What Does A Growth Chart Tell The Pediatrician?

Today, we have a great video from Dr. Wendy Sue Swanson. In this video, she explains what are important things one, as a parent, should look for and what are the not so important things to look for when checking your child’s growth. She also explains when to be concerned and what the chart actually tells your pediatrician.

The video is just 2:49 seconds, but it has a lot of great information. Make sure to check it out.

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 the Department 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.

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17-Tips to help you remain compliant with your child’s medication

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

1. Use a pill box for pills. They come in various sizes and either single daily dosing or am/pm dosing, depending on your needs. Pill boxes allow you to:
   • be sure you have enough for the upcoming week,
   • remember if they were taken today,
   • keep several types of pills for each day together if taking more than one pill.
2. Liquid medicines: Wash the syringe after each use. Empty the dish drain of all contents daily so you find the syringe and remember to use it. Or put a clean syringe in visible sight where you often look (tape it to the milk jug, in a glass next to the kitchen sink, in a glass near your coffee pot). Remember the medicine needs to be out of reach from kids… not necessarily the syringe!
3. Refrigerated medicines: Put the medicine on a shelf that is eye-level, right in front. Don’t let it get pushed to the back. Return the bottle to the fridge before giving the medicine to lessen the chance you leave it on the counter. Remind older children that can access the refrigerator that the bottle is off limits!
4. Keep medicine next to something you do daily (coffee, toothbrush). *Always keep out of reach of young children.*
5. Use a specific glass that is unique that goes from table to dishwasher to table and never is put away. Every time you empty the dishwasher, put water in the glass and set it on the table for medicine.
6. Refill the medicine 1 week before you run out. This allows you flexibility in case you forget to pick it up. It also allows recognition that there are no refills if that was missed, giving one week to see your doctor. You can have enough for vacations if you routinely do this, since you can only fill one week earlier than the last fill… plan ahead if travelling!
7. Keep tabs on number of refills left. The pharmacist should let you know with each refill how many are left. If there are none, call right then to set your next appointment if you haven’t already.
8. Set your phone or watch to alarm at the times the medicine is due. Change the tone to one that is unique to remind you.
9. Put a reminder on your calendar to call for refills and/or schedule appointments before the last minute.
10. Leave sticky notes around the house or in your bathroom and kitchen if necessary!
11. Keep some medication in your purse (or at the school nurse) to take if forgotten in the morning if this might still be a problem. Remember to not leave your purse in the car or other places the medicine will get too hot or cold. If the school nurse will keep some, be sure to ask for a nurse’s note when getting the prescription.
12. If you travel often, it helps to keep an empty pill box in your toiletry bag, so when packing it you see the empty box that needs to be filled. Or you could put a sticky note in the toiletry bag reminding you to pack them.
13. Regular prescription medications goes hand in hand with regular follow up with your doctor to manage the medication dosing. This is important for many reasons, so I try to give as many refills that will be needed until the next visit. Ask your doctor how they handle refills before the medicine runs out so there are no delays in treatment. Remember to schedule your next visit!
14. If able, schedule the next visit before you leave the doctor’s office. Bring your calendar to each visit!
15. Call as soon as you can to schedule if you don’t have your calendar available at the doctor’s office or you were unable to schedule for any reason.
16. If you notice no more refills on the bottle when picking up your medicine, call that day to schedule an appointment. The later you wait, the fewer appointment times will be available. Early morning and later in the day fill first!
17. If you are filling the prescription at a time that your doctor’s office is closed, look for options for them to call you. Some offer online appointment requests. You can request appointments from our website at any time day or night. Leave the best numbers for us to call during business hours. Many offices have a voice mail that allows leaving a message for them to call you to schedule an appointment.

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

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

Do You Feel Cheated When You Don’t Get a Prescription After Visiting the Doctor?

Written by Jennifer Shaer MD, FAAP, FABM, IBCLC

It makes sense that physicians want to DO something to help their patients get better. That’s what we went to medical school for, right? Sick patients tend to expect the same from their doctors, a quick fix for their illness. One of the hardest things to learn as a doctor is that sometimes the best thing we can do for a patient is to get out of his way and let his body do what it does best, heal itself.

How many times have you heard your doctor say, “it’s a virus” or “you’re fine”. How many times do you feel dissatisfied when you leave the office without a prescription? The fact of the matter is that doctors prefer to give medicines to help you get better. It’s very easy to say, “you have strep throat, here is an antibiotic and you should feel better in a day or two”. It’s a lot harder to tell a parent that her sick child has a virus and that the best thing she can do is give supportive care until the child fights it off.

Here are some things to consider the next time you leave the doctor without a prescription.

The hardest thing your doctor does is diagnose your problem.

The symptom of a stomach ache can be caused by anything from appendicitis to gas. A headache can be caused by anything from stress to a brain tumor. When you visit the doctor, you should focus on how thoroughly your doctor listens to you, examines you and explains to you what she is thinking.

When your doctor says “you have a virus” or “I don’t find anything”, it doesn’t mean that you are not sick.

Understand that your doctor can be frustrated that he has nothing to offer you to get better. He would LIKE to give you a medicine but sometimes a medicine is not indicated and all you need is “tincture of time” to get better.

Do not feel cheated if you do not get a prescription.

Sometimes it takes a doctor more time and energy to explain an illness and why antibiotics are not needed.

Doctors do not want to withhold antibiotics.

When we choose not to give an antibiotic it is because we do not believe it will help and in fact in many cases it will make the situation worse. Certain viral illnesses react badly to antibiotics. Antibiotics can cause allergic reactions and gastrointestinal side effects.

Every time doctors prescribe a medication, they have to weigh the risks and the benefits. Everyone who watches television has heard the disclaimers at the end of medication commercials. “This medication can cause a multitude of problems. If you feel X,Y,Z stop taking this medicine and call your doctor immediately.” Even routine fever control medications have the possible side effect of liver injury. It stands to reason that if the doctor is certain your illness is going to get better without medication then he will not want to take the chance of exposing you to a medication side effect.

On the flip side, don’t be afraid to take antibiotics when indicated.

Recently there has been so much bad press about antibiotics that people seem afraid to use them at all. Antibiotics are absolutely indicated to treat bacterial infections. Let your doctor determine whether or not you have a bacterial infection.

Remember that you and your physician are partners in your health.

Don’t stop going to the doctor because you think you won’t get medication. Remember, it’s the diagnosis that you really need your doctor for. Make sure you keep the lines of communication open. Explain your concerns, let your doctor explain his and make sure you understand and agree with his recommended treatment plan.

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.

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Things To Consider When Calling Your Pediatrician on the Phone

Written by Kristen Stuppy MD

 

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

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

Many calls start off like this:

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

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

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

Or like this:

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

My thoughts so far: Get to the point.

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

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

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

It’s the same thing with phone calls to your doctor’s office or on call provider. We have thousands of patients. Not all call the same day, but during peak cold and flu season last year our office we took 50-90 calls/day (the highest numbers on Mondays). One phone nurse has 8 hours to answer up to 90 calls in addition to filling out insurance forms and other tasks. (We have great nurses that help out if they have time, but if the phones are busy, I guarantee the office is busy too!)

They simply can’t spend 15 minutes chatting about every detail. That’s for your friend and you to discuss over coffee.

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

Things that help us help you over the phone:

1. Know what is going on. When a parent calls and the child is at daycare or grandma’s so the caller doesn’t know details, we can’t really help. Write down the pertinent facts to get them straight if you need to.
2. Start with your child’s full name and birth date. Include any significant past history, such as your infant was born at 28 weeks gestation, or your coughing 3 year old has a history of wheezing.
3. Give pertinent facts related to the concern.
4. If your child has a fever, give the number of days of fever, the maximum temperature, and how it was taken. If you have given a fever reducer, share that.
5. Briefly describe symptoms and what you have done to help them as well as if your child responded or not to the treatment. Remember treatments are not only medicines, but if you use a vaporizer or saline for a cold, or have stopped dairy and used G2 for vomiting, let us know.
6. If your child has a rash, it is typically best for us to see the rash, but if you call about a rash describe it in terms of location, color, and size (many find it helpful to relate to common objects, such as quarter-sized).
7. Note if there is a pattern to the symptoms, such as headache every day after school or barky cough only at night.
8. Let us know any medications your child typically takes in addition to ones you have tried for the current symptoms.
9. Leave out details that don’t help. Trends and generalizations work well. If we want more details, we can always ask.

Examples of good call starters:

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

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

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

Things that cannot be done by our on call providers:

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

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

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

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

Dr. Stuppy is a practicing pediatrician in Kansas. I feels privileged to be able to help families keep their children healthy and she loves watching entire families grow!  Dr Stuppy is active on Facebook and puts a more personal touch to pediatric topics on her blog.  

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Why would a six-month old infant still need to be fed every four hours through the middle of the night?

Written by Jesse Hackell MD

Ah, yes, one of the most vexing new-parent questions, brought on by, yes, six months of interrupted sleep, daytime drowsiness and increasing irritability.

Why, indeed?

The answer is that it is usually a habit engendered in the infant, learned by the repeated feedings that he or she has received at all hours of the night. But how, and when, can this habit be broken?

Remember, first, that no one—not the parent, not the doctor not the grandmother—can determine when and how much a baby needs to eat.

Only the baby knows that for sure, based on the body’s need for growth and maintenance. And worst of all, those needs are not the same every day—a baby’s growth is not the same from day to day, nor is his energy expenditure.

But nature built in a wonderful system for appetite control—if given access to food throughout the day, an infant will eat what he needs, and then stop. Healthy babies do not starve themselves; neither do they overeat, unless they have been taught to do so by repeatedly being fed when they are not asking to be.

Think of a baby’s nutrition needs—for protein and calories, mainly– in terms of a 24 hour day.

Based on internal signals, the baby will require a certain amount of nutrients during each 24 hour period. If you feed the baby every four hours by the clock, the baby will essentially divide these needs into six portions, and eat one portion at each feeding time—which might well lead to one or more middle-of-the-night feedings.

But if the baby gets larger feedings during the daylight hours, her needs will have been met by bedtime, and there will not be the same signals prompting eating during the wee hours.

This will not occur instantly, however. In order to prompt the baby to eat more during the day, he needs to be hungrier than usual for those daytime feedings. So the first step should be to begin skipping the early morning feeding, and allowing the child to cry himself back to sleep. Then when he wakes a few hours later, he will be ravenous, and eat more than usual—which in turn will lead to a longer break before the next feed, a hungrier baby again, and greater intake through the day.

Then on the following night, secure in the knowledge that your child has taken more food than usual that day, the tired and sleep-deprived parent can be comfortable forgoing the nighttime feeding yet again. And with a small amount of manipulation, voila—your baby has given up the middle-of-the-night chowdowns.

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.