childhood is linked to many health issues such as high cholesterol, diabetes, metabolic syndrome, and it can trigger earlier puberty- leading to overall shorter adult height. Not to mention the psychological and social implications of bullying, depression, eating disorders, and more.

Why is weight so much more of a problem now than it was years ago? As a child I did not have a perfect diet, yet I was not overweight because we spent most waking moments outside if we weren't in school. My mother packed a dessert in every lunch box. We ate red meat most days. We usually had white bread and butter on the table at dinner. We drank 2% milk and I ate ice cream every night. But we walked to school-- without a parent by the time I was in 1st grade (gasp!) There were only a couple tv channels, and Saturday morning was the only time we could watch tv. We were able to ride bikes, go to a wooded area, play on a nearby playground, dig in the dirt, you name it - we found something to make it fun! Today's kids are shut up in the house after school watching one of many tv channels or playing video games. Even those who are shuttled to activities get overall less exercise because it is structured differently. They ride in the car to practice or class, then sit and wait for things to start. They might sit or stand while others are getting instruction. Simply put: they don't get to do things at their own pace with their own creativity for as long as they want.

What to do??? On one hand kids need to learn to make healthy choices to maintain a healthy body weight for height, but on the other hand you don't want to focus so much on weight that they develop eating disorders. I think this is possible if we focus on the word healthy, not weight. Starting at school age I ask kids at every well visit if they think they are too heavy, too skinny, too short, or too tall. If they have a concern, I follow up with something along the line of, "How would you change that?" I am often surprised by the answers, but I can use this very important information to guide how I approach their weight, height, and BMI. We talk about where they are on the graph, and healthy ways to either stay in a good place or how to get to a better BMI. I focus on 3 things we all need to be healthy (not healthy weight, but healthy):

Healthy eating
Exercise (with proper safety equipment- but that's another topic!)
Sleep (again, another topic entirely!)

Food is a part of our daily needs, but much more than that. It is a huge part of our lifestyle. We have special meals for celebrations but on a day to day basis it tends to be more repetitive. We all get into ruts of what our kids will eat, so that is what we prepare. The typical kid likes pizza, nuggets, fries, PB&J, burgers, mac and cheese, and a few other select meals. If we are lucky our kids like one or two vegetables and some fruits. We might even be able to sneak a whole grain bread in the mix. If our family is busy we eat on the run-- often prepared foods that are low in nutrition, high in fat and calories, and things our kids think taste good (ie things we won't hear whining about). We want our kids to be happy, and we don't want to hear they are hungry 30 minutes after the meal is over because they didn't like what was served and chose not to eat, so we tend to cave in and give them what they want. We as parents need to learn to stop trying to make our kids happy for the moment, but healthy for a life time.

There is often a discrepancy between the child's BMI (body mass index) and the parent's perception of healthy. The perception of calorie needs and actual calorie needs can be very mismatched. I have seen a number of parents who worry that their toddler or child won't eat, so they encourage eating in a variety of ways:

turn on the tv and feed the child while the child is distracted
reward eating with dessert
refuse to let the child leave the table until the plate is empty
allow excessive milk "since at least it's healthy"
allow snacking throughout the day
legitimize that a "healthy" snack of goldfish is better than cookies

Any of these are problematic on several levels. Kids don't learn to respond to their own hunger cues if they are forced to eat. If offered a choice between a favorite low-nutrition/high fat food and a healthy meal that includes a vegetable, lean protein, whole grain, and low fat milk, which do you think any self-respecting kid would choose? If they are only offered the healthy meal or no food at all, most kids will eventually eat because they are hungry. No kid will starve to death after 1-2 days of not eating. They can, however, over time slowly kill themselves with unhealthy habits.

So what does your child need to eat? Think of the calories used in your child's life and how many they really need. Calorie needs are based on age, weight, activity level, growing patterns, and more.

One of my personal pet peeves is the practice of giving treats during and after athletic games. It is not uncommon for kids to get a treat at half time and after every game. Most teams have a schedule of which parent will bring treats for after the game. Do parents realize how damaging this can be?

A 50 pound child playing 15 minutes of basketball burns 39 calories. Think about how many minutes your child actually plays in a game. Most do not play a full hour, which would burn 158 calories in that 50 pound child.
A 50 pound child burns 23 calories playing 15 minutes of t-ball, softball, or baseball. They burn 90 calories in an hour.
A non-competitive 50 pound soccer player burns 34 calories in 15 min/135 per hour. A competitive player burns 51 calories in 15 min/ 203 in an hour.
Find your own child's calories burned (must be at least 50 pounds) at CalorieLab.

Now consider those famous treats at games. Many teams have a half time snack AND an after game treat. Calories found on brand company websites or NutritionData:

Typical flavored drinks or juice range 50-90 calories per 6 ounce serving.
Potato chips (1 ounce) 158 calories (A common bag size is 2 oz... which is 316 calories and has 1/3 of the child's DAILY recommended fat intake!)
Fruit roll up (28g) 104 calories
1 medium chocolate chip cookie: 48 calories
Orange slices (1 cup): 85 calories
Grapes (1 cup): 62 calories
Apple slices (1 cup): 65 calories

So...Let's say the kids get orange slices (a lot of calories but also good vitamin C, low in fat, and high in fiber) at half time, then a fruit drink and cookie after the game. That totals about 200 calories. The typical 50 pound soccer player burned 135 calories in a one hour game. They took in more calories than they used. And I chose the cookie, which has fewer calories than other options (we're not talking nutrition here) and only let them have one...

What's wrong with WATER? And eating real food after the game. As a family. Around the table. That snack is likely to decrease appetite for the next meal, and it isn't needed. And if they're hungry, they're more likely to eat the healthy foods on their plate.

There are many resources on the web to learn about healthy foods for both kids and parents. Rethink the way you look at how your family eats.

Simple suggestions:

Offer a fruit and vegetable at every meal. Fill the plate with various colors!
Picky kids? Hide the vegetable in sauces, offer dips of yogurt or cheese, let kids eat in fun new ways - like with a toothpick. Don't forget to lead by example and eat your veggies!
Buy whole grains.
Choose lean proteins.
Eat together as a family as often as possible.
Turn off the tv during meals.
Encourage the "taste a bite without a fight" rule for kids over 3 years. But don't force more than one bite.
Don't buy foods and drinks with a lot of empty calories. Save them for special treats. If they aren't in the home, they can't be eaten!
Drink water instead of juice, flavored drinks, or sodas.
Choose low fat milk (1% or skim) after 4 years of age. (Whole milk from 1-2 years is okay for the normal weight toddler. 2% milk is okay for the normal weight 2-4 year old. It is now acceptable for most kids to take in lesser milk fat than previously recommended.)
Limit portions on the plate to fist sized. Keep the serving platters off the table.
Don't skip meals!
Eat small healthy snacks between meals. Think of fruit, vegetable slices, cheese, and nuts for snacks.
Don't forget to move every day and get enough sleep!

On the Job Training for Doctors?

2011-09-06T07:08:00.000-05:00

A recent report showed a large discrepancy between what pediatricians believe they should do to advise parents and kids on sleep, and what they were actually trained to do, which begs the question: What are pediatricians NOT trained to do but must do as a routine part of their job?

What is this discrepancy? The Journal of Pediatrics published a report that only 18% of pediatricians reported having formal training in sleep disorders, but 96% felt it was their job to treat them. Their conclusion is that training programs should provide sleep education.

While on the surface this sounds like a great idea, reflecting back on my training and early years in practice, residency would have to be extended by many years to teach all that I need to know at my job. Teaching sleep hygiene (or not teaching it) is just the tip of the iceberg. Not to mention that there is new information all the time about how to do things better, so the learning should really never end.

I learned about car seats after my son was born during the end of my 3rd year of residency.

How did I make it 3 years without learning about car seats??? I would simply mention to parents to be sure to use one. If they had specific questions about if the baby was properly in the seat, I referred them to a car seat expert. (We refer to a lot of experts in residency.)

We took my son home from the hospital on an icy February day in a warm jacket buckled into the car seat. When we got home and I went to unlatch the buckle I realized it had never clicked. The jacket was too bulky!!! We went to a car seat check a couple weeks later and his car seat wasn't even tight enough ~ this is before the LATCH system helped secure the seat. My own baby had been unsafe. How awful is that after nearly 3 years of pediatric residency? Of course now, 12 years later, many car seat rules/recommendations have changed. Gotta keep learning!

I had a little formal education about breastfeeding, but it was mostly the technical aspects of how milk is produced, not how to help a mother/baby be successful with breastfeeding. That I learned when struggling to breastfeed my first baby, and along the way with other moms and their various problems. My second came along and breastfeeding went great, but she wouldn't take a bottle. Boy, did I learn a lot from my own kids with two very different feeding problems.

I don't remember a single lecture on nutrition, though I'm sure we had them. Not much on exercise that I recall. These would have been considered "easy" topics and as a resident we were more focused on studying acid base disorders and intricate diseases because that would be what we would be tested on. I wish I learned more about nutrition and exercise psychology because of the current level of obesity, but it is a relatively new problem in pediatrics -- one even the specialists aren't sure how to manage.

It is estimated that 40% of primary care visits involve behavior problems, yet I only had a single one month rotation on psychiatry. I am still learning new tricks 12+ years into practice. Many of my experiences as a parent color what I have learned in this arena. I also have the privileged position to learn from the families I see at work. All of this information I use to counsel families about these issues. I could never have learned this in a lecture, or even in a clinic with a preceptor for a one month rotation.

Simple things, like what to do with a baby who has a nose filled with mucus, were not discussed in lectures because there were more advanced things to learn, like how to manage a child on a ventilator. I don't ever manage ventilator's now, but I had to learn how in residency. Why learn that? Because it teaches doctors to think.

We need to learn the basics in school about how the body works. The psychology, pharmacology, physiology, and all the other -ologies.

Residency teaches us how to apply these things to the human person. Treating the sickest of the sick in the hospital setting teaches us to recognize sick and become independent learners.

Starting up in practice teaches us more about common illnesses and concerns. We sharpen the skills of disease management and normal growth and development with all of its variances from following the same kids over years. We must incorporate everything we know from books, lectures, clinical experiences, personal experiences, and more into caring for our patients with the most current evidence based and practical methods available.

And that keeps changing,

keeping pediatricians life long learners!

Concussions in Athletes

2011-09-02T20:44:00.001-05:00

Concussions in athletes has been the subject of many headlines over the past couple years. For as much as we know about concussions, there is still much more we need to learn about head injuries and their healing. While most kids recover from concussions within days to weeks, there are some who suffer for months. This can disrupt not only sport participation, but also reading, concentration, and the ability to learn.

What we know:

We know that children's brains are still developing and are more at risk with concussions than mature brains.
We know that many athletes attempt to hide symptoms of a concussion so they can continue to play. (Bad idea!)
After a concussion -- even serious ones that affect the daily activities of a teen -- kids are often eager to return to the game that puts them at risk for another injury.
Symptoms of a concussion range from mild to severe.

headache
nausea or vomiting
slurred speech
dizziness
ringing in the ears
trouble concentrating
sensitivity to light or noise
sleep problems
balance problems
memory loss

Treatments:

There are no specific treatments for concussion.
Rest is important. This includes not only avoiding activities that increase the risk of another injury, but also brain rest. Some kids need quiet time in bed without lights, sounds, television, computers, or books.
Headaches can be treated with pain relievers and sometimes migraine medications.
Memory and thinking problems are treated with rehabilitation and memory devices (like a calendar or planner). Occasionally stimulants (the medicines used for ADHD) are used temporarily.
Depression and anxiety should be managed by someone experienced in dealing with post-concussion syndrome.

Return to play is a gradual process, in which the athlete progresses in a step wise manner. If any symptoms return during the stepwise process, the athlete must stop activities and return to a medical practitioner for evaluation.

Step 1: Light aerobic exercise 5-10 minutes without weight lifting, resistance training or other exercises

Step 2: Moderate aerobic exercise 15-20 minutes of running at moderate intensity without a helmet or other equipment.

Step 3: Non-contact training drills in full uniform. May begin weight lifting and resistance training.

Step 4: Full contact practice.

Step 5: Full game play.

Kansas has a new Concussion Law effective July 1, 2011, that requires the State Board of Education and the Kansas State High School Activities Association to provide information about the risks of head injury to coaches, athletes, and parents and guardians of the school athletes. This information should include the risks of playing or practicing with a concussion. Under the new law an athlete may not participate in a school sport or practice unless the athlete and the parent/guardian have turned in a signed head injury release form each year. Any school athlete who is suspected of having a concussion or head injury will immediately be removed from play or practice and will be allowed to return to play only after a health care provider gives medical clearance to return to play.

Athletic trainers are available at many local schools to help identify the athletes at risk of concussion. They will be testing kids with various methods, and at this time there is still a lot of variability in what each school program is doing. It is best to have baseline testing done BEFORE any brain injuries (ie the start of the season) to compare to testing done after a suspected concussion.

If your child is suspected of having a concussion, bring any available test results (both from before and after injury if possible) to your appointment with a healthcare provider.

Prevention is still the best medicine!

Wear proper gear at all times.
Be sure helmets are in good condition and fit properly.
Wear mouth guards at all times.
Follow the rules of the game.
Sit out if injured.
If you suspect someone might have a concussion, speak up!

To read the Kansas State High School Activities Association Recommendations for Compliance with the Kansas School Sports Head Prevention Act and Implementation of the National Federation Sports Playing Rules Related to Concussions, click here.

Potty Training

2011-08-26T08:16:00.000-05:00

I remember long ago when I was a relatively new mom I still had insecurities about what I was doing (despite the fact that I was a pediatrician with extra training with kids). Well, to be honest, I still have lots of great advice for parents, but with my own kids I often struggle to know what's best. But my kids are way beyond the potty training years, so I feel like I have that hurdle down now...

My son's baby book's potty training page shows my naivety. He started showing interest in the potty and even telling me appropriately when he needed to go about 18 months of age. I knew that he was on the early side of potty training (normally between 18 months and 3 years). This is especially unusual for boys, but he was a smart kid, was directing it all himself, and why not potty train him if he's interested? I was so excited for him (and me!) that he was interested. We put out the potty chair. We clapped and praised. He was so happy to make pee in the potty.

Then he lost interest. Out of the blue. Done.

It is almost a year to the day later that the baby book says he was interested again. I actually tried to not let him train, since my 2nd baby was due soon, and I didn't want him to regress.

When the daycare teacher said, "he's been in the same diaper all day for 3 days in a row, he needs underwear!" I decided it was okay to break out the Buzz Lightyear underwear. When he did it this time, he did it well. He easily mastered the skill and didn't have accidents.

When my daughter started using the potty early (about 15 months) I thought it was a fleeting interest as well, but she continued to regularly use the toilet. Wow! Easy... she did it all on her own. (Her independent streak has it's negatives, but I liked this aspect of it.) She never had accidents. Ever. I stopped bringing extra clothes for her cubby at daycare, she was that good.

Then she lost interest. Out of the blue. Done. At 3 years!

One day she woke and said she was a baby and needed a diaper. By this time, we had no diapers. I told her she was a big girl, got her dressed, and sent her off to daycare as usual. When I picked her up there was a bag of other kid's wet clothes. She was on her 4th outfit of the day, but we had no extras at school because she was my never has accidents kid. I knew she wasn't sick. (UTI's can cause accidents.) She had simply decided that she wanted to be treated like a baby.

I had to go out and buy diapers. We stocked her cubby with extra clothes. She LOVED being treated like a baby. The daycare even moved her to the toddler room because the 3 year room didn't allow diapers. She loved being with the babies, so it suited her just fine. The problem was the teachers made such a big deal about how she was a big girl and didn't need the diaper. When I finally convinced the teachers to just matter of factly change the diaper and ignore her behaviors, she decided it wasn't fun any more to be a baby. Suddenly she was potty trained again. No more accidents. Ever.

Kids develop at various stages. My advice has always been to let them take the lead when to start potty training, which can happen anywhere from 15 months until 3 years of age.

Kids leading the way? They are ready to take the lead and potty train when they show interest (wanting to sit on a potty chair, wanting a wet diaper off, telling you when they are wet). If you push, they will resist. Teens and toddlers are one and the same: they both try to exert independence and do it their own way. The more you push, the more they pull.

If you think your child is aware of when he/she needs to urinate or have a bowel movement, put out a potty chair that is in full view when in the bathroom.

Buy potty training books geared toward toddlers.

Show excitement and give praise for interest and any steps in the right direction (sitting on potty, peeing in potty, washing hands, etc.). You can do a potty dance, give stickers, call Grandma, and do whatever makes a big deal for each little step!

Praise others for using the bathroom. Invite play dates who are similar ages and are potty trained over so your child can see them in action. Praise older siblings for going to the bathroom.

You can put the idea in their head: "I'm going to the potty. Boy, do I feel good! I went on the potty, didn't get my pants dirty, got to flush the toilet, got to use the foamy soap, etc." but don't tell them directly to go. They resist being told anything!

Scoop on Poop: Many kids are ready to go pee in the potty, but are afraid to poop there. That is okay. Offer a diaper at the time of day they often have a bowel movement. It is not good to try to force stooling in the toilet if they don't want to go there. They will hold it and end up constipated. Don't go there!

You can take them to the bathroom after the bowel movement and drop the stool into the toilet, then have the child flush. Then they associate the stool going down the toilet, which sometimes helps. Encourage lots of fruits and water so the stool stays soft. If it hurts to poop, they hold it longer, which then hurts again, which reinforces holding and then constipation. (See also our website page on constipation for more hints to keep the stool soft.)

Don't worry about setbacks. (See above!!!)

Many kids show a temporary interest in potty training, but then stop wanting to go completely. Return to diapers, but leave the potty chair visible. When the child starts to show interest again, give praises.

Remember: normal children do not go to kindergarten in diapers! They will all potty train. If your child isn't potty trained during the day by 3 1/2 years, talk to your doctor.

Nighttime accidents are actually normal much longer, see our bedwetting information.

Welcome to our new blog!

2011-08-23T15:01:00.001-05:00

The doctors at Pediatric Partners will be sharing childcare tips, insight into new medical advances, and thoughts on various topics related to the practice of pediatrics.

We welcome any ideas for future blogs! Help us communicate with patients and their families.

Dr Stuppy