Visiting The Pediatrician With Your Teen. What Are They Talking About In There?

Written By Nelson Branco, MD FAAP

As a parent, the teen years can be like a roller coaster ride. Thrilling, fun and scary – and sometimes you just want to cover your eyes and hope it will end soon. Your pediatrician* wants to support you and your family in providing the knowledge and guidance your teen needs to navigate these exciting years.

screen-shot-2016-10-17-at-12-28-48-pmWe are here to educate your teen and monitor their physical, mental and emotional health.

Teen physicals are very different from earlier visits or check-ups.

At a teen visit, we want you to have time to talk to us about your questions and concerns and pass on important information about your child’s health.

Because we want to give teens a chance to talk to us one on one, the parent will be there for some of the visit, but not the whole time. This is so that we can bring up subjects that teens may be shy about discussing in front of their parents.

They need to feel comfortable talking about issues related to their health – it’s time for them to gain some independence and responsibility around diet, exercise, sleep and other health habits.

The time we spend with your teen will be confidential

The pediatrician won’t go over the details of what they talked about. One exception to this rule is when something comes up that makes us worry your teen may be in danger.

If your teen needs help we will find the help they need, and help them talk to you about whatever the issue may be.

After the visit, you should ask your teen what we talked about. It’s a good way to start a discussion about topics that can sometimes be uncomfortable.

Your child may be asked to fill out a questionnaire about their mood and generally how they are feeling.

These questionnaires are important for us to ‘break the ice’ and convey to kids that we are ready and willing to talk about their feelings, especially if they are feeling anxious, down or depressed.

This questionnaire also helps us identify kids who may be having trouble but are reluctant to talk about it.

Insurance companies require us to bill this separately from the visit, but some have decided that this charge should be paid by you as part of your co-insurance or deductible.

Don’t be surprised if you see this noted separately on your Explanation of Benefits (EOB) or bill.

During the visit, your pediatrician will cover a wide range of topics.

We always discuss overall health as well as injuries, complaints or health conditions your child may have. If your child is playing sports we will also ask about family history of heart issues, lung or heart issues while exercising, concussions and past injuries.

We will be talking to your child about their home and school environment and relationships, school performance and goals, and activities, hobbies or sports that they are involved in.

Diet is an important topic, since we want to make sure your child is eating a healthy, appropriate diet and growing well.

We talk about depression, anxiety, mood and social issues with all teens. We all know that the teenage years can be stressful and it’s important that teens have a trusted adult to turn to for help when they need it – we hope to be one of those trusted adults, but also want them to have someone else in their daily life who is there for them.

Drugs, alcohol and tobacco are important topics.

We know that our kids may be exposed to these substances, and a significant number of teens are experimenting with or using nicotine, alcohol, marijuana, prescription drugs or other illegal drugs.

We want to make sure that kids are healthy, safe and making good decisions.

Please remember that your kids are watching and learning about these issues from you.

Think about your own attitudes and use of alcohol and drugs, and make sure you are sending the right message to your teen.

Relationships, gender, sexuality and sex are topics that all teens think about and sometimes struggle with.

Our kids have lots of different sources of information – parents and other adults, school, the media, the internet and friends. Teens need the right information and resources to make healthy choices.

Their relationships with peers – both friendships and romantic – are important for their growth, maturation and happiness. We want these to be healthy, respectful relationships.

From the time your child was an infant we have discussed sleep and screen time. This doesn’t stop in the teen years, but now your child has more control over their digital devices and their bedtime.

We want to make sure that the work, entertainment and social life that is happening on these devices isn’t interfering with school, relationships and sleep.

These visits take a bit longer than checkups for younger kids.

Hopefully this has helped you understand why. Your pediatrician has spent time over the years getting to know you, your family, and your child. Young adults should know that we are here to help them when they are hurt, sick or not doing well.

We also want them to know that we are proud of their good decisions and ready to celebrate their success. Everyone should get off this roller coaster smiling.

*Throughout this article, I’ve used the term pediatrician to mean someone who provides medical care to teens. This can be a pediatrician, adolescent medicine specialist, family physician, nurse practitioner, physician assistant or another medical specialist.


Dr. Branco is a practicing pediatrician at Tamalpais Pediatrics. He works in both the Novato and Larkspur offices. Dr. Branco is very active with the local chapter of the American Academy of Pediatrics and is a member of the AAP Committee on Native American Child Health. He is also an Assistant Clinical Professor of Pediatrics at UCSF.


13 Tips to Help Parents Address Prom Night

Written by Nelson Branco MD and Nell Branco, MPH, LCSW

PromProm season and graduations are here. Any adult who works with teens or has a teen in their life wants them to fully enjoy this big event while somehow managing to keep it in perspective.

The prom is a time to dress up for a fancy event planned just for them. Kids get to celebrate their friendships and the years they have spent together. We all have memories (good, bad or indifferent) from our high school years, and I’ll bet the prom picture is the first one grandma whips out when she’s trying to embarrass you with your kids.

High school juniors and seniors are young adults, and prom is another opportunity to build trust and foster their ability to be self-reliant. It’s also a good opportunity for parents to communicate clearly about your expectations. Here is a list of issues and suggestions for making prom night stress-free, safe and fun for all.

Planning for prom may be stressful or frustrating for your teen.

Try to be open and supportive through the ups and downs. There may be a logistical or social aspect of the prom that is worrying your son or daughter. Let them problem solve, using you as sounding board, but don’t try to fix it for them.

Don’t side-step the topic of drugs, alcohol, and safe sex.

If you have reasons to be concerned about these issues, bring them up. The emphasis should be on making responsible decisions in addition to having fun.

Discuss rules for the prom; your own rules, the school rules, and consequences for breaking them.

The goal is not to lecture. You want to have a discussion to set positive expectations for a fun and safe night. Tell your teen that you trust their ability to made good plans and reasonable decisions, and that you know they want the night to go well. Begin the conversation with “I know we’ve discussed this before…” or “I know you know this already but I think it is a good idea to review ….”

Make a plan with your teen that you can both stick to.

You might agree to one phone call check-in vs. multiple calls or texts through the night. For older, more independent students a check-in may not be necessary.

Ask who they are going to be with.

It’s reassuring to know your son or daughter’s date, and if they plan to go with a group of students you already know. Have the name and cell phone of one other person in the group as a backup contact.

If your teen is going to a pre-prom or after party, find out who is hosting and who is supervising.

You should feel free to talk to those parents beforehand if you have questions. There are lots of reasons to call each other; to thank them, to offer help, to arrange a pick up time, etc. Often, students and their parents have put a lot of planning into these parties and have rules and guidelines that guests are expected to follow.

Have a backup plan for getting home.

Even if your teen is going with a group in a limo or bus, make sure they have money for a cab or another ride if needed.

Does your teen know how to contact you throughout the evening?

Tell them where you plan to be and how they can reach you. Some parents and teens set up a code or agreed upon phrase that will cue parents to pick them up, no questions asked.

Plan for changes.

If their plans for the evening change (and they may) make sure they know to check in and let you know the new destination and who they are with.

Renting hotel rooms for students is not recommended.

Not only are there issues of supervision and cost, but a large group of teens may run afoul of hotel noise policies and have a negative impact on other hotel guests.

If you are hosting a party review your town’s Social Host laws.

Parent hosts are often responsible for the safety of their guests. For more information about social host laws, see or

Driving safely.

Reinforce the message that they shouldn’t ever drive if they’ve been drinking or using drugs, and shouldn’t let their friends dot it either. It’s also worth reminding your teen that driving while tired can be just as dangerous as driving while they are intoxicated.

Most importantly – with all the excitement (and worry) don’t forget to say

“I love you and have a good time”

as they get ready to leave, and take lots of pictures.


Dr. Branco is a practicing pediatrician in the San Francisco Bay Area and is very active with the local chapter of the AAP. Ellen Branco is a School Counselor and Health Educator in the San Francisco Bay Area. She has been working at independent high schools and counseling since 2001.


Why Our Office Requires MMR Vaccine

Written by Nelson Branco MD FAAP

Vaccines have been a hot topic among parents, pediatrician and in the media for many years. Recently, there have been many news stories about pediatricians who will not care for families who either choose not to vaccinate their children or who do not follow the recommended schedule.

These policies are based on knowledge about the safety of vaccines, the effectiveness of the recommended schedule and concern about the spread of a vaccine-preventable disease in the community.

No pediatrician wants to see a child suffer from a condition that could have been prevented, and we certainly do not want those illnesses to be spread in our offices.

My practice is in Marin County, California – an area that is known for high rates of vaccine delay and vaccine refusal . After much thought and careful consideration, my partners and I recently decided to change our policy related to immunizations.

Starting this spring, we will require that all patients age 2 and older be immunized with the Measles, Mumps, Rubella (MMR) vaccine in order to remain patients of our practice.

We have a responsibility to protect the health of all of the children in our practice, and decrease the risk of vaccine-preventable diseases in our community. We have chosen to require the MMR vaccine because we are extremely concerned about the possibility of a Measles outbreak in our community.

Vaccine preventable diseases are still a threat to the health of our children and our community. In 2010, the Pertussis (Whooping Cough) epidemic in California affected children in Marin County at eight times the rate seen in California overall, in part because of low immunization rates.

There was recently a case of Mumps in a school-aged child in our county, and last year there was an outbreak of Mumps in a dormitory at the University of California at Berkeley.

There have been Measles cases and outbreaks associated with the 2012 Super Bowl, and in recent years in San Diego, Quebec, Indiana and Minnesota. In 2011, there were 222 reported cases of Measles in the US, the highest rate in 15 years. Ninety percent of these cases were associated with air travel, but not all cases were in travelers.

Measles has become much more common in Western Europe, Africa, Asia and the United Kingdom due to dropping vaccination rates. The CDC is already warning us that with the Summer Olympics in London and the Eurocup Soccer Championship in the Ukraine, the possibility of a US traveler to these countries coming back with Measles is high. Because of this, we are concerned that Marin County is at risk for a Measles outbreak.

Because Measles is so easy to spread, in order for a community to be protected from an outbreak, 95% of the population must be immunized. Right now, the number of Kindergartners in our county who are up to date on all of their vaccines is 83%, and there are schools and communities in Marin County where less than 50% of Kindergarten students have had all of their required vaccines.

Certain areas in our community are clearly at risk of a Measles epidemic. In our practice, we have many children who are too young to receive the MMR vaccine as well as many children who have chronic illnesses that compromise their immune system and put them at risk. This policy is meant to protect not only these children, but also our entire community from a Measles outbreak.

We respect that the parents in our practice have the ultimate responsibility for making decisions about their children’s health care, but we have to weigh their personal decisions against the available data and the needs of our community.

In our practice, we feel strongly that communicating and collaborating with our patients and their families is the best way to provide excellent care. We also feel strongly that vaccines save lives and that this policy protects our patients and our community from a preventable disease and all of its repercussions.

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


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.


In Defense of Cough

Written by Nelson Branco MD


There are always coughing kids, but this time of year the number of visits to pediatricians for “cough” begin to outnumber almost everything else. Once the kids have been back in school for a few weeks, and they’ve had a chance to cough and sneeze all over each other, the cough season has begun.

Most parents worry that their child might have asthma, pneumonia or some other infection causing the cough. Your doctor will be running through a much longer list of possible reasons for cough – pneumonia, wheezing, croup, asthma, bronchitis, congestive heart failure, viral upper respiratory illness, bronchiolitis, reflux, post nasal drip due to allergies or sinus infection, habit cough, aspirated foreign body and a few others. It usually takes only a few questions to narrow down the possibilities, but sometimes it takes a bit more work, especially if the cough has been going on for some time or has not responded to treatment.

Obviously, many of these causes will have a specific treatment – antibiotics for pneumonia or sinusitis, steroids and albuterol for asthma, antihistamines or nasal steroids for allergies, antacids for acid reflux. But how about if your child has a viral illness? These illnesses – upper respiratory infections (the common cold), tracheitis, bronchitis, and bronchiolitis, are usually self-limited and don’t need any specific treatment.

Cough is a protective reflex that keeps the lungs clear of mucous, irritants and infection. Cough is usually involuntary, and it’s difficult to suppress a cough when your brain says it’s necessary. Cough can interrupt sleep, be disruptive at school or irritating to your child, and cough is a very efficient way to pass infections to others (Cover That Cough!). So, given all this, why don’t we generally prescribe cough suppressants? The first reason is that most don’t work. Even codeine, when studied in large groups of children, doesn’t work well at suppressing cough. Over-the-counter medications don’t work too well either, though there are many available and lots of people use them.

Another reason not to suppress all coughing is to prevent pneumonia or lung infection. Cough is a helpful reflex – it keeps mucus from the throat and upper airway out of the lung, and helps move mucus up and out of the lung. Most of this mucus is swallowed; this is fine. The lungs are lined with cells that have tiny hair-like projections called cilia. These cilia all beat in one direction to help move mucus and debris out of the lungs, like an escalator. The cough helps move things along even faster.

One of the biggest problem with cough is that it can interrupt sleep. Because sleep and rest is important to help fight off any virus or other infection, we often recommend treatments that will help with sleep. A teaspoon of honey given at bedtime has been proven to be just as effective as an over the counter cough syrup. You can also use herbal tea with lemon and honey, and vaporizers/humidifiers, steamy bathrooms, and saline nose drops can help to thin the mucous so that it’s easier to cough up.

Remember – not all cough is bad. Sometimes cough is a sign that there is a problem that you need to talk to your doctor about. Most of the time, though, cough is just doing its job to keep the lungs clean. Teach your kids to wash their hands frequently, cough into their elbow instead of onto surfaces or their hand, make sure to get a flu shot and, as much as possible, avoid people who are obviously sick.


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


Mom and Dad, Did You Ever…

Written by Nelson Branco, MD, FAAP and Ellen I. Branco, MSW, MPH

Adolescence is filled with challenges – at school, at home, with friends, on stage and in sports.  Even their own body betrays them from time to time.  Acne, hair, changing bodies and voices, parents, siblings and friends are all possible sources of gut-wrenching shame for a normal teen.  Parents of teens have challenges too – and high on the list is the challenge of talking about important topics like sex, drugs and rock and roll.  The natural process of becoming independent, separating from parents and identifying with peers is difficult but ultimately rewarding.   Through it, teens need their parents to step back, set appropriate limits and be there when they fail or hit a bumpy patch.
This is also a time when experimentation with alcohol and other drugs often happens.

According to the 2009 Youth Risk Behavior Survey, 37% of high school students have tried marijuana and 73% have had a drink of alcohol at some time in their life.

Lots of teens will do this without their parents’ direct knowledge, but when parents learn about their child’s drug or alcohol use, it can be an opportunity to have an honest and frank talk about difficult subjects.  For the teen, there is often a mix of dread at being found out but also relief that they aren’t keeping a secret any longer.

Research shows that open talk about drugs or alcohol between parents and teens has a protective effect, and can lead to students waiting longer to experiment.

In this talk, parents need to be explicit about what they think, and not assume that their actions demonstrate their beliefs.  Teens are acutely aware when parents are saying one thing but actually feel differently, even if the difference is subtle. 

Students and parents alike have a lot of questions about marijuana.  They are surrounded by news stories about medical marijuana, the legalization debate, questions about enforcement of current laws, and almost constant references to marijuana and marijuana use in popular media.

For the teen, the question is: “How bad is it really? How seriously do I take this?”  The message is often not clear, even from their own and their friends’ parents.  Some parents say “I smoked pot, it wasn’t a big deal, and I turned out fine,” and others “My nephew smoked pot and everything went downhill from there.”  Adults understand that both can be true, but this can be difficult to communicate to a high school student. Younger adolescents see the world as black and white – marijuana, like other things, is an either/or – good or bad, which one is true?

As parents, you must be clear about what you want to communicate to your teen.  Here are five points that may be helpful.

1. Every person’s brain reacts differently to THC, the active drug in marijuana.  You have no idea how you are going to respond to a particular drug until after you have tried it.  Some of the factors that affect response to drugs are genetics, setting, mood and stress, but ultimately your brain is unique and will determine how you respond.  What is OK for a friend or sibling could create a very different reaction for you.  Even the same drug could be very different a month later in a different situation.

There is also research showing that a small percentage of teens with a predisposition to schizophrenia put themselves at risk of having a psychotic episode at a younger age if they become chronic users of marijuana.  More research is being done on this topic, as well as the connection between chronic marijuana use and other psychiatric disorders.  It’s critical to be honest with your teen about any family history of depression, schizophrenia, bipolar disorder, substance abuse or other mental health disorder.  This family history puts them at risk, especially if they become a chronic user of marijuana.

2. The marijuana that people smoked 25 years ago is different than what is available today.  There is a greater range of THC levels in marijuana, especially marijuana grown in Northern California. The average THC concentration 25 years ago was somewhere in the range of 3%.  Marijuana now has a THC concentration in a wide range from 3 to 15%.  In general, the marijuana available today is more potent that what was around in the past.

3. You can’t become addicted to marijuana, but you can become dependent. This means that chronic users of marijuana become dependent on this drug to help them cope with stress, failure, anxiety, boredom and any other uncomfortable emotion.  Chronic marijuana use can also lead to Amotivational Syndrome, which is very familiar to all of us who have laughed at the “stoner” character onTV or in the movies.

4. If you are going to smoke pot, it’s better to wait.  The latest research on teen brains shows that a teen’s brain is still in an intensive developmental phase, with lots of growth and pruning of connections in the frontal cortex.  THC is a potent chemical and affects the parts of the brain that control short term memory, learning, coordination, and problem solving.  The latest brain imaging tools have given us a new vantage point into the developing brain – stay tuned for more information on this in the years to come.

5. There are real legal repercussions to being caught with pot.  There could be repercussions at school, at home and with the police.  These repercussions can be harsh if a teen is caught with a large amount of marijuana, is driving while under the influence, or in a vehicle where pot is being smoked.  Legally, your teen may face anything from a fine to jail time, and any school disciplinary actions related to drug use may affect their chances for college admissions.

Many parents wonder how much to share of their own marijuana experience.  In general, it is best not to over-share.

You can tell your teen that you have smoked or experimented with marijuana, but you will have opportunities to share details as time goes on.  Even though you turned out fine, it could be different for your teen, and there are reasons why your teen should wait to experiment or use marijuana.

If you suspect your teen is already smoking pot, or if you find a pipe or marijuana, talk to them about it immediately. Many teens will say “it isn’t mine.”  Question that.  Even in the unlikely event that the pot is not theirs, a willingness to hide it for a friend means that they are either also using or close enough to someone who does that they can be convinced. If you or a teacher suspects your child is smoking marijuana at school, address it right away. This is a significant warning sign for a concerning level of marijuana use.

All  parents will have a different message around marijuana, alcohol and other drugs.  Some parents will convey the message that they want their teen to wait until they are older and then decide if they are going to drink or experiment with marijuana.  Others say absolutely no use. Others may be more permissive.  When you decide what message you want to convey, be consistent, firm and caring.  No matter what message you decide to convey, you must let your teen know that you want to talk about this if it becomes an issue for them or their friends, or if they have any questions.

This is an opportunity to have a real conversation with your teen about an important health topic.

You want your child to share what they know, what their thoughts and opinions are, and what their friends are doing. Please listen and then express your opinions, knowledge and concerns for their safety.  The ultimate goal is to keep our kids safe, and teach them how to have fun and relax without turning to a substance that may have a real impact on their health and learning.

Dr. Branco is a practicing pediatrician in the San Francisco Bay Area and is very active with the local chapter of the AAP. Ellen Branco is a School Counselor and Health Educator in the San Francisco Bay Area. She has been working at independent high schools and counseling since 2001.


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.