Is Your Child A Proud Member of The Picky Eaters Club?

Written by Melissa Arca, MD., FAAP – This post appeared originally on Dr. Arca’s blog Confessions of a Doctor Mom. 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

Having a picky eater seems to be the norm these days. I’d almost dare to say that children between the ages of 2-7 more often than not wind up in the picky eater category.

Why oh why the sharp jump in membership of The Picky Eaters Club during this time? Researchers believe it could be evolutionary. That way young “cave toddlers” wouldn’t walk around tasting every potentially dangerous thing in sight. Can you imagine? Still, there are far more factors involved here: genetics, personality, and family eating habits to name a few.

My son is no exception. He is a proud card carrying member of The Picky Eaters Club and I am a reluctant member by association, trying to sway my son in another direction.

It all began at the ripe old age of 2. Previously my baby boy would gobble anything placed before him: peas, squash, avocados, blueberries, you name it. I was proud as could be, snapping up pictures of his cherub face smothered in green bean puree.

Then at the age of 2, it was like a switch was turned off (or on, depending on how you look at it), and he was suddenly suspicious of everything that was placed before him.

Pancakes, orange juice, and chocolate milk seemed like the only foods acceptable to his new found sensitive taste buds.

This sent me in a crazy spin for awhile. I wondered what I had done. Certainly I must have caused this sudden disdain for all things considered healthy. I was convinced it was because I introduced bananas first. Or, that I failed to introduce the veggies in the proper order.

Worse yet, I figured I must be missing the magic mommy touch. You know, I didn’t have the finesse to cajole, coerce. or otherwise threaten bribe my child to eat well.

I know (now) that none of that is true. He is five now and I finally took a step back and realized there is only so much I can do. I can’t force feed the kid.

Although I admit, the thought had crossed my mind. I finally made a mental list of the things I could do and stuck to those. The rest is up to him and his discerning palate.

I continue to offer him his daily dose of veggies. All I ask is that he give them a try. It’s up to him whether or not he eats the rest. Did you know it can take up to 10-15 times of being offered a new food before a child will try it? Except, in my son’s case, it’s more like a 100 times…I’m still waiting.

He’s old enough to understand that his body requires a balanced diet. We talk to him about needing protein, fiber, and the good vitamins found in fruit and veggies.

He gets it. Hopefully one day it will sink in enough to not gag at the mere sight of broccoli.

Getting upset at him because he won’t eat the peas on his plate won’t make him want to eat those peas. He knows that he must taste them. Then, we move on. No long drawn out bribing session. We do encourage and praise his efforts though.

I have to admit I still do modify his meals somewhat. If we’re having spaghetti and meat sauce, he gets plain spaghetti with Parmesan cheese and a side of chicken. This is a kid who used to scarf down spaghetti and meat sauce at 18 months old…and yes we have a picture of that too!

Him being a picky eater has nothing to do with my mothering ability. Thankfully my daughter taught me this. At age 3, she is a much more adventurous eater and will gladly eat carrots, broccoli, edamame, and tomato soup. I can’t take credit for that either. Just the luck of the draw really.

I remind myself to look at the big picture. Instead of dissecting what he eats at each meal, I look at how he eats over the course of the week. Some days are better than others but overall, I am usually surprised to discover that he covers most of the dietary bases.

He continues to broaden his food horizons over time. It’s not overnight and I give him a multi vitamin to fill in the gaps. I hope someday he will allow a green vegetable past the obligatory “no thank you” bite. However, I am confident that his membership in The Picky Eaters Club is not lifelong.

So my fellow reluctant members of The Picky Eaters Club, take heart, it won’t last forever. I promise. One day you’ll wake up and find your formerly picky eater can’t get enough of your famous beef stew with peas and carrots.

Are you dealing with your own picky eater? Have you found ways to enjoy mealtime in spite of it?

How Well Visits Are Billed and What Happens if a Problem is Found?

Written by David Sprayberry MD

In a previous post, I tackled the subject of what constitutes a well visit. Today I will try to explain the way well visits are billed and what happens if a problem is found and/or addressed at the same visit.

Medical billing is quite complex and is based on a process called coding. I will see if I can explain it in a way that makes sense. Let me know if I was successful.

Think of your medical bill for an office visit as being similar to the bill you receive at a restaurant. Each service, procedure, lab, and screen is billed separately just like each menu item is billed separately at a restaurant.

When you go to your doctor for a visit, he or she is required to follow certain rules, called CPT and ICD-9 rules, for describing what happened during the visit (unless he does not accept any insurance and is paid directly by the patient for the visit).

Each thing that is done during the visit has a code and each diagnosis has a code.

The physician must report these codes to the insurance company in order to get paid for the work that was done. There are codes for well visits, codes for sick or problem visits, codes for each test, codes for each vaccine, and codes for each procedure.

If these codes are not reported correctly, your doctor will not be paid for the visit.

Many times they are reported correctly and your doctor still does not get paid correctly by the insurance company (which is generally due to a “mistake” by the insurance company).

Most medical offices have one or more employees whose entire job is to report these codes and to make sure the insurance company or patient actually pays correctly for them.

At a well visit, the typical codes that are reported to the insurance company are the well visit code, codes for each vaccine, codes for the administration of each vaccine, and codes for each test or procedure (like hearing, vision, hemoglobin, lead testing, developmental screening).

These codes are all linked to the diagnosis “well child”. Depending on the insurance plan, some or all of these codes are “covered services” and are paid by the insurance company.

Sometimes the insurance company requires the patient/parent to pay for all or part of a visit (either in the form of a co-pay, deductible, or because the insurance company doesn’t cover a particular service).

This depends completely on the contract between the patient/parent and the insurance company. The physician’s office is required to collect from the patient/parent whatever the insurance company didn’t pay.

What often causes confusion is when there is an illness or other problem that is addressed or treated at the same visit.

For example, if I were to find an ear infection and treat it, I would be required to submit a code that told the insurance company I had taken care of a problem and done more than just the well visit. This is where the confusion for parents may start and here’s why:

Many, if not most, insurance plans require the patient to pay for a portion of any services that are not part of the well visit. Depending on the plan, the patient may need to pay a co-pay or may pay the entire amount of the extra service if they have not met their deductible.

Whether they need to pay this is determined by their insurance company, not their physician. The insurance companies have intentionally designed this system to create tension between the patient and physician, when, in reality, the insurance company has caused the need for the parent to pay the extra amount.

The physician merely did her job and described the visit accurately to the insurance company.

To summarize, the physician reports the codes that describe what occurred at the visit to the insurance company. The insurance company reviews the codes and determines if the patient owes any additional fee to the physician.

Whether the patient owes anything depends entirely on the patient’s contract with the insurance company, not by the physician.

I hope this helps clarify the issue. Please feel free to share your comments or questions.

Dr. Sprayberry is a practicing pediatrician and believes there is more to medicine than shuffling patients in and out the door. To read more about Dr. Sprayberry’s medical trips to Kenya, visit his blog, Pediatrics Gone to the Dawgs.

Photo Credit – Dr. Nan

What Causes Nosebleeds in Children?

Written by Jennifer Gruen MD

The purpose of the nose is to warm and humidify the air that we breathe in. The nose is lined with many blood vessels that lie close to the surface where they can be injured and bleed.

Once a vessel starts to bleed, the bleeding tends to recur since the clot or scab is easily dislodged. Nosebleeds, called epistaxis, can be messy and even scary, but often look worse than they are.

Many can be treated at home, but some do require medical care. Most nosebleeds occur in the lower, inner, anterior portion of the nose (the nasal septum) where multiple blood vessels meet to form the Kiesselbach’s plexus

Common causes of nosebleeds in children include:

• Dry, heated, indoor air, which dries out the nasal membranes and causes them to
• become cracked or crusted and bleed when rubbed or picked or when blowing the nose (more common in winter months)
• Dry, hot, low-humidity climates, which can dry out the mucus membranes
• Colds (upper respiratory infections) and sinusitis, especially episodes that cause repeated sneezing, coughing, and nose blowing
• Vigorous nose blowing or nose picking
• The insertion of a foreign object into the nose (we have seen legos, crayons, peas…)
• Injury to the nose and/or face
• Allergic and non-allergic rhinitis (inflammation of the nasal lining)
• Tumors or inherited bleeding disorders (rare)

How are nosebleeds stopped?

Follow these steps to treat a nosebleed:

• Have your child sit with her head slightly forward. This will keep the blood from running down the throat, which can cause nausea and vomiting.
• Do NOT have your child lay flat or put her head between her legs.
• Have your child breath through her mouth.
• Use a tissue or damp washcloth to catch the blood.
• Use your thumb and index finger to pinch together the soft part of the nose. Make sure to pinch the soft part of the nose against the hard bony ridge that forms the bridge of the nose. Squeezing at or above the bony part of the nose will not put pressure where it can help stop bleeding.
• Keep pinching the nose continuously for at least 5 minutes (timed by clock) before checking if the bleeding has stopped. If the nose is still bleeding, continue squeezing for another 10 minutes.
• You can spray an over-the-counter decongestant spray, such as oxymetazoline (Afrin®, Dristan®, Neo-Synephrine®, Vicks Sinex®, others) into the bleeding side of the nose and then hold apply pressure to the nose as described above.

WARNING: These topical decongestant sprays should not be used for more than 2-3 days.)

• For several days after a nosebleed (or on a regular basis if your child tends to have nosebleeds frequently) apply Vaseline with a cotton swab to the inner, lower third of each nostril to help protect the mucosa from drying out and rebleeding.

When should your child be seen for nosebleeds?

• Bleeding persists after more than 15 to 20 minutes of applying direct pressure.
• Repeated episodes of bleeding.
• The bleeding is rapid or the blood loss is large (exceeds a coffee cupful).
• The bleeding was caused by an injury, such as a fall or other blow to the nose or face, and is not easily stopped.
• The blood goes down the back of your child’s throat rather than out front through the nose even though she is sitting down with body and head leaning slightly forward.
• (This may indicate the rarer, but more serious, “posterior nosebleed,” which almost always requires a physician’s care. This condition occurs more frequently in older people).
• Nosebleeds accompanied by unusual bruising all over the body, or other types of bleeding (heavy periods, frequent bleeding with toothbrushing, etc.)

How to prevent nosebleeds:

• Use a saline nasal spray or saline nose drops two to three times a day in each nostril. These products can be purchased over-the-counter or made at home. (To make the saline solution at home: mix 1 teaspoon of salt into 1 quart of tap water. Boil water for 20 minutes, cool until lukewarm.)
• Add a humidifier to your furnace or run a humidifier in your child’s bedroom at night.
• Place water-soluble nasal gels or ointments in your nostrils with a cotton swab.
• Bacitracin®, Vaseline®, or Ayr Gel® are examples of over-the-counter ointments that you can use. These gels and ointments can be purchased in most pharmacies.
• Teach your child to sneeze through an open mouth (into the crook of the arm).
• Teach your child not to put anything into their nose, including fingers and cotton applicators.
• If nosebleeds seem to worsen with allergen exposure (pollens, molds, animal dander) your child may need a prescription nasal spray- please call for an appointment.

Dr. Gruen opened her practice, Village Pediatrics, in 2009, but prefers spending time creating fantastic kids birthday parties

A Little Info On Wellness Visits

Written by David Sprayberry MD

As a pediatrician, I often have expecting parents who come in to interview me or my partner to decide if they want to use us as their pediatricians.

At the visit, we talk about how our practice works and we present them with the recommended schedule of well visits (established by the American Academy of Pediatrics). This schedule can be found here.

Parents are often surprised at the number of visits that are recommended.

If they want more information, we explain a bit about what goes on at a well visit and why they are important.

We mention that we review the growth and development of their child, perform a head to toe physical exam, provide guidance on things like feeding and safety, give immunizations, and perform a variety of screens, labs and other assessments depending on the age of the child.

If you look at the Bright Futures schedule linked above, you can see how involved some of these visits are. As a result of all that is required, the visits (including paperwork, tests, and vaccines) can take anywhere from 20-60 minutes, so parents should probably plan that it will take approximately an hour to complete the visit.

Some of the visits that are less involved (like the 9 month visit) may be faster and a few may take longer (like the 4 year and 11-12 year visit).

Another thing that sometimes surprises parents is how these well visits are billed and what charges are incurred during a well visit. Medical billing is complex and is based on a process called coding.

I will address that in an upcoming post. For the time being, think of your medical bill for an office visit as being similar to the bill you receive at a restaurant.

Dr. Sprayberry is a practicing pediatrician and believes there is more to medicine than shuffling patients in and out the door. To read more about Dr. Sprayberry’s medical trips to Kenya, visit his blog, Pediatrics Gone to the Dawgs.

Photo credit – AppleTree Learning Centers

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• Expecting a Child? Need to Find a Pediatrician? What Questions Should You Ask? (survivorpediatrics.wordpress.com)