What Can Your Pediatrician do for You—and What Can S/he NOT Do?

By Jesse Hackell, MD

When I made the decision to become a doctor, there was no question in my mind from the start that I would be a pediatrician. Why? Well, I liked children, even back then, just barely out of my own childhood. I also liked the pediatrician who had cared for me as I grew up—he wore sandals and love beads, which made him seem relevant to me, coming of age in the 60’s. (Thanks, Dr. Johnny!)

We all have our reasons for entering this challenging and ultimately rewarding and fulfilling field. But I think it is safe to say that at least one reason which we all share is that we truly want to provide care to children as they grow from infancy through childhood, and through adolescence into adulthood. We like children, and we want to see them grow up healthy and happy. So the broad answer to the question in the title about what can your pediatrician do for you is: We can do our best to help keep your children healthy as they grow, and help you to respond to the myriad challenges along the way.

But I really want to address the more mundane issues about what we can and cannot do for you.

We CAN provide you, as parents, with information and education about the choices you have when it comes to making decisions about your children. These decisions come even before your baby is born — from hospital care, circumcision for a boy, feeding choices — and continue every day (or so it seems) until your child is truly capable of making mature decisions on his or her own. This chance to teach is yet another reason many of us became pediatricians, and we relish and enjoy it.

We CANNOT make those decisions for you, however. They are often very personal, and each family will look at the choices through its own eyes. What is right for one family is not necessarily right for another. But we CAN support you in the decisions which you do make, as long as they do not pose a threat to your child’s well-being.

We CAN be available by telephone, and after hours, especially because we realize that children do not get sick only during business hours on weekdays.

But in most cases we CANNOT treat your children over the phone, without having a chance to see and examine them. We trust your reporting as a parent, but we need to make our own diagnosis.

We CAN respond to your concerns about your children, and answer your questions.

But we CANNOT make you ask those questions in the first place. If something concerns you, please ask. There are no stupid questions.

Apart from direct medical issues, we CAN help you deal with your health insurance company. Sometimes health insurance seems like a mystery wrapped in an enigma—but only the company knows the rules and answers. This is frustrating for your pediatrician, for sure, and many times more frustrating for you who have obtained the insurance. We can follow the insurance company’s rules, as best we understand them. Remember, however, that the insurance is a contract between the insurance company and you, not your pediatrician.

We CANNOT do things or provide care which is not covered under the terms of the policy that you have chosen, unless you understand that payment for these services will be your responsibility and not that of the insurance company. And we cannot get the insurance company to pay for things which are not covered in your contract with them.

We CANNOT write “letters of medical necessity” for specialized infant formulas, for example, when your insurance policy specifically states that it does not cover nutritional products. We CANNOT change the date on an office visit or report a diagnosis which does not exist in our medical records, simply because that would allow the insurance to pay. We CANNOT put someone else’s name on a prescription, simply because that person has better prescription coverage. These actions constitute insurance fraud, and put a physician’s license at risk.

We CAN treat many common and not-so-common pediatric problems in the office which is most familiar to you and your child. If the problem is beyond our expertise, we CAN work with you to get needed specialty care, and provide referral forms as required by your insurance. We CAN refer you to the best specialist who is in your insurance company’s network.

We CANNOT back-date referrals if you have seen a specialist without getting the required referral. And we CANNOT fight the insurance company for out-of-network referrals when there are in-network specialists who can serve your children.

Most of all, we CAN be a resource and a support for you as you navigate the course of what is undoubtedly both the toughest and most rewarding task that any of us will likely encounter. By treating each other with mutual respect, and having reasonable expectations of each other, parents and pediatricians can build a warm, long-term relationship. After all, we all share the same goals—watching the growth and development of happy, healthy children (and even, dare I say, grandchildren.)

Dr. Hackell is a founding member of Pomona Pediatrics PC, a division of Children’s and Women’s Physicians of Westchester. He practices in the lower Hudson River Valley just north of New York City.

What can I do to help my child’s allergies?

Written by: Kerry Frommer Fierstein, MD, FAAP

Pollen counts are high and allergies are bad. Phone calls and office visits regarding allergy have risen sharply in the last week or so. There are many steps you can take to help your child with allergies this time of year. We hope these suggestions will help, but if they don’t, please make an appointment with your pediatrician to learn about further treatment options.

The best way to decrease allergy symptoms is to avoid the things to which you are allergic.

• Wash hands when coming indoors – at school and at home.
• Change clothes upon entering the house and do not keep the laundry hamper in the child’s room.
• Shower nightly and as soon as possible when finished playing outside.
• Keep plenty of tissues around and teach your child not to use a tissue to rub his eyes, especially outdoors, because this brings the pollen right to his eyes.
• A cool compress will also help reduce swelling and itchiness.
• If the allergy is to pollen, keep the windows closed and the air-conditioner on. (Clean filters regularly.)

What over-the-counter (OTC) medicines can I use?

Allergies are caused by the body’s release of histamines. Anti-histamines are a mainstay of allergy treatment. They treat the general symptoms of runny nose and itchiness.

 Benadryl is the most widely known anti-histamine, however, it is not the best choice for allergy sufferers, because its effects only last a few hours, and it often causes sleepiness. It can be useful at bedtime when symptoms are interfering with sleep.

Claritin (Loratadine is the generic name) is the most commonly used OTC allergy medication. It is dosed once a day, usually in the morning. The dose for ages 6 and up is 10mg – given either as a pill or a dissolvable tablet. A liquid form is available. It comes as 5mg per teaspoon. Children over 6yrs get 2 tsp. Children 4-6yrs get 1 tsp. Children 2-4yrs. get ½ tsp.

Zyrtec, generically known as cetrizine, is another commonly used allergy medicine available over-the-counter. Often providing more effective relief than Claritin, Zyrtec is also slightly more likely to cause sleepiness, so most physicians recommend using this once daily medication at night. The dose for ages 6 and up is 10mg – given either as a pill or a chewable tablet. A 5 mg chewable is available for children 4-6 years old. A liquid form is available as well. It comes as 5mg per teaspoon. Children over 6yrs get 2 tsp. Children 4-6yrs get 1 tsp. Chlidren 2-4 yrs get ½ tsp. Zyrtec brand liquid was taken off the market last year (along with Tylenol) and has not come back yet. Store brands of Cetrizine will work as well.

Allegra (fenofexadine) just became available over-the-counter in March 2011. If you have noticed that claritin or zyrtec are not working as well for your child, you should try Allegra. Dosing for those 12 years and older is 60 mg twice a day or 180 mg once a day. Dosing for children 6-12 years is 30 mg twice a day. For children under 6 years, check with your pediatrician. Allegra comes as liquid -30 mg per teaspoon and as 30 mg ODTs (orally disintegrating tablets.) It also comes as 60 mg and 180 mg tablets.

Decongestants, like Sudafed, can be added to antihistamines when congestion is the major problem, but this is not typically needed for Spring-time allergies.

If OTC antihistamines are not working make an appointment to discuss a prescription strength anti-histamine.

Will eye drops help?

Yes, if eye itchiness is a major symptom, then allergy eye drops will help. Zaditor is a medicated eye drop that is now available over-the-counter. It can be used in children as young as 3 yrs. It can be used on an as needed basis but will be more effective if used every day. If your child’s eye allergies are very bad this year, next year we would recommend starting eye drops in April, just before the season hits.

What can I do if over-the-counter medicines don’t work?

There are lots of prescription medicines for allergies. There are antihistamines such as Clarinex and Xyzal. Also, there are anti-inflammatories such as Singulair and there are eye drops such as Pataday, Elestat and Optivair. Lastly, pediatricians often recommend nose sprays  such as Nasonex, Flonase, Veramyst and Rhinocort.

As always, we recommend to make an appointment with the pediatrician to help you map out a plan for your child.

My child is on prescription medicines but is still having symptoms.

Often, when one medicine doesn’t work, another medicine in the same class will be more helpful. Or, it is possible to combine several different medicines. Make an appointment to see us and discuss the situation.

How can I tell an allergy from a cold?

• Allergies don’t cause fevers.
• Allergies often cause itchy eyes and noses, along with the clear runny nose.
• Allergies cause sneezing “fits” as opposed to the occasional “achoo” of a cold.
• Allergies can linger for weeks to months; colds are usually done within 2 weeks.

Do I need to see an allergist?

Allergists can be helpful when your child has not found relief from OTC meds or the prescriptions we have given you. Allergists can be helpful in many ways – identifying the cause of allergies, helping to adjust or minimize medications in chronic sufferers, and as a last resort, the formulation and treatment with allergy shots (immunotherapy).

Dr. Fierstein is a practicing pediatrician. Born in the Bronx and raised in Queens, Dr. Kerry Frommer Fierstein is a New Yorker all the way. She works atPediatric Health Associates, PC, a division of Allied Pediatrics of New York.

Are High Fevers in Children Dangerous?

Written by Dr. Herschel Lessin MD

The mother of my 6-year old patient explained to me that her daughter always gets high fevers, especially when she is sick. Mom says she keeps on bringing her child in to see the pediatrician, but the doctor never seems to be concerned about it. Aren’t fevers dangerous?

The short answer is that high fevers, in and of themselves, are not dangerous in normal children. The only fevers that are dangerous are those that occur with heavy exercise in hot conditions where the body’s fever control thermostat breaks down.

Fever is a symptom, not a disease. It is not the height of the fever that is of concern, but the nature of the illness causing the fever.

In the case of viral illnesses of childhood, the body will not allow a fever to get high enough to cause damage. Unfortunately, there is a “fever phobia” in America. Surveys of parents over the past 20 years have shown little change in it.

In fact, the American Academy of Pediatrics recently issued an updated clinical report titled “Fever and Antipyretic Use in Children” The Academy says it has issued the report to help pediatricians and primary care physicians (general practitioners) educate parents and families about fever and fever phobia.

This unreasonable fear of fever stems from the basic misconception I mentioned: that fever is a disease. It is not. It is the body’s response to an infection

Like most normal bodily responses, it has a purpose. Mild to moderate fevers actually promote the body’s defense against illness. Temperatures less that 100.5 F are not fever at all, they are NORMAL. Fever’s up to 102 F rarely makes kids sick and is often beneficial.

Most Pediatricians do not consider a fever “high” until it is 104 F. or greater. Even then, the disease causing the fever may not be serious at all. A lot depends on the age and clinical appearance of the child and other symptoms that might be present.

You must assess how the child appears; how he or she is acting; do they make eye contact? Are they drinking? Are they consolable? Therefore, if your child has a fever, it is always good to call your Pediatrician for advice. It is not good to be frightened or panic and run to an emergency room, since the vast majority of fevers are caused by common viral illness.

The only exception to this advice is in the very young infant.

If your child with fever is less than 3 months of age or appears very ill, however, then an immediate call is mandatory.

Dr. Lessin has been a practicing pediatrician for 30 years. He is a founding partner and serveD as both Medical Director and Director of Clinical Research at the Children’s Medical Group.

Schoolteachers Are Awesome – School Health Policies, Less So

Schoolteachers are awesome.

They exhibit saintlike patience and calm with tantrums, vomit, and playground injuries. They watch child development in real-time and understand intuitively that what is normal for one child might not be normal for another. And they genuinely love children, which makes them good parent material. It’s probably not surprising that schoolteacher moms and dads top the lists of my favorite families in our practice.

I also have a lot of respect for schoolteachers because they seem to deal with many of the same frustrations that pediatricians struggle with. Teachers, like pediatricians, find that parents can be a child’s biggest advocate in life, but also parents can be a child’s biggest barrier to success. Teachers also seem perpetually consumed with meetings, regulations, and paperwork, with less and less time given to one-on-one classroom care each year. Teachers also suffer the consequences of unfunded mandates.

It seems a no-brainer that pediatricians and teachers ought to be allies for children’s well being.

So why do pediatricians seem to be at odds with the school system so much of the time?

My colleague Dr. Fierstein posted recently on Survivor Pediatrics the absurdity of needing a doctor’s note to apply sunscreen in New York schools. Her plaintive appeal to common sense seems a no-brainer and started me thinking about other ways that our public school systems suck health care dollars.

The cost of school notes.

In most school systems, children are allowed a certain number of “mommy excuses” per semester or year. However, children who exceed this threshold must have their absences excused by a doctor’s note; parents without doctors’ notes face truancy charges. Consequently, parents want to collect a doctor’s note each time their child is sick so they can save their few “Get Out of School Free” cards for emergencies.

Some doctors are OK with issuing these notes by telephone. Certainly, there is still a cost to this; someone has to answer the phone, get the information, and fax a note to the school. As I’ve said before,  I’m hesitant to certify over the phone an illness that I haven’t personally evaluated.

In this case, my main reason for refusing to do doctor notes over the phone is that it adds nothing. If a mother calls the school and says her child is sick, the school won’t accept it. But if a mother calls me and says her child is sick, and I write a note to the school saying “Mom says her child is sick,” that somehow becomes acceptable documentation for the school.

The school expects me to take mom’s word for it but is unwilling to do so itself more than five times per semester.

This neatly passes the buck (or should I say, the bucks) to me, the de facto attendance secretary. And an MD is a pretty expensive attendance secretary. So our policy is: if you’re sick enough to miss school and need my note, you’re sick enough to come in.

In these cases, parents know their children have colds, stomach viruses, and other mild self-limited illnesses which require kids to miss a day or two of school. There’s no diagnostic dilemma, no prescription needed, no particular question that needs my expert opinion. Nonetheless, I estimate that at least 15% of school-aged children coming to my office for a sick complaint are doing so simply to get a school note.

Direct medical costs of getting school notes

What does it cost the health care system to provide these kinds of notes for a school system? Here’s a very rough estimate.

· Number of sick visits to our pediatric practice of school-age kids between August 2009 and May 2010: 5700

· Percent of visits just for school notes: 15% (low estimate)

· Cost per sick visit of this type: $50 (low estimate)

· Total annual cost: $42,750+ just for patients of our practice.

This would more than cover the salary and benefits of a full-time county schools employee, who could monitor attendance and follow up by telephone or home visits to frequent absentees.

If our practice is representative, Tennesseans are spending at least $14 million per year in private and Medicaid health dollars to fund school notes. (This doesn’t, of course, account for the indirect costs to parents, such as transportation to and from my office.)

I suspect that if school systems needed to foot the bill for these office visits, they would quickly find more cost-effective ways to monitor attendance. And I’m not sure we pediatricians have done enough to discourage these kinds of school policies; as you can see, this fairly reliable revenue stream might present a conflict of interest. But it’s not a good use of limited health care dollars. Let’s save the doctor-issued school notes for when there’s really a question for the doctor – like, “Is Kaitlyn’s rash contagious, or can she go back to school?” or “When can Chad return to football after his concussion?” Something may be able to subsidize a cash-strapped educational system, but it shouldn’t be the health care system.

Suzanne Berman is a general pediatrician in Tennessee. Both she and her son, Simon, think that his third grade teacher, Mrs. Hutchings, is really awesome.

Does the word “natural” on products mean the product is safe?

Written by Herschel Lessin MD

I am constantly amazed at the power of the word “natural”.  People seem to think that if something is “natural” then it must be completely safe.  If only it were true.  If “natural” means coming from herbal or other sources arising in nature, then most of our prescription drugs (made by the “evil” pharma companies) are “natural”.  “Natural” medicines, sold in “health food” stores, online, and in pharmacies are not without serious side effects ,and are not sold without profits in mind.  The heart drug, digitalis, comes from the foxglove plant.  This was used as a natural herbal remedy for years. If you eat too much of the “natural” Foxglove herb, you are likely to suffer a cardiac arrest, since it is the source of the drug Digitalis.

Just how do these “natural” remedies actually work?  If herbal remedies actually are effective (which a few certainly are), then they must have an active ingredient.  But many people, blinded by the word “natural” (and cursing the word “drug”) think they work without any such ingredient.  Do they work by magic?  Of course not.  Any compound that has effects on the body or brain is a drug, regardless of whether it is “natural”, or created in a lab.

Almost all drugs that exert good effects also exert some bad ones, known as side effects.  When I see people ingest an herbal remedy without any knowledge of how the drug it contains works, I get quite concerned.  They have no idea exactly what drug they are taking. There have no studies to determine proper dosing.  There have been no experiments to discover how the drug works (if it works at all). There have been no efforts to learn about side effects. The person taking such remedies is really taking a leap of faith that these compounds will do no harm.

Even with massive studies, many pharmaceuticals have unexpected side effects when taken by large numbers of people.  So do many herbal products when anyone bothers to take the time to examine them.  For example, the herb Ma Huang, or ephedra, taken by many, is associated with stroke, hypertension and cardiac arrest. St. John’sWort interferes with birth control pills. The list is quite long. What do we really know about these remedies?  When we take one, we are hoping it will work, without knowing how, without knowing the effective dose, and without knowing the side effects.  We are reassured, because it is “natural”.  Why would you give such a drug to your child?

Dr. Lessin has been practicing Pediatrician in the Hudson Valley since 1982. He is a founding partner and serves as both Medical Director and Director of Clinical Research at the Children’s Medical Group

Dirty Dozen – 12 Reasons Many Science Studies Stink

By Jonathan Caine, MD

Nearly every day medical studies are published, or simply announced to the media. Depending upon how sexy the headlines are the more publicity for the authors. Unfortunately, most of the public (reporters included) are blissfully unaware of how to evaluate a study’s methods (often biased) and conclusions (often overstated or simply wrong). Not to mention my own pet peeve: The fact that often the articles about the studies appear in print long before the actual studies themselves.

So, when the phones start ringing in doctor’s offices from patients concerned about what they heard on the “Today Show”, we have no way of searching for the source material to intelligently try and answer their concerns.

For the past 15 years I have been teaching 3rd year medical students as they rotated through their Pediatric clerkship.

Over the years, I have developed my “Dirty Dozen” list of “Rules for Reading and Interpreting Medical Journal Articles.” I talk to the students about this on Day 1 of their rotation and hand them a copy.

1 – Even the most prestigious of medical journals can still publish junk science.

Exhibit A – The Lancet. A British medical journal that published the original Andrew Wakefield article that spawned the MMR vaccine and Autism brouhaha. The journal subsequently took the highly unusual step of retracting the article not only because they found in retrospect it was not only bad science, but deliberately fraudulent as well.

2 – Many studies are poorly designed and have serious methodological flaws making their conclusions invalid.

Nevertheless, somehow they still get funded and they still get published, despite what is supposed to be editorial review. Perhaps the image of the large glossy medical journals filled with expensive ads from large pharmaceutical companies is too great a lure to resist.

3 – Beware of making conclusions from studies with inherent selection bias of participants.

Stan Freberg, among his other talents, was a marketing genius and one of the first to inject parody into advertising. He once created a magazine ad for Chun King Chinese Food. It showed a lineup of nine smiling Chinese men and one frowning Caucasian man all dressed in scrub suits and white lab coats with stethoscopes. The tag line was:   “Nine out of ten doctors recommend Chun King Chow Mein!” A funny, but brilliant demonstration of selection bias.

4 – Prospective Studies are better than Retrospective Studies, which in turn are better than Case Controlled Studies.

As the study design becomes less reliable the conclusions become more suspect.

5 – When reading Case Reports remember the plural of Anecdote is Anecdotes, not Data.

An Anecdote is an interesting story, nothing more. Often it is a “One Hit Wonder” whose results are never to be duplicated.

6 – Statistical Significance is not the same as Clinical Significance.

The benchmark in publishing study results as “significant” is often the famous P-value less than 0.05. That is, there is a 95% confidence level that the results of the study could not have happened merely by chance alone. Even so, many studies have results that are statistically significant, but have no real significance in the diagnosis or treatment of patients. For example, a study may show that the residents of one town may have an IQ 1/10 of a point higher than another town. Statistically quite valid, but with no perceived value in the real world. But, statistical significance can make the study “important” enough to be published.

7 – Correlation is not the same as Causation

A recent headline in the news was: “Conception during winter raises autism risk.” This was an article describing a study in the as yet unpublished June issue of Pediatrics. The researchers found an increased correlation of the month of conception from December to March with the subsequent diagnosis of autism. However, there was no direct evidence that the winter time was the cause of this alleged increase. Maybe it was something occurring in the second trimester, not the first that is the significant factor. Maybe spring is the problem season, not winter. Or, maybe neither has anything to do with it.

8 – The Consensus of Expert’s Opinions are often wrong, but seldom in doubt.

Or, as Dr. Alvan Feinstein opined, “The agreement of ‘experts’ has been a traditional source of all the errors that have been established throughout medical history.”

9 – Variations of Normal does not equate with Pathology.

Pediatricians see this all the time since we are pouring over BMI percentile graphs daily. The muscular, but lean athletic teen whose BMI is greater than the 95th percentile, but who looks like Michaelangelo carved his body out of marble. The graph says he is “obese”, but your eyes tell you a different story.

10 – Clustering of symptoms without a clear etiology do not make a distinct Clinical Syndrome.

My favorite non-syndrome syndrome is Chronic Fatigue Syndrome. You name the symptom and it’s part of this elusive “Syndrome”: Fatigue, aches, pains, sleep problems, allergy symptoms, hypotension, dizziness, anxiety and depression. The following have at one time or another been used to “treat” this condition: Rest, exercise, SSRIs, analgesics, antihistamines, decongestants, Florinef, Tenormin, clonazepam, methylphenidate, acyclovir, immune globulins, interferon and galantamine.

11 – Increased awareness of a condition is not the same as increased incidence.

I refer you to the current autism controversy. The conventional wisdom is that the incidence of autism have been rising dramatically over the past several years casting doubt on the theory that autism is somehow a genetic condition. A recent study fromEnglandin adults purportedly shows that the prevalence of autism among British adults is 1% – closely matching the rate in recent studies of US and British children. The authors conclude, “This favors the interpretation that methods of ascertainment have changed in more recent surveys of children compared with the earliest surveys in which the rates reported were considerably lower.”

12 – Relief of anxiety is a form of treatment and may affect the results of a study.

We all know about the so-called “Placebo Effect” where an inert substance can have an unexpected positive result in treating a medical condition. Medical studies often compare drug treatments head-to-head against placebo treatments to see if they actually work. A 2008 study showed that about 50% of internists and rheumatologists that participated had prescribed placebo treatments to patients who were unaware of this. In a more recent study from December, 2010 patients with Irritable Bowel Syndrome (Yes, syndrome) were actually told they were going to be receiving a placebo drug treatment. Sixty percent of them showed improvement compared with only 35% of those with IBS who remained on their standard treatment.

After the students are done, I give them one Bonus Rule to follow once they go into practice that may prevent future cases of agita:

“First do no harm” doesn’t mean, “If it’s not that harmful, then do it, because it just might work.”

Dr. Caine has been a solo pediatrician in Norwood, MA since 1992. He also serves on the MCAAP (www.mcaap.org) Pediatric Council and is a Board Member of Affiliated Pediatric Practices, LLC ().

Why wasn’t my son treated with antibiotics for his red ear?

By Herschel Lessin, M.D.

Before entering the room, I looked at the chief complaint of my new 15 month old patient: pulling at his ear. I was also  seeing her 6 year old with an earache. Mom was concerned with her children’s frequent ear infections. They were always on antibiotics.

After my exam, I tell her that while her infant’s ear was a little red, it was not infected. Her 6 year old had an ear infection. Neither needed antibiotics.

Mom was most definitely not happy. The antibiotic seems to always help. Why weren’t they being treated this time?

The answer was that I was one of the good pediatricians who only used antibiotics when they were appropriate.

For decades, US physicians have been treating every red ear as an ear infection. There is now compelling evidence that not only is this practice wrong, but it is dangerous as well.

First of all, a mild red ear is absolutely NOT a sign of an ear infection. In order for the infection to be present, the entire structure of the eardrum must be distorted and bulging. In addition, there must be fluid behind the eardrum that restricts its movement with air pressure. The mild red ear does not meet any of these criteria and is not a sign of an infection that requires antibiotics. Most red ears are due to infants’ crying while being examined.

The indiscriminant use of antibiotics has resulted in many bacteria that are resistant to many antibiotics and can cause severe, difficult to treat illnesses that may be life threatening

Current American Academy of Pediatrics Policy is to not treat ear infections at any age unless examination reveals the bulging distorted ear drum that I mentioned earlier. Definite ear infections should be treated in children less than 2 years of age.

The recommendation that has caused the most resistance from both parents and pediatricians alike, is the “Observation Option”. Older kids can be observed with aggressive pain relief. If pain cannot be controlled or symptoms last more than 2-3 days, then antibiotics can be used. This idea has met with significant resistance from both parents and pediatricians alike.

Trying to teach old dogs new tricks has always been difficult. Add to this the fact that parents want us to DO SOMETHING! It is a brave pediatrician who does not give parents what they want. Finally, it takes a lot less time to write an antibiotic prescription than to explain to an angry parent exactly why it is not needed. Not to mention the fact that many adults with simple colds get antibiotics from their own physicians.

The indiscriminant use of antibiotics for viral infections and earaches must cease since it is causing enormous problems with bacterial resistance to our strongest antibiotics.

I explained to the parent that while there is a small chance that her son will go on to develop a real ear infection requiring a second trip to the doctor, that is a small price to pay to avoid exposing our children to unnecessary antibiotics that can cause real harm.

Many of us have used a compromise called the SNAP (safety net antibiotic prescription). A time limited prescription for antibiotics is provided to the parent to only fill if they really need it. We trust our parents to do this. Studies are ongoing to see how many actually do not fill the prescription.

Dr. Lessin has been a practicing pediatrician for 30 years. He is a founding partner and served as both Medical Director and Director of Clinical Research at the Children’s Medical Group.

Why Can’t The Pediatrician’s Office Tell Me What Services Will Be Covered By My Health Insurance Company?

Written by Cliff Wu M.D.

Medical insurance in the United States has to be one of the most complicated and frustrating systems that a family can endure. One question that has arisen recently has been whether a clinic can tell what services are covered by a given insurance plan and whether or not our clinic is in network.

Unfortunately, the answer to both of those questions is no. We frequently do not have access to that information because of all the different insurance plans, and each plan will have different variations. For example, we can be in network for Branch A of Insurance X but not for Branch B within Insurance X and there is no way for us to tell until after we submit the bill to Insurance X. In fact, we won’t even know that there is a Branch A or a Branch B. Of course, that doesn’t help when we try to determine whether we’re in network at the appointment time.

So what’s a family to do? The only answer we have is for each family to check with their own insurance company about what benefits are offered and which clinics are in network. The insurance carriers will release a book every year with which clinics are in network; they may also post clinics and doctor names on their website. Even then, it’s not always foolproof because the carriers may or may not keep these resources up to date.

As pediatricians, we would absolutely love to be able to streamline the process for families, verify our network status, and determine the coverage and benefits, but we simply do not have access to that information, and we are just as frustrated by this process as the families that run into this problem are. Again, a family’s best bet is to check with the carrier using the policy number in hand because that is something that we cannot do until it is too late.

This piece is just a small part of American healthcare complexities. If you are interested in a bigger picture of this nightmare, Planet Money did a blog and an eye-opening podcast entitled “The Pain-In-The-Butt Index” in July 2010 that details the staggering burden that we all endure.

Dr. Wu is a practicing pediatrician in Lakeville, MN. He runs a family-oriented practice built on love for children and the desire to make them feel comfortable with healthcare. 

Is Providing Food Snacks To Children Contributing To Obesity?

Written by Dr. Jesse Hackell

I recently had a call from a local child psychologist, one to whom I regularly refer patients. After the usual pleasantries, and her report on her findings about, and treatment plan for, the most recent patient, she hit me with a question that I had never been asked before. “Why,” she inquired, “do so many patients seem to think that my waiting room is a picnic area?” When I inquired about what she meant, she went on to describe a recent family who brought a child in for an appointment, and while sitting in the waiting room, proceeded to spread out a cloth on the floor, and actually start giving the three year old child a variety of snacks. This was not, she was careful to inform me, at a normal lunch hour.

I had no good answer, but it did set me to observing my own office. I quickly came to realize that not a day goes by that the exam rooms and waiting area are not littered with candy wrappers, discarded juice boxes, raisins and crumbs of all descriptions. And while I have not found chewing gum stuck to the underside of the exam tables (yet!), many surfaces in the office end the day with unidentifiable sticky patches on them. But maybe worst of all is asking a child to open his or her mouth and finding the mushy remains of a chocolate cookie, pretzel or bagel coating the tissues one is trying to assess.

We do a pretty good job of running on time most days, getting patients out of the office within a half-hour or so of their arrival (see Dr. Lessin’s recent post), so most of the time patients are not sitting around waiting for more than a few minutes, either in the waiting room or the exam room. Are our children so nutritionally deprived that they cannot go thirty or even sixty minutes without some sort of food or drink, lest they starve?

But it goes further than the crumbs underfoot in the exam rooms (where we do expect our patients to be barefoot during some examinations) or the sticky patches on the waiting room chairs. Children in pre-school and all the way through elementary school seem to have snack time, sometimes twice a day, with cookies and juice provided two hours after breakfast and two hours after lunch.

With the national alarm increasing about the rate of obesity in our children (and adults as well), what message are we giving our children about eating when we provide them with a continuous stream of things entering their mouth throughout the day? We know that eating habits and relationships with food which are developed and reinforced in childhood will persist readily into adolescence and adult life. I fear that we may be creating problems for a whole new generation of people when we make food and snacks available at every waking moment of a young child’s day.

Signs in the office requesting patients and family members to refrain from eating and drinking have some effect, at least on our office cleaning bills. But I think we need to carefully think about the messages we give to parents about feeding their children. Breast feeding, even on demand, is fine, but even feeding an infant too frequently can develop a “snacking” habit, where the baby never learns to take a full feeding which will last a few hours until the next feeding time. But once the child moves on to beikost (German for foods other than milk or formula), we need to help parents develop a schedule where times for meals are separate and distinct from times where food and drink is not offered.

There are a whole host of potential benefits to this pattern, not the least of which might be less of a focus on food and drink as a continuous feast, and, just possibly, a reduction in a child’s total daily calorie intake. But teaching our children that the times when we eat are discreet and separate moments might also go some way to returning eating to a social, and not just refueling, activity.

Dr. Hackell is a founding member of Pomona Pediatrics PC, a division of Children’s and Women’s Physicians of Westchester. He practices in the lower Hudson River Valley just north of New York City.