The Cost of Servicing Your Child

Written by Suzanne Berman MD

Several years ago, when I took my car in for servicing, I noticed this clever message printed on the back of the mechanic’s invoice:

This simple, honest explanation of my bill impressed me so much that I kept the invoice. More recently, I’ve thought about using a similar illustration for patients who ask, “I don’t understand why my pediatrician’s bill is so high – I only saw the doctor for about 10 minutes!”

Using the auto mechanic’s model, I’ve taken our practice’s actual expenses for 2010 and broken them down by category, as well as percent of our total budget, to give you an idea of where the money goes.

So with apologies to the creator of the automobile piece, here’s what goes into the cost of servicing your child:

Utilities and rent: 10% We spend a tenth of our budget just keeping the lights on, the telephone ringing, the heat and A/C running, and the rent paid.
Supplies: 9% Nearly another tenth of our expenses go to supplies, both clerical (appointment cards, copy paper, and pens) and medical (gauze pads, diapers, and casting supplies.) The largest single supply expense we have is vaccines; it’s not uncommon for a busy pediatric practice to have many thousands of dollars in vaccine inventory at a time.
Clinical staff: 13% Our nurses and medical assistants are busy from open to close – they weigh and measure our patients, draw blood, give shots, answer medical questions, complete school and camp forms, return phone calls, coordinate referrals, talk to the home health agency, refill prescriptions with the pharmacy. All these astute individuals are friendly and talented; we want to keep them, so we try to pay them well.
Receptionists: 5% Our front office staff answer the phone, verify insurance, check in patients, distribute paperwork, send and receive medical records, mail and fax documents, process co-payments, confirm appointments, order supplies, and more.
Insurance jockeys: 4% We don’t have “car jockeys,” but we do employ three full-time staff who could be described as “insurance jockeys.” These longsuffering individuals send claims to insurance companies (a big task) and argue with insurance companies when payments aren’t made properly (an enormous task, as it’s estimated that 20% of insurance payments are wrong.) They try to keep up with policy changes in the 200+ insurance plans our office sees in a year. They also work with families who need to establish payment plans, need to get insurance, or who are having trouble navigating their insurance plan.
Supervisory staff: 8% All our other staff have to be trained and supervised. Someone has to approve their mileage forms, overtime requests, time clock totals, and benefits changes. Someone has to negotiate scheduling squabbles, process payroll, conduct staff meetings, plan the office’s Christmas party, write policies (then rewrite them when they’re unclear), meet with vendors, fix the computers when they’re acting up, call a plumber when a toddler accidentally flushes a toy down the toilet, and about 384 other major and minor things to keep our office running. These staff also have associated professional costs, like dues and subscriptions.
Building maintenance: 4% Keeping our office clean and well-maintained is hard work for the husband-and-wife team who spend several hours 5 evenings a week cleaning, disinfecting, dusting, vacuuming, waxing, touching up the paint, wiping fingerprints from walls, emptying the trash, getting bugs out of the light fixtures, and more. Seasonally, we also pay a landscaping service (to maintain our grass and plantings) and a guy with a big truck (to salt and de-ice our parking lot). This also includes budgeting for major repairs, like resealing and restriping our parking lot every couple of years, fixing leaks in the ceiling, and cleaning up fallen debris after a bad storm.
Specialized physician training: 22%. This represents the salaries for the pediatricians in our practice and, yes, paying the doctor is the largest single expense in a practice. Much of this goes to the doctor’s personal overhead: Physicians now graduate med school with an average of $150,000 in educational debt.
Capital investment: 6% We use electronic medical records at our office, so all of our staff have their own computers, and there are computers in each of our exam rooms. Computers have to be replaced every few years, as do other electronics, furniture, appliances, and tools.
Taxes: 6% The largest part is payroll taxes for our employees and self-employment taxes for our physicians – but also unemployment tax (federal and state), property tax, professional privilege (license) tax, and sales tax.
Insurance: 7% We pay malpractice insurance for our professional employees, of course, but also insurance on our building and equipment, health/dental/life/disability for our employees, worker’s comp insurance, and some other odds-and-ends premiums.
Fringe pay: 5% This includes vacation/sick pay, holiday pay, and our company’s contributions to our staff retirement plan.
Wage and hour regulations: 1% Overtime wages for our employee constitute nearly 1% of our total annual expenses.


When you pay your pediatrician’s bill, your pediatrician certainly takes home a portion of that, but most of it goes to other things to keep the office ready and running. While our practice isn’t necessarily representative of all pediatric practices – and I know from published benchmarks that our practice is atypical in at least a few ways — this hopefully gives a rough idea of where the pediatric healthcare dollar goes.

Suzanne Berman is a practicing general pediatrician in rural Tennessee.


Back to School Illnesses… Please Don’t Spread the Lovebugs

Written by Melissa Arca, MD

First of all, realize it’s inevitable: Children will get sick. I have yet to meet a child in school who went the whole school year without coming down with something. That being said, there are measures we can take to lessen the chances of our children falling prey to some of these viruses.

First, I will outline 5 of the most common culprits causing illness in the preschool and school age child during fall and winter. Then I will give you some practical tips on containing these viral bugs.

Hand Foot Mouth Disease: This is most commonly caused by the coxsackie virus and peaks in the summer and early Fall. This virus affects mostly young children (children under 10). The symptoms consist of a fever, decreased appetite, and sore throat. Usually painful mouth sores develop on the tongue, inside of cheeks and back of throat. This may or may not be accompanied by the non-itchy skin rash on palms and soles of feet.

The Common Cold: Your child may be afflicted with this a few times a year. The most common culprit here is the rhinovirus though there are several different viral strains producing symptoms of the common cold. Hence, several colds can be caught during one season. The symptoms vary but most commonly include: stuffy nose, sore throat, cough, mild fever, and sneezing.

The Flu: Ahh… the dreaded flu. Influenza and its various strains cause the dreaded flu symptoms. As opposed to the common cold, the flu gives more pronounced and severe symptoms: high fever (usually over 100.4), sudden onset of symptoms, profound body aches, headache, and general malaise with decreased appetite. With the common cold, respiratory symptoms such as sneezing, congestion and cough are more prominent than in the flu. So far, the only preventive medical defense we have against this is the seasonal flu shot.

Strep Throat: Unlike the above conditions, this one is caused by a bacteria (Group A Strep.) and not a virus. So, this must be treated with antibiotics. So how do you tell the difference from a common sore throat (viral pharyngitis) and strep throat? Here are the key differences: strep throat involves a higher fever (usually above 101 F), red and swollen throat with possible pus formation, absence of cough, and swollen lymph nodes in neck. Strep throat may also be accompanied by abdominal pain, possible vomiting, and a body rash.

Gastroenteritis, aka the “stomach flu,” is caused by several different types of viruses, most notably rotavirus and adenovirus. The most prominent symptoms are vomiting and diarrhea. Some children may only have the vomiting, some only the diarrhea, and the unlucky ones will have both. This may be accompanied by fever and stomach ache. Having the so-called “stomach flu” does not mean you have the “flu” as in influenza.

I picked the above 5 conditions because they are by far the most common this time of year and they are highly contagious. There is just no way around it. Okay, so having thrown all that at you, what can you do to help minimize and contain these nasty viruses?

  1. Frequent hand washing is the number one way to help prevent the spread of these bugs. Encourage and teach your child to wash their hands several times throughout the day. Before eating, after using the potty, after playing outside, etc. Have them sing a song while washing to make sure they wash long enough (ABC song is a good one).
  2. Carry sanitizer. I always wipe my kids’ hands as soon as they get into the car from school. This time of year, it’s just a good habit. Wipe down shopping cart handles too.
  3. Encourage children to sneeze and cough into their arms or a tissue.
  4. Keep children home if they have a fever, are vomiting, or have significant diarrhea. Of special note: keep them home if they have eye drainage, this could signify a conjunctivitis and should be evaluated by a doctor.
  5. Teach them not to share drinking cups or utensils with their friends.
  6. By all means, sanitize the toys and personal items in your house after a bout with any of the above.
  7. Make sure your children get enough sleep, eat well balanced meals, and exercise regularly. All of these will help insure that their immune systems stay in tip top shape.

Treatment: Since the above, with the exception of strep throat, are caused by viruses, antibiotics will not help. Keep your child comfortable by treating their fever with a fever reducer. Give plenty of fluids and rest. With the stomach flu, keep your child’s diet bland and make sure they stay hydrated with small and frequent amounts of liquids.

Possible Complications: Secondary infections can set in following colds or the flu. Ear infections and pneumonia are common secondary infections. Watch for fever recurrence, chest pain, difficulty breathing, or worsening cough. Dehydration can set in following a bout of gastroenteritis. Stay on top of your child’s liquid intake. These conditions should be evaluated by your child’s pediatrician.

Do not hesitate to contact your child’s pediatrician whenever you’re concerned or have questions regarding your child’s health.

Good luck to all of you this fall and winter season. Unfortunately, these bugs will make their way into our households — just make sure your child gets plenty of rest, fluids, and love.

We’ve already battled a short bout of gastroenteritis and a nagging cold. How about you? Have your children been afflicted by any of these back to school bugs yet?

Dr. Arca is a pediatrician, mom of two, writer, and blogger who works part time in a community clinic while raising her two young children. She has become passionate about writing and speaking about motherhood, parenting, and children’s health. She is author of the blog, Confessions of a Dr.Mom and writes a weekly column in her local newspaper, The Sacramento Bee.


Brain-eating amoebas, internet info, and risk (oh my!)

Written by David Sullo MD

It was with great sadness that I read of the third case of Naegleria fowleri infection (the “brain-eating amoeba) this summer.  Death in children is always tragic, but especially so when it is so unexpected and brought on by something so innocent as hitting the local swimming hole.

As a physician, I expected parents to be asking about it in the coming days and weeks, so decided to educate myself.  I thought I would write how I went about it, and how I think about it, as there are some good things to be learned about how to find medical info AND interpret it.

My first stop was to Wikipedia for some general info on the bug itself:

Interestingly, it isn’t actually an amoeba as billed in the press, but that’s a tangent.  That then led me to the CDC website, which had more specific information on the actual rate of infections, possible treatments, and prevention strategies:

So in the end, there’s a couple of things to say:

a) Get your info from reputable sites.  Note I did not use a site that says “BRAIN eating AMOEBAS can KILL YOU!  Buy our nose spray and you’ll be protected!  Our nose spray is scientifically proven to block all amoebas!”

b) Some things are just tragic.  The CDC site makes an important point, which is that over 10 years there’s been 32 cases of this disease, but millions of people have gone swimming in these same places and NOT gotten this disease.  We’ll probably never know why these very few kids get the disease and the vast majority do not.

c) Modern medicine doesn’t have all the answers, yet.  This disease is almost uniformly fatal because it often is not recognized as Naegleria until late in the illness (or even post-mortem), and there is not a good treatment even when it is diagnosed early.  If we can develop better methods of detection and better treatments, the prognosis for these kids may improve.

d) Educate yourself.  The vast majority of cases are in southern states, in fresh water, and usually in warmer water (hot springs, etc).  There’s been only one case in a northern state (Minnesota).  So if you are going to the beach for a week on the Jersey shore, you can relax.

e) Take reasonable precautions.  You can 100% avoid this by never swimming again, but that’s not what I would call reasonable.  The CDC suggests this:

  • Avoid water-related activities in warm freshwater during periods of high water temperature and low water levels.
  • Hold the nose shut or use nose clips when taking part in water-related activities in bodies of warm freshwater.
  • Avoid digging in, or stirring up, the sediment while taking part in water-related activities in shallow, warm freshwater areas.

f) Remember what’s important.  Remember the 32 cases in 10 years noted above?  In a typical 10 year span, there are 36,000 drownings in the US.  Drownings don’t make national headlines like brain-eating amoeba do, but your child is literally 1000 times more likely to drown than to catch Naegleria.  So don’t lose sleep over the brain-eating amoeba but then take your child on a boat without a life jacket.

I hope this glimpse into the brain of a pediatrician was helpful.  I would also like to extend our sincerest condolences to the families of these children; we can only hope that  the increased public awareness from these cases leads to work on an effective treatment.

Dr. Sullo is a pediatrician at Genesis Pediatrics in Rochester, New York. He admits to having gone to computer camp in 5th grade when everyone else was playing baseball, and is an “Apple Fanboy.” He does his best to offset the geekiness by throwing in some winter backpacking.


What I Wish Parents Knew About Medical Billing

Written by Brandon Betancourt

One of the things that I do a lot here at our practice is talk to parents about their health insurance coverage. The conversation is usually about why they have a balance on their child’s account.

Health insurance is very complicated. At our practice, we deal with health insurance all the time and even for us, it gets to be very complicated sometimes.

Today, I had a conversation with a patient’s parent regarding medical billing issues. After explaining some in-and-outs about why we do certain things, the parent mentioned she had no idea things were the way they were and now understands why doctors’ offices have to do what they have to do.

She also mentioned that we should do something to spread the word. She said, “I think it is important for other parents to know this. Otherwise, how are things going to get better?”

I thought her idea to spread the word was very good. Therefore, I decided to summarize our conversation in an effort to help other parents understand, at the very least, a portion of medical health insurance.

Coding — a lot of what doctors do

At a restaurant, generally you’ll get an itemized check that shows all the things you’ve ordered. Doctors do the same thing, but they do it in the medical chart.

Virtually every doctor who accepts health insurance uses codes (called CPT codes) that are assigned to every task they and their staff performs. Everything from a simple blood draw, to immunizations, to the ear check, to specimen handling — all these things are “coded” separately.

Why do docs do it this way?

These codes are used by the patient’s health insurance company to determine the payment amount that the doctor will receive for his or her services. In other words, the health insurance company (the one actually paying for the services) wants to see what was done during a patient’s appointment. Hence, everything the doctor and the staff does has a code.

For example, if you are coming in for a child’s well visit, the pediatrician will submit a “claim” to the insurance company using the following codes:

  • Established Well Visit – 99392
  • Developmental Testing – 96110
  • Hemoglobin – 85018
  • Finger/heel/ear stick – 36416
  • Lead Testing -83655
  • Hearing Screen – 92587

If the child gets immunizations, those have codes too.

  • DTAP-IPV – 90696
  • Flu – 90660

Vaccine administration also uses a distinct set of codes. To further complicate things, some vaccines have a single administration code used with them, and others have multiple administration codes for a single vaccine.

  • Admin – 90460
  • Admin – 90461
Oh, by the way…

Let’s say while you are in the examining room, you ask the doctor, “Ya know doc, little Lisa here has been pulling on her ear lately… she may have an ear infection. Can you check that for me really quick?”

This question requires the doc to perform an entirely different assessment than the well visit the child was getting.

The doctor, in order to show the insurance company that she did a completely different assessment, codes the ear pain diagnosis and adds a 99213 – which is an evaluation and management code that documents in the chart and on the claim to the insurance company that the doctor also checked the patient’s ear.

But we feel like we are being squeezed for every penny

Parents often think when they are looking at the bill that the doctor is nickel-and-diming parents, when in reality, it is the insurance company that requires the doc to show their work in this matter.

The health insurance company doesn’t accept the doctor telling them, “I did a well visit — pay me our agreed-upon fee.” They want to know all the things the doctor did during a patient’s visit so they can decide how much they ought to pay the doctor for his/her services.

Since most patients (or in the pediatrician’s case, parents) don’t pay the doctors directly, but rather the health insurance company, they want to know what took place during the visit so they know how much they ought to pay the doctor.

It is the same as going to the restaurant and getting billed for all the side and extra orders. Although the main meal is accompanied by other things, like french fries or a salad, refills, side orders, substitutions and additions to the order are billed as extra.

Health care services are a la carte as well. 

Why then do patients have balances if insurance ought to have paid?

The insurance policy that a patient has chosen may not pay for all the services the doctor performed. So when the doc’s billing staff submits a claim for a visit, the health insurance company often comes back and says, “We are not responsible for these codes/services; these are the member’s responsibility per the member’s health insurance policy. ”

For example, the health insurance company may say, the policy your patient chose pays for a vision screen, but not for a hearing screen. Or they may say, we cover the well visit code, but not the ear ache code at the same time as the wellness visit.

Doctors get stuck with the bill

The doctor, already having performed services, now has to go to the patient and say, “Hey, remember that school physical I performed and you asked me about little Lisa’s earache? Well, your insurance says that the policy you have doesn’t cover the earache part, so I’d like to be paid for the work I perform in assessing your child’s earache.”

Of course, doctors don’t actually say that, but when a parent gets a bill for the earache, that is in essence what the doc is trying to say to the parent. And if one looks carefully at the  explanation of benefits (that document that the insurance company sends after they process a patient’s claim) one will notice they give an explanation as to why they are not going to pay the doctor for the service.

Funny how things work

Here is an interesting, but crazy fact. In many cases, had the doctor deferred the earache question and told the mom to make another appointment to address that issue during another appointment, the health insurance company would have most likely paid for the office visit.

However, had the doctor done that, the patient would have most likely gotten upset at the doctor.

By treating the earache question during the wellness visit, the doctor runs the risk of not being paid despite doing the work. On the other hand, not addressing the ear ache, the doc runs the risk of upsetting the parent, who will probably think the doc is trying to squeeze another $30 copayment, which is clearly not the case.

Cutting cost — not always a good idea

One of the major problems with this is that patients don’t understand what they are financially responsible for. Or, it’s often the case where patients don’t understand what type of health insurance they’ve purchased.

Just like with anything else, you get what you pay for. But patients overlook this issue when purchasing health insurance. They usually look at the monthly premiums and choose the lowest one. But by doing that, they are often reducing the amount of coverage, which means patients will get stuck with larger portions of their medical bills.

Growing trend to save cost

The health insurance company, in an effort to keep their premiums low, have shifted the cost to customers and their doctors. While in the past health insurance companies may have covered 100%, now they are reducing the monthly premiums but only covering 70% of one’s medical expense. Hence allthe high deductible plans out there.

Why wasn’t I told they insurance doesn’t cover?

In our practice – which is a small three-provider practice – we see on average 60 to 75 patients daily.

Add to that there are virtually thousands and thousands of different health plans. In fact, we have patients whose parents work for the same company, but because they are at different pay grades, have different insurance plans.

The answer is, we don’t have enough manpower or time to sit on the phone verifying every single patient’s healthcare coverage. I know of practices that do, and God bless them. But as a practice we believe it is the patient’s responsibility to find out what is covered and what is not covered. The more time we spend on the phone with a patient’s insurance company, the less time we are able to spend providing health care for our patients.


As a practice, we consider that treating patients based on what the insurance covers and what it doesn’t, instead of treating by what the patient actually needs, is an unethical way to practice medicine.

Although most doctors that I know will take into consideration health insurance stipulations, they will not compromise a child’s health as a result of health insurance restriction and cheap health insurance coverage plans.

I hope this post will give all that read it some insight and perspective on medical billing. If you have a question, or don’t understand why doctors’ office do medical billing, feel free to leave a comment and we will try to address it.

Oh, and thanks for reading…

Brandon Betancourt is a practice administrator for Salud Pediatrics. You can follow him on Twitter  @pediatricinc


When Should My child Start Seeing My Adult Physician?

Written by Richard Lander MD FAAP

As a pediatrician I am sometimes asked, “When should my child start seeing my adult physician?”

My answer is not until their early 20’s.

Pediatricians are trained to treat babies, toddlers, children, adolescents and young adults. Pediatric training encompasses four years of medical school and a minimum of three years of residency in pediatrics.

Throughout our career, we are constantly attending conferences and reading journals or medical literature to ensure that we are always current and apprised of cutting-edge pediatric medicine.

Your pediatrician helps you deal with your baby’s acid reflux, guides you on how and when to introduce solid foods and thrills with you when your baby speaks his/her first words.

At your well visits, your pediatrician asks questions to determine if your infant/child is developing properly and if not, you will be directed to the proper place for evaluation. You are counseled on proper nutrition and exercise for your child and encouraged to expose your child to a range of cultural and educational experiences.

When your child is wheezing or crouping in the middle of the night, it’s your pediatrician you call on for help. When your child has a 104 degree fever on a Sunday morning your pediatrician tells you to come over to the office to be examined. It is your pediatrician who is there with you as your child becomes an adolescent and together we deal with adolescent issues such as acne or uncomfortable menstrual cycles.

With some of you, we traverse the difficult terrain of painful adolescent anxieties or drug and alcohol problems. It is your pediatrician you consult for concussions and sprains from sports. When your child begins thinking of college and a future career, your pediatrician is as excited as you are, because your pediatrician has been there with you as your child has grown into a young adult.

It is your pediatrician who takes your child’s phone calls from college to help with a health issue or an emotional problem. When it becomes time to move on to an internist, it is a happy but also sad parting of the ways.

And then of course the fun begins again as your pediatrician begins to care for your child’s child: a very special pleasure for your pediatrician — the second generation.

As you can see, there is no other healthcare professional who knows your child the way your pediatrician knows your child.

The walk-in clinic has no frame of reference; they have not treated your child throughout the years. Many internists and family practitioners do not treat large numbers of children and are therefore not equipped to handle the range of issues involved in treating children and adolescents.

Many non-pediatrician physicians do not have the vaccines needed to keep your child properly immunized. Most do not see patients after hours; they send patients to the emergency department.

With your pediatrician you have grown accustomed to being seen right away and in the office where you are comfortable. Your pediatrician has been trained to deal with your child’s health issues from birth until they are young adults. We know your family and we know your child’s history. We know you and we are always there for you.

Dr. Lander has been practicing pediatrics for 32 years in New Jersey and is the immediate past chairman of the American Academy of Pediatrics Section on Administration and Practice Management.  He says if he had to do it all over again he wouldn’t hesitate to be a pediatrician.


Does Your Child Need to Wear a Helmet When Riding?

Written by Joanna E. Betancourt MD FAAP

Recently, two patients of ours had accidents when they were hit by a car while riding their bikes. Both suffered head trauma because they were not wearing their helmets

The American Academy of Pediatrics reminds us that head injuries can occur on sidewalks, on driveways, on bike paths, and in parks as well as on streets. You cannot predict when a fall from a bike will occur. It’s important to wear a helmet on every ride.

Below are four suggestion that could help you get into the habit of telling your kids to wear a helmet.

  • Are you wearing a helmet? We’ve all heard the saying, “…do as I say, not as I do.” But the truth is, children learn best by observing you. Thus, whenever you ride a bike, set a good example and put on your helmet. Not only will this reinforce the message, but you will be setting a good example.
  • Start Early. If your kids are small, have your kids wear a helmet as soon as they start to ride a tricycle or when they are riding as a passenger on the back of an adult’s bike. If your children learn to wear helmets whenever they ride tricycles and bikes, it becomes a habit for a lifetime.
  • No helmet; no bike riding. Don’t let children ride their bikes unless they wear their helmets. Being consistent is a big part of the process. If you allow your children to ride occasionally without their helmets, they won’t believe that helmet use really is important.
  • Use professional athletes as examples. My husband likes to watch the X-Games. For those that don’t know, X-Games are a yearly competition where athletes perform extreme sports such as skateboarding, roller-blading, motorcycle jumping and various other high risk, death defying stunts. All of those athletes wear helmets at all times. Thus, using professional athletes such as those on the X-Games as an example, drives the message home of how important the use of helmets can be.

Your child needs to wear a helmet on every bike ride, no matter how short or how close to home. Many accidents happen in driveways, on sidewalks, and on bike paths, not just on streets. In fact, the majority of bike crashes happen near home. A helmet protects your child from serious injury, and should always be worn. And remember, wearing a helmet at all times helps children develop the helmet habit.

Thankfully, both patients are doing fine. But these incidents are a sure way to remind parents that helmets are very, very important and should always be worn when bike riding, roller-blading or playing hockey. No exceptions!

For information on how to select the right helmet, clink on the link

Dr. Betancourt practices in the western suburbs of Chicago. She has 3 children and loves to ride her bike with her family. She blogs at:

Portable Pools: Real Responsibility, Real Risk

Written by Wendy Sue Swanson MD

I’ve got 2 boys under the age of 5. While reading a Pediatrics article just now my stomach flipped. It’s because I read:

 Children younger than 5 years, especially boys, are at greatest risk from drowning in swimming pools.

The words startled me as pediatrician but as Mama, too. Three thousand children under the age of 5 were treated in the ER each year between 2006-2008 for injuries associated with submersions.

Private pools were the riskiest pools of all. Over half of the children who drowned and died (129/209) did so at their own home. Wrong, terrible, traumatic.

94% of the fatal and nonfatal downing injuries in portable, above-ground pools in the US between 2001 and 2009 were in children younger than 5 years. If you have, or entertain, or care for, or ever have the responsibility for a child under age 5 near water, think about safety ahead of time. That pool you buy at Target for $11.99 comes with real responsibility. That pool you buy at Target for $11.99 comes with real risk. Don’t believe because of a portable or above-ground pool’s size, cost, or convenience, it’s any safer than the ginormous pool at the YMCA. The article this week would suggest it may be alarmingly deceptive from a danger stand-point. Those plastic blow up pools just look so benign…

Click here to continue reading…

Dr. Swanson practicing pediatrician and the mother of two young boys.  She sees patients at The Everett Clinic in Mill Creek, Washington. She is also  on the medical staff at Seattle Children’s and am a Clinical Instructor in theDepartment of Pediatrics at the University of Washington. Dr. Swanson is passionate about improving the way media discusses pediatric health news and influences parents’ decisions when caring for their children.

You want me to what? 10 Tips on going back to work while breastfeeding

Written by Jennifer Shaer MD, FAAP, IBCLC

The working mother has a lot of responsibilities. She is usually expected to run the household, take care of the kids and succeed at the office. She is expected to do all of this and make it look effortless. Now, throw in a new baby and a mother is expected to breastfeed while going back to work. The modern day mother has a lot on her plate. Here are 10 tips to help ease the transition back to work for the breastfeeding mother.

  1. Set your goals and expectations: Doing something for your baby while you are at work often helps you feel connected despite being separated. As in everything you do, setting a goal will help you achieve success. If you plan to pump when you return to work then you will succeed.
  2. Plan in advance: Think about your day at work. When can you pump, where will you pump and where will you store your milk? Speak with your employer about your intentions. Many states have labor laws requiring employers to accommodate nursing mothers. Don’t forget to plan your clothes. You will need easy access for pumping at work.
  3. Ease back into the workforce: If at all possible, start back to work midweek. This way you will have a weekend home with your baby in just a few days.
  4. Take one day at a time: You do not have to plan to pump milk for the next year. Each day that you bring home a bottle of pumped milk is a gift for your baby.
  5. Take time for yourself: As difficult as this seems, it is critically important to your mental health. A happy woman makes for a much better mother. Figure out what works for you and make it happen. Less stress is healthy for you, your baby, your family and your job. It also helps protect your milk supply.
  6. Multitask: Most women are masters at multitasking. Often work does not need to stop while you are pumping. With hands free breast pumps, many women can pump while working at their desks. Some women even pump while commuting to and from work.
  7. Find a breastfeeding friendly daycare or supportive babysitter: In general, it is best to surround yourself with people who are supportive of your breastfeeding goals.
  8. Continue nursing when home: Plan to nurse before work and when you get home. Tell the sitter when to expect you and do not give a bottle just before you arrive. Nursing when you are home and on the weekends helps maintain supply and helps you feel close to your baby.
  9. Be flexible and reassess your goals: If you do not maintain a full milk supply, do not get upset. There are many things you can do to increase your supply. Nursing at night and on the weekends often helps. You might want to seek help from a professional lactation consultant. Remember, if you do not have enough breastmilk then you should use formula. It is not the end of the world if you can’t keep up completely. If your supply is not complete, it does not mean you should quit. Partial breastmilk is always better than no breastmilk. Keep it up and be happy for what you can give.
  10. Enjoy: You CAN do it all and you should enjoy the process. Have fun, enjoy your baby and be proud of yourself!
Dr. Shaer is a pediatrician, board certified lactation consultant (IBCLC) and a member of the Academy of Breastfeeding Medicine. She is founder of the first breastfeeding medicine practice on Long Island. Dr. Shaer is dedicated to helping nursing mothers achieve their breastfeeding goals.

What is the most important thing I can do to make sure my child is as healthy as possible?

Written by Nelson Branco MD

No pediatrician can answer the question: “What’s the most important thing I can do to keep my child healthy?” without listing three of four things.

I’m no different, but right now family dinners are at the top of my list. You could argue that immunizations, car seats, bike helmets, 9-1-1, sleep, or good hand washing are just as important, and I won’t disagree.

But it’s hard to overlook the overwhelming research on the positive effects of family dinners on children’s diet, social development, and sense of connection with their parents and siblings.

Family dinner means sitting down to eat with an adult, without any distracting screens, on most days of the week. It also means everyone eating the same meal. With our busy lives and overscheduled kids, this can be difficult but not impossible. Even if you can’t do it every night, it’s worth rearranging the schedule so that some nights everyone can eat together.

Benefits of the family dinner vary depending on the ages of your children. For the toddler and preschooler, the family dinner will be short. Most toddlers will sit at the table for just a few minutes before getting distracted and wanting to run off and play.

The importance of the family dinner for them is modeling good eating habits and improving their diet. Children who are fed a separate meal will eat from the “Kids Menu” more often. This usually means hot dogs, pasta, chicken nuggets, macaroni and cheese and other foods that they are quick and easy to prepare, and don’t challenge their taste buds too much.

When you serve a meal for the entire family, the toddler is forced to watch you eat all sorts of different foods. (Assuming that your diet is better than the “Kids Menu” choices.) Colorful things – green, yellow, red, and sometimes even blue. Lots of textures and tastes, and more variety than they would choose on their own. This isn’t going to be immediately popular unless you have an adventurous eater. But over time, even the pickiest eaters will try new and different foods – after watching you eat them 100 or 1000 times.

For the school-aged child, family dinners are a time to share and talk. This is where they practice telling you about school, their friends, the picture they drew that day, the insect they found in the backyard or what books they are reading.

This is a time to practice manners – I can guarantee that you will have at least one conversation about the appropriateness of potty talk at the dinner table, and if say it enough times, they may start to use a napkin to wipe their mouth instead of a sleeve.

Many families have a regular way of sharing the day’s experiences: “What was the best and worst thing that happened today?,” “Highs and Lows,” or “What are you thankful for?”

The family dinner provides opportunities for assigning chores and responsibilities. Kids should learn that being part of the family means sharing the work as well. Setting the table, pouring drinks, clearing plates and washing and putting away the dishes are all things they can do to help.

If your child is interested, they can even take part in planning meals, shopping and cooking. For the very picky eater, helping cook can get them interested in foods they would otherwise never think about eating.

As kids get older, family dinners are even more important. Teens are going through a developmental stage where they are separating from their parents and joining a peer group.

Keeping tabs on them while they make this transition is important, and family meals give you a regular time to sit and talk about what’s up. If family dinners are a regular occurrence, you’ll notice when something is bothering your teen.

Take the time to sit down and eat with your kids, even if it’s not convenient. It doesn’t have to be every night, and it doesn’t have to be both parents. Eating healthy meals with your kids is a win for everyone.


Dr. Branco is a practicing pediatrician in the San Francisco Bay Area and is very active with the local chapter of the AAP.

Eating healthy meals with your kids is a win for everyone.

Dr. Branco is a practicing pediatrician in the San Francisco Bay Area and is very active with the local chapter of the AAP.


How Pediatricians Can Help Through Your Adolescent’s Transition

Written by Jesse Hackell MD.

In pediatrics, perhaps uniquely among the fields of medicine, change is more than something which just happens. It is at the very core of growth and development.

There is no stage of life which manifests growth and development more than childhood. For pediatricians, change is a part of every visit (“her development and growth have been right on track since your last visit”) and part of every piece of guidance and advice that is given to parents.

In fact, “anticipatory guidance” is specified as a standard element of preventive care visits, at every age through the pediatric and adolescent years. We comment on how a child has changed since the last visit, and suggest the changes to be anticipated during the months before the next one.

A child who does not change from day to day, month to month, is so unusual as to be cause for concern.

I have watched the transitions of my now-adult son and daughter, living through every stage of their growth and development, from infancy and toddlerhood, through the early years of school, sports, friendships, puberty, right on through college and graduate school, into adulthood, marriage and, soon, parenthood. Living with this change on a daily basis, one can almost forget the magnitude of the changes they go through, as they seem mostly the same day to day, until, suddenly, they have woken up one morning as a totally new person.

But in practice, we see children episodically—frequently in the early years, but less so as they grow, so from one visit to the next, the changes are notable and dramatic.

I was particularly struck by this recently, when on one busy Monday, of the 12 well visits I had that day, nine were for long-time patients getting ready to start their freshman year of college.

Many of these young people had been my patients since birth—one mother reminded me that I had attended the delivery of the young woman I was about to examine, and thus had really been the “very first person to see her.” While others had become patients at somewhat later ages, none were strangers—all had been coming to our practice at least since before they entered the teen years.

I had seen them over the years for visits both well and sick; had treated their acute illnesses; had counseled them on exercise and health, safety and risk behavior; and had gotten to know them and their families, and watched the changes that are common to us all as they occurred in each of them.

The pre-college physical is a different sort of visit. Many of the kids, as I still call them, come on their own, without a parent.

But it is most different in my view for what it represents in terms of the adolescent’s burgeoning independence.

While they may have varying degrees of independence while in high school, and living at home, for those who choose to live away at college, this is often the first prolonged period of time living away from their parents, as well as the first episode of living in a peer group, and having to learn the new social skills necessary to get along, fit in and succeed in that new environment.

While most of these 18 year olds are excited about the prospects of college, it is fair to say that most are also having some trepidation about it as well. It is always a part of the visit for me to mention this ambivalence that many fear, and to let them know that it is normal and expected, as well as that it usually eases quickly upon meeting new people who are also going through the same experience.

It is also important to acknowledge the transition that occurs when young people start living independently in terms of needing to develop the skills of self-monitoring and self-control, in the absence of supervising parents.

Many will need to assume primary responsibility for managing chronic health conditions, from diabetes to asthma to ADHD, and part of this pre-college visit is concerned with making sure that they are current with their management, as well as knowing how to get help if things do not remain stable once they are away from home.

Alcohol, drugs and other risky behaviors are an inescapable part of college age, and it never hurts to remind the newly independent that they, alone, will be responsible for the choices that they make, in terms of both health-related behaviors as well as academic behaviors such as classwork and studying.

One aspect I emphasize is the benefits of having a medical home.

We have been their trusted source of care for many years, and I emphasize that we are happy to continue to provide that care for them until they graduate from college (always emphasizing that I mean on the “four-year plan.”)

For practical reasons, since many are only at home sporadically over the course of a year, it makes little sense to try to establish a relationship with a new physician in bits and pieces.

Additionally, we know their medical history, and we make it a point to see them (as we do for any of our patients) on an immediate or same-day basis for their acute problems, which is important when they may only be in town for a long weekend and cannot wait three days for the next available appointment.

It always amazes, and gratifies, me how many respond to my offer to continue to be their physician with a comment such as “I don’t ever want to go to another doctor, even after I graduate.” It just demonstrates, once again, that transitions, although ongoing and inevitable, are fluid and variable in their nature.

That is part of the beauty of change—it is going to occur, but we can all do things to help make it smoother and easier. It is what you make of it.

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.