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.

We 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.

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*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.

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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.

 

Why don’t you have separate sick and well waiting rooms?

Written by Suzanne Berman MD. Dr. Berman is a practicing general pediatrician in rural Tennessee.

We’re occasionally asked by families why we don’t have separate waiting rooms for sick and well patients.  It’s a good question, especially given that many pediatric offices are designed this way.  There are several reasons why we chose not to do this.

 What ‘s a “sick” visit vs. a “well” visit?  

The first problem is one of definition.   While some kids are very clearly sick and other kids are clearly well, many of the visits we do don’t fit nearly into one category or another.  Is a depressed teenager “sick” or “well” ?

What about a 4 year old with a possible urinary tract infection?   An infant who’s not gaining weight?  An 8-year-old with belly pain?   A better way to separate the waiting rooms would be a “contagious” waiting room and a “noncontagious” waiting room.

However…

Parents often don’t know whether a child is contagious or not when they check in.  

We don’t expect them to be – that’s our job.   If a child comes in with a new rash, it might be eczema (not contagious at all), chickenpox (very contagious), or ringworm (only very mildly contagious, and certainly not enough to keep them out of school or sports.)   Fifth disease is contagious and causes a rash – but once the rash appears, the child is no longer contagious.

Knowing whether the child is contagious (and how contagious, and for how long) first requires a medical evaluation – and that happens after the child has been brought back, not in the waiting room.

What about siblings? 

We often see double or triple appointments in a family.   If Dad brings in a 6-month-old baby for a checkup (a well visit) and his two year old sister for a cough (a sick visit), what side of the waiting room should the whole family sit on?

We could put the well baby on the sick side (since he’s already been exposed to the two year old’s illness, presumably), or we could put the sick child on the well side (to keep the well baby well.)   There’s no good answer.

And I can’t put a number on the times I’ve seen a well child who was accompanied by a parent who was coughing and sneezing uncontrollably.

It actually can make crowding in the waiting room worse.

Our office’s single large waiting area measures about 20 x 30 feet.   Let’s say we divided it in half, to create separate sick and well waiting areas, each about 20 x 15 feet.

In the summer, when 70 percent or more of our visits are “well,” our patients would be crammed in a much smaller room while our “sick room” would be underutilized.

The exact opposite would be true in the winter months –a crowded waiting room of sick children half as big as it could be.   When we have a single large area, we can make the most of our space; families can sit wherever they wish, near or far away from anyone else in the waiting room.

Parents are sometimes not honest about their child’s contagious condition.

I once reviewed a malpractice case in which the plaintiff contended that the defendant pediatrician didn’t recognize a baby’s sickness. The defendant’s attorney asked the plaintiff’s grandmother (who had brought the baby to the office) whether the grandmother chose the sick or well side.

The grandmother said, “We sat on the well side.”  The defendant’s attorney asked, “If the baby was sick, as you say, why did you sit on the well side?”   The grandmother replied, “Well, she wasn’t very sick at the time – just a little sneezing and cough.  And I didn’t want her catching something from the sick side.”

Honest parents will admit that they’re usually more concerned about keeping their own child away from other sick children, rather than worried that other well children will catch their child’s illness.

Our receptionists don’t want to police the waiting rooms.

Colleagues with separate sick and well waiting rooms tell me that their receptionists spend at least part of each day helping parents decide which waiting room to sit in, moving patients from one waiting room to another, or settling angry squabbles between two families who are convinced the other’s child is in the “wrong” area.

Our receptionists would rather check in patients quickly – validating insurance information, updating phone numbers, and processing questionnaires — rather than serving as “waiting room police.”

There’s no evidence separate sick and well waiting rooms make a difference in controlling the spread of infection.

The American Academy of Pediatrics’ statement on controlling infection in pediatric offices states, “No studies document the need for, or benefit of, separate waiting areas for well and ill children.”

We believe that other commonsense precautions are more effective – like making masks, tissues, and hand sanitizer available in the waiting room; bringing children suspected of having an extremely contagious disease in through the back door; bringing extremely fragile/susceptible children back as soon as they enter the office.

When Should You Allow Your Child to Have A Cell Phone

This is a very common question from parents. I know my wife and I had to answer this question not too long ago.

Funny thing is, that our parents, and our parents, parents, didn’t have to answer this question. I find that fascinating. But our world is different now.In more ways than one.

Makes me wonder the type of questions they will have to ask themselves as parents 20 or 30 years from now. I can’t even imagine.

In this video, Dr. Wendy Sue Swanson from Seattle Mama Doc talks about when we should allow our children to have a cell phone.

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. Dr. Swanson blogs regularly at Seattle Mama Doc

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

Related articles

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

Expecting a Child? Need to Find a Pediatrician? What Questions Should You Ask?

Written by Natasha Burgert MD

Photo Credit – http://blog.cakehealth.com/

“Who is going to be the doctor for your new baby?”

Your OB wants to know. Your friends have asked. Your mother is wondering.

Finding a pediatrician is on the “to-do” list of all expectant mothers and fathers. New families often begin the search for a potential baby doctor by asking for recommendations from their OB doctor, family, and friends.

Some families begin by looking at the American Academy of Pediatrics website.Regardless of how you find a pediatrician, truly determining if a doctor is going to be a good match for your family is often done by interviewing.

I have seen plenty of glowing mothers-to-be sitting in my office with the seemingly standard “interview sheet” from babycenter.com or WhatToExpect.com.

Parents come to my office with a “recommended question list” because they don’t really know what to ask. This is certainly understandable since, for most families, interviewing a doctor is new territory.

But although these lists of questions are a good start, I don’t think they get to the heart of the matter.

What most parents really want to know is if a pediatrician is likable. Is this person going to be someone I can ask questions? Do we have something in common? Are we going to get along?

Compatibility is what most parents are searching for.

Here are 5 questions I would ask a potential baby doctor during an interview.

1. “Tell me about your office.”

Office hours and locations, contact numbers, hospital affiliations, and basic biographical information is fairly standard on every medical practice website. Use the web to get the basics, but let the doctor tell you where he thinks his office really shines.

This open-ended approach gives the doctor an opportunity to say what he thinks is the most important, interesting, or significant about the place where he works.

If the doctor does not cover any specific question you have about the function of the office, then ask.

2. “Why did you choose to become a pediatrician?”

The million dollar question. This is an opportunity for you to learn about the person behind the white coat. Of all the medical specialties, why did she choose to take care of kids?

3. “What are your thoughts on antibiotics and vaccinations?”

For most doctors in pediatric healthcare, antibiotics and vaccinations are common medical interventions.

How a doctor chooses to use antibiotics, and for what illnesses, does vary. With the increasing concern of antibiotic resistance and super-infections, having a physician who can clearly define when antibiotic use is appropriate for your child is important.

Vaccinations are a fundamental building block for child health. A physician’s beliefs and attitudes towards vaccinations will effect the recommendations they may or may not provide.

Also, some physicians will not see patients if the recommended vaccination schedule is not followed. Allowing a doctor to openly express his opinion on immunizations can begin productive dialog about this very important topic.

4. “What do you love about your job?”

Does this doctor have a passion for the underserved? Does he love to see kids with chronic illnesses, like asthma or ADHD? Does she love to teach?

Asking a doctor to share the best part of his job may reveal a common interest. Or, allow you to determine if your family’s needs will be best supported.

5. “What do you like to do outside of work?”

Pediatricians often look alike on paper. We all go to medical school, complete a pediatric residency, and get certified by the American Board of Pediatrics.

Asking the doctor what she enjoys doing outside of work may be enough to make the person on paper become a new partner in the care of your family.

Good luck in your search!

Dr. Burgert is a pediatrician. She works at Pediatrics Associates in Kansas City, MO .  She is a distance runner and enjoys road races around the city. She also has a passion for travel that will certainly lead to many memorable family vacations with her husband and two children. And, of course, she bleeds Husker red. Dr. Burgert regularly blogs at kckidsdoc.com

Vaccines Save Lives

Talking about gun safety is an important part of preventive counseling

Written by Seth D. Kaplan, M.D., F.A.A.P.

Counseling patients about safety issues is one of the most important parts of my role as a primary care pediatrician. One of the main goals of working with my patients is to reduce the risk of injury to children in the environments in which they live and play.

Thus, I spend time discussing potential problems related to seat belt use, tobacco exposure, storage of household chemicals, swimming, sun and playground safety, and more.

Talking about firearm safety and storage is part of this conversation as well.

The answers I get to questions about firearms are fascinating. Many people say, “We don’t own guns, so we don’t worry about this.” When asked if they know if there are guns in the houses of children their kids play with and if their kids would know what to do if they saw a gun, they often answer, “I hadn’t thought about that.”

Those who do have guns have a chance to talk about safe storage, and often have tips that I can pass on to other families, such as where parents can find good training courses for their kids, when appropriate.

I believe talking about gun safety and other safety-related issues is an important part of the preventive counseling I provide patients and their families. When the government tries to dictate what a physician and his or her patient can and cannot discuss in the confidential setting of an exam room, I no longer can perform the preventive aspects of pediatrics expected of me.

Thus, I applaud the decision of the U.S. District Court for the Southern District of Florida.

The Florida chapter of the American Academy of Pediatrics, along with other groups, sued to block the law. Recently, a federal court declared the law unconstitutional, saying it was a violation of physicians’ First Amendment rights to speak with their patients about gun safety.

To learn more, read the court’s decision.

Dr Seth D. Kaplan, who practices general pediatrics in Frisco, TX, but finds every excuse he can to get out to the ballpark. Go Rangers! 

Dr. Kaplan posts topics on Facebook at TLC Pediatrics of Frisco.

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

How Pediatricians Can Help Through Your Adolescent’s Transition

Written by Jesse Hackell MD.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Dr. Hackell is a founding member of Pomona Pediatrics PC, a division of Children’s and Women’s Physicians of Westchester. He practices in the lower Hudson River Valley just north of New York City.

Many Parents are Afraid of Fever. Don’t Be.

Written by: Kerry Frommer Fierstein, MD, FAAP

In a recent article the American Academy of Pediatrics reviews the facts and fiction that surround fever in children and reminds nurses and pediatricians to better educate parents about fever.

Important fever facts:

The following information does not apply to infants under three months of age for whom you should contact your pediatrician urgently for any temperature of 100.4oF (38oC) or higher.

• There is no “normal” temperature. 98.6 is an average and many children will normally run a little higher or a little lower. In addition, throughout the day, a given child’s temperature will vary by as much as a full degree.
• Fever can be helpful in fighting infections. Fever slows down the growth of viruses and bacteria while activating our immune system.
• Higher fever does not necessarily mean a more seriously ill child. Most fevers, no matter how high, are brief and not dangerous. However, if your child has a fever greater than 101 degrees Fahrenheit for more than 48 hours you should see the doctor to discover the cause of the fever.

Fevers do not cause brain damage or death. Children with fevers above 104 degrees are not at increased risk of problems because of their temperature (the one exception is heat stroke, which usually occurs from over activity in warm weather.) Fevers can cause “febrile seizures” but these types of seizures, though scary to watch, do not cause any permanent effects. Furthermore, there is no evidence that Tylenol (acetaminophen) or Motrin (ibuprofen) use will reduce the risk of fever seizures.

Parents should remember:

• The #1 reason to bring down your child’s fever is to make him/her more comfortable.
• It is not necessary to wake your child to give him/her fever medicine.
• Look at your child, not the thermometer. If your child is drinking, quietly playing, or sleeping, do not worry about fever. If your child looks poorly and is too weak to drink, he/she should be seen by the doctor regardless of the temperature.

Dr. Fierstein is a practicing pediatrician. Born in the Bronx and raised in Queens, Dr. Kerry Frommer Fierstein is a New Yorker all the way. She works atPediatric Health Associates, PC, a division of Allied Pediatrics of New York.