Top 10 Pediatric Post of 2011

We had some really great post this year. But only 10 made it to the top. Below are our TOP 10 post of 2011.  Hope you enjoyed them as much as we enjoyed writing them.

1. Why Can’t Pediatricians Prescribe Medicine Over the Phone?
2. If a patient can charge for her time, why can’t the doctor charge for his?
3. She has a fever, her temperature is 99.2. Is It Normal?
4. Michele Bachmann Is Not a Doctor (she reveals), But Pediatricians Are
5. What I Wish Parents Knew About Medical Billing
6. Things Your Mother Told You That Were Wrong
7. In Defense of Cough
8. Six Reasons You May Want to Bring Your Child to the Pediatrician’s Office Instead of a Retail Based Clinic
9. Are High Fevers in Children Dangerous?
10. What is the most important thing I can do to make sure my child is as healthy as possible?

Well, there you have them. Do you have a favorite one? We’d love to hear your thoughts.

Contagious Diseases and Siblings

Written by Jesse Hackell MD

In the fall of 1957, the Asian influenza pandemic was spreading across the country. My younger sister had just been diagnosed with that flu, and my grandmother had arrived shortly thereafter to help at our home when my mother entered the hospital to give birth to another sister. In those days, one could count of a solid seven days in the maternity hospital, even for an uncomplicated delivery.

Knowing the extremely contagious nature of the flu (she had lived through the devastating influenza pandemic of 1918), my grandmother set out with every weapon known to modern grandmotherhood to prevent my father and me from getting sick, fearing the consequences for my mother and newborn sister. With isolation, chicken soup and constant scrubbing and disinfecting, my father and I were spared the disease, as were my mother and sister, and, as long as she lived, my grandmother delighted in telling the story of how she confounded the pediatrician who had predicted that we would all very soon be ill.

Flash forward fifty-four years to 2011. What are the risks to siblings today when one member of a family contracts a communicable disease, and how should we respond? I think that the answer depends on many factors, one of which concerns the nature of the particular illness that one person has contracted.

Viral Illnesses

Some viral illnesses are highly contagious, even without direct contact. Certainly chicken pox and measles used to spread through families like wildfires, but immunization has largely reduced the occurrence of these diseases, primarily by greatly reducing the amount of disease in circulation, and, further, by producing immunity in children who might somehow be exposed. The same goes for influenza, the bane of my grandmother; since universal influenza immunization was recommended a few years ago, the burden of disease has been reduced, although not as much as it could be if everyone actually did get their flu shots.

Contagious Illnesses

How about other types of infectious, contagious illnesses? The common cold is just that, common, and most people will suffer one or multiple episodes each year. Unfortunately, there is no effective preventive immunization, and it does tend to spread readily; fortunately, it tends, in most people, to be relatively  mild and of short duration.

Strep Throat

Strep throat is another common contagious illness, especially in children. There certainly are families where multiple members will get strep in close temporal relationship to each other, and these may be the result of spread within the family.

But it is also possible that multiple family members were exposed at school or work, and contracted the illness elsewhere.  But strep is harder to spread than some of the illnesses discussed previously, and there are many cases where one family member gets it, and no one else becomes sick. This is one illness where good handwashing, and avoidance of sharing of food, utensils and so on, can be a useful preventive measure.

Infectious Mononucleosis

The same can be said for infectious mononucleosis–“mono,” also known as the “kissing disease,” primarily for its reputation as a common occurrence during adolescence. Yet in most of the families where one child has mono, it is very uncommon for other siblings to also contract it. Thus simply sharing a room, or time at the dinner table, is generally not enough to transmit an illness like mono.

Pneumonia

Pneumonia in children is also common, and the vast majority of cases are viral in origin–and they are often caused by the same viruses which cause the common cold. I tend to think of most cases of pneumonia as “a common infection in an uncommon place,” and generally feel that, while another member of a family might catch the same virus, it is far less likely to be caught as pneumonia. Rather, it might cause a head cold, sore throat or ear infection in someone else.

So why does this matter?

Rare is the day which goes by that I am not asked a question like “his brother has strep (or pneumonia of the flu or…), so why can’t you just treat all my kids for it without having to see them?” In response, it is important to point out that every person who gets a fever after being in contact with someone who has strep is far from guaranteed to have strep as the cause of that fever; most illnesses are just not that contagious, and most fevers require individual evaluation regardless of the person’s exposure.

The same thinking goes into my response to the schools who send home notices every time someone in a class is diagnosed with strep, ostensibly warning parents to be on the lookout for strep in their children. About the only thing these notices accomplish is the wasting of paper.

I would far prefer that parents react to each of their children’s illnesses in a vacuum, paying no attention to what the child might have been exposed to (assuming, of course, that the child has been fully immunized, thus pretty effectively–but not 100% completely– ruling out those preventable illnesses as a cause of the fever.)

What to do when your child is ill

When your child is ill, pay more attention to how he or she is acting, how sick he or she appears, and how well the illness is being handled by the child, than to what diseases he or she might have been exposed to.  Discussing that information with your pediatrician will enable you to better decide what y our next course of action should be for evaluating the illness in that child.

 

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.

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10 Tips To Help Your Child Make The Medicine Go Down

Written by Denise Somsak MD

Explain that medicine needs to be taken to make your child feel better.  Around the age of three years old, this explanation will have much more meaning and may increase ease of compliance. In the words of Yoda, “Truly wonderful, the mind of a child is.”  They sense your compassion and conviction.  You don’t need luck.

1. Ask your doctor before you start.  Better to avoid screaming than to manage it.  Some kids do better with liquid others chewable.  Many medications can be crushed and put in food.  Pharmacist can add flavoring to liquid medications.  This is usually better than adding the medication to juice or milk because not all meds can be mixed in other beverages and more importantly, the child might taste it and refuse the rest leaving you with an even larger amount of liquid to get down.  Rectal medication is sometimes an option, but few medications other than tylenol, anti-emetics and seizure medications are made for this route.
2. Know you can.  There is no try.  Only Do or Do Not.
3. You need a syringe.  No, not to give the child a shot.  An empty syringe that you can fill with the correct amount of medicine.  The pharmacy should have given you one.  Always ask especially for children less than 3 years old.
4. Make sure the child is not afraid of the syringe.  Let him hold it.  Fill it with water and let him sip it and drip it into his hand.
5. If the child will try a little medication willingly, give a little more.  If the Force is with you, that’s all it takes.
6. If the child does not like it, promise a chocolate milk chaser or some other highly desired treat that the child can only earn after the medication and at absolutely no other time.  This technique only works for children who can understand cause and effect and delayed gratification, about 2.5 to 3 years old and up.
7. If the child spits the medicine back at you immediately or vomits within 10 minutes, you need to repeat the dose.  Call your doctor with variations on this theme.
8. To avoid the spitting, lie the child on her back.  You might need a holder to steady her head.  Slowly drop the medicine in a little at a time by putting the syringe at the back of the throat, but DO NOT GAG the poor girl.  A few drops at a time even during crying should get the job done.  It will feel like forever, but I promise you it is less than a minute.  She might cough a little.  Go slow.
9. If she will not open her mouth, gently hold her nose until she does.
10. Do not reward the child for protesting.  In other words, refusing and protesting the first dose should not mean that he never has to take it again.  In the words of Mary Poppins, “Be firm but kind.”

Always keep medicine safely out of the reach of children and never confuse them by calling medication candy.  Apparently this is confusing enough according to recent research presented at the National AAP conference which showed that both kindergartners and teachers had difficulty telling the two apart.

 

Dr. Somsak was born and raised in the heartland. She describes herself as a no frills, practical gal.  She writes regularly at http://www.pensivepediatrician.com. 

Paying for your restaurant bill and your doctor’s bill is not that different

Written by Brandon Betancourt

I got a call from a mom recently. She wanted to know why she was being charged for both a preventive wellness visit and an office visit on the same date of service.

For those that don’t know, most visits to a pediatrician’s office are either considered an office visit, which generally include visits where the patient is sick, and wellness visits – which are those visits where the doc does a more comprehensive head to toe assessment of the child otherwise know as a physical.

This particular patient came in for a wellness visit, but the doctor also documented and addressed a heart condition that the patient has. The heart condition assessment triggered an office visit in addition to a yearly physical. In other words, our office submitted a claim to the patient’s insurance stating that both an office visit and a physical occurred during the encounter.

Mom wanted to know why the two charges since she was under the impression that checking a patient’s heart should be part of the physical.

I understood where the mom was coming from. Medical billing is very complicated and in many instances doesn’t make any sense. Not because the doctor or her office makes it complicated, but because the insurance companies designed it that way.

Here is how I explained it to her.

When you go to a restaurant, and order a dish, generally the meal will come with side foods. So, let’s say one is ordering a pasta primavera. The expectation is that in addition to the pasta, the dish is going to come with vegetables, which are included in the price of the dish.

Let’s say one decides to add chicken to the pasta primavera and the server says, “sure, but that will be extra.”  Meaning, she will have to charge extra for the added chicken. When asked what you’ll like to drink, 9 out of 10 times, beverages will also be extra. And so will appetizers.

Healthcare is like an a la carte restaurant where some things are included in the price of the visit, but others are not.

But here is where it get a little complicated. Unlike the the restaurant, patients don’t pay for their bills directly to the doctor; insurance companies pay the doctor. And insurance companies, in an effort to provide more shareholder value, prefer to pay for the least amount of claims possible because the less they have to pay, the more money they make.

Thus, they require physicians to document everything that happened during the visit so they can determine how much they have to pay based on the policy purchased by the patient. In other words, they won’t take the doctor’s word for it. They want to see and review everything that was discussed during the visit  with the patient so they can decide what should and should not get paid.

During this particular patient visit, I explained to the parent, in addition to the wellness visit, the doctor also assessed the child’s medical condition, which required the doctor to prescribe medication, order x-rays and a consult with a specialist.

Just like the appetizers and the added chicken is billed as “extra” at a restaurant, the assessment on the child’s condition was extra work for the doctor that is not included with the wellness visit payment.

And in her documentation, the doctor described to the the insurance company that the patient had required an “appetizer” and “chicken,” thus they should pay her more.

Essentially, the doctor was simply documenting the visit with everything she did in order to demonstrate to the insurance company what was done. And the heart condition assessment documented by the doctor triggered an office visit.

The parent appreciated the analogy and said that it was perfectly reasonable explanation. I was happy. I was able to communicate without insurance jargon and was understood. In my world, this is considered a good day.

Brandon is a practice administrator, speaker and blogger. He blogs regularly at PediatricInc.com

Confused Which Vitamin To Give To Your Child?

Written by Sandra Graba, MD

With so many vitamin options available, choosing the right vitamin for your child can be a daunting task.

Not all vitamins are all the same! The age and health history of your child are important factors to consider. A premature infant will have different requirements than a healthy 2 year old.

My goal here is to give a sense of direction in the vitamin isle, but it is important to discuss individual needs with your doctor.

Often doctors will prescribe vitamins for your newborn, so that makes it much easier! Other times, they tell you the name of the vitamin to choose in the isle. The vitamins your pediatrician recommends at this age is a little different depending on whether your breastfeeding your child or not.

Vitamins For Newborns

Vitamin K is very important in the newborn period but thankfully all babies get a vitamin K shot right at birth and the subsequent needs are met by breastmilk and formula. Breast-fed babies need extra vitamin D: 400 IU and iron supplement of ~ 11mg daily starting at 6 months.

Six Month Old

Typically, pediatricians will give D-visol (vitamin D) through 6 months of age, then switch to poly-vi-sol (multivitamin) with iron starting at 6 months, but some pediatricians opt to start the multivitamin from the start. Either choice is fine. All formulas are iron and vitamin fortified to contain at least the recommended daily amounts for the first year of life.

12 Month Old

After the 1st birthday, life is completely different! Your little baby is turning into a toddler and with it comes a whole new challenge: feeding. We switch them from their vitamin fortified breastmilk or formula to whole milk and table foods.

Toddlers

The tricky part is that toddlers are inherently picky! They manage to get enough calories through all of the “picking” of their food, but do they get enough vitamins and minerals?

Consider this: One cup of whole milk (about 8 oz) has only ¼ of the recommended daily allowance of vitamin D, ½ to 1/3 of the amount of calcium, and no iron. This means that your child will need to drink 16- 32 oz (2-4 glasses) of milk to get all the vitamin D and calcium they need – but you would still need to consider their iron needs.

Also, high volume of milk intake (more than 16 oz a day) can lead to anemia. Translation: your mom was right that milk is good for you but there is too much of a good thing.

So, what to do? In general, all vitamins and minerals are important, but some are easier to get them to eat than others. We can focus on a few important ones: vitamin D, calcium, iron, B vitamins, and folate.

Iron is important in red blood cell formation and neurologic development among other things. It is plentiful in meat, dark leafy green vegetables, beans, tofu, cereal and bread. 1-3 year olds need about 7mg per day, 4-18 year olds about 10-12 mg per day except for menstruating adolescent girls who need about 15mg daily.

B vitamins are important for production of oxygen carrying cells and can be found in fish, poultry, meat, eggs, dairy, leafy green vegetables, beans/peas, breads and cereals. B6 and B12 are fairly easy to get in the diet. 1-8 year olds need about 0.5 – 0.6 mg per day and teenagers need about 1.0-1.3 mg/day.

Calcium is very important for growing bones. Some sources of calcium include cheese, yogurt, orange juice, fortified breads and cereals, spinach, and salmon. 1-3 year olds need ~ 500 mg a day, 4-8 yo need ~ 800 mg a day. and 9-18 year olds need ~ 1,300 mg a day.

Vitamin D is a tough one! The best source is the sun…but we spend most of our year bundled in sweaters, coats, scarves…you get the idea. There are a few natural food sources: cod liver oil, salmon, mackerel, tuna, liver, and egg yolk. My 3 year old definitely won’t eat liver. Thankfully, cereals and dairy are fortified. The current recommendation for all age groups is a minimum of 400 IU daily.

After sorting through the vitamin isle, it seems that either Flintstones’ Complete – it is ½ tablet for 2-3 year olds and a full tablet for older than 4 years or Centrum Kids Complete Multivitamin are the best bet for toddlers and school age kids.

Even still, they don’t provide 100% of the calcium and vitamin D in 2-3 year olds but they are pretty good for iron, B vitamins, and folate.

There are so many character and flavor choices available but the nutrition guide for these two vitamin types can at least provide a guide to compare the other vitamins to while your head is spinning in the isle. Overall, remember that vitamin supplements are just that – supplements to a healthy diet. Children with any special needs will have different requirements.

A few words on Gummy vitamins…

Though they taste good and are probably easier to get your children to take, the vast majority I have seen fall short in providing the necessary daily nutrients. Many contain ¼ to ½ the amount of vitamin D and 10% or less of the needed calcium;No gummies contain iron. Many have the minimum amount of B vitamins but less than the recommended folate. Each gummy does, however, contain about 3g of sugar. If the serving size for your child is 2 gummies, giving them their vitamins is about the same as giving them a ¼ cup of soda!

 

Dr. Graba is a practicing pediatrician at Salud Pediatrics.

You Think You Know A Lot, Then You Have Kids

I’ve seen this post in and around the Interwebs before. As far as I can tell, this was originally posted by an anonymous Mother in Austin, Texas. She describes the 26 things her children have taught her. Every time I read it, I giggle. Not only is it funny, I think it is brilliant. Only a parent can truly appreciate it.

Enjoy!

1. A king-sized waterbed holds enough water to fill a 2000 sq. ft. house 4 inches deep.
2. If you spray hair spray on dust bunnies and run over them with roller blades, they can ignite.
3. A 3-year old’s voice is louder than 200 adults in a crowded restaurant.
4. If you hook a dog leash over a ceiling fan, the motor is not strong enough to rotate a 42 pound boy wearing Batman underwear and a Superman cape. It is strong enough, however, if tied to a paint can, to spread paint on all four walls of a 20 x 20 ft. room.
5. You should not throw baseballs up when the ceiling fan is on.
6. When using a ceiling fan as a bat, you have to throw the ball up a few times before you get a hit.
7. A ceiling fan can hit a baseball a long way. (a wiffle ball still does enough damage)
8. The glass in windows (even double-pane) doesn’t stop a baseball hit by a ceiling fan.
9. When you hear the toilet flush and the words “uh oh,” it’s already too late.
10. Brake fluid mixed with Clorox makes smoke, and lots of it.
11. A six-year old can start a fire with a flint rock even though 36-year-old man says they can only do it in the movies.
12. Certain Lego’s will pass through the digestive tract of a 4-year old.
13. Play Dough and microwave should not be used in the same sentence.
14. Super glue is forever.
15. No matter how much Jell-O you put in a swimming pool you still can’t walk on water.
16. Pool filters do not like Jell-O.
17. VCR’s do not eject PB&J sandwiches even though TV commercials show they do.
18. Garbage bags do not make good parachutes.
19. Marbles in gas tanks make lots of noise when driving.
20. You probably do not want to know what that odor is.
21. Always look in the oven before you turn it on. Plastic toys and ovens are a bad combination.
22. The fire department has a 5-minute response time.
23. The spin cycle on the washing machine does not make earthworms dizzy.
24. It will, however, make cats dizzy.
25. Cats throw up twice their body weight when dizzy. (Very True)
26. The mind of a 6-year old is wonderful. First grade…true story.

P.S. 25.6% of the men who read this will try mixing the Clorox and brake fluid

Should I Ditch the Pacifier?

Written by Melissa Arca, MD

My baby girl, who is on the verge of turning three, has three big loveys in her life: blankie, paci, and bear. And I, nor she, are in any rush to give them up. Still, the question creeps in from time to time…Should I ditch the paci?

With my firstborn, my son, I felt pressured to wean him by a certain age. Mostly because I was a first time Mom and Pediatrician and felt I should do things “right”. So I was all proud as could be when his paci was completely weaned by the time he was two. Even at that age I felt I waited too long.

Well guess what went along with the pacifier? Nap time. Now I would NOT call that a success story. I would call that a painful mistake. He never went back to his daytime naps after that. Why oh why did I hold firm? I should have just gone out and bought another one.

Now, here I am, a bit more experienced. More comfortable with my mothering and doctoring abilities. The Mom side of me knows the comfort it provides my daughter while the Doctor side still wants to make sure I’m not overlooking any potential harm.

So in my effort to answer my own question, I’ve decided to have a conversation about the paci…with myself. Yes you heard me right…Mom and Doctor discussing the whole pacifier issue. Bear with me, it should be good…

Melissa: Do you think it’s time to wean my daughter from the pacifier?

Dr.Mom: Why? Does her pacifier use bother you?

Melissa: No, not really.

Dr.Mom: Does it bother your daughter?

Melissa: No. Actually, it is a great comfort to her.

Dr.Mom: What is your concern about the pacifier?

Melissa: Well, I’ve read that it can interfere with speech development.

Dr.Mom: Does your daughter have her pacifier in her mouth all day?

Melissa: No, she only uses it for nap, bedtime, and car rides.

Dr.Mom: And, have you noticed any impairment of her speech?

Melissa: No, she’s quite the talker.

Dr.Mom: Okay then…

Melissa: Well, I’ve also heard that it can effect the development of her teeth, is she going to have crooked teeth?

Dr.Mom: Well, she might but then again, she might not. The changes are usually temporary and self correct once the pacifier is no longer in use.

Melissa: Okay then…I won’t worry about it anymore.

Dr.Mom: One last thought Melissa

Melissa: Yes, Dr.Mom?

Dr.Mom: Honestly, when is the last time you’ve seen a child walk in to kindergarten with a pacifier in her mouth?

So there you have it…no I’m not going to ditch the paci…not for now anyway. I’m sure the day she’ll have to give it up to the paci fairy is just around the corner. I’ll let her lead the way and we’ll see how things go. It’s one of her comforts and as far as I can see, there is no harm…only comfort.

I really love how Joey from Big Teeth & Clouds put it: “…hang onto whatever she needs. Life is tough, we should use what we can to get by”. Fantastic point Joey and I couldn’t agree more.

So, tell me, what do you think? Did you feel pressure to ditch the pacifier by a certain age? If so, what did you do?

Dr. Arca is a pediatrician. She works part-time while raising her two young children, Big Brother (age 6) and Little Sister (age 3). She is passionate about writing and writing about motherhood, parenting, and children’s health is what she does best. Dr. Arca blogs regularly at Confessions of a Dr. Mom