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Daily Dose

Get the Most fromYour Child's Well Check

2.00 to read

When was the last time you saw your pediatrician for a “well child check up”?  Can you remember how much time you spent with your doctor?  According to an article in the October issue of the journal Pediatrics, 33% of parents surveyed spent less than 10 minutes with their child’s doctor.  Another 47% stated that they spent between 11-22 minutes with the doctor and 20% stated that they spent 20 minutes or longer.

This study really only reinforced what I already know…it takes longer than 10 minutes to do a comprehensive well child exam and have enough time to discuss all of the topics that need to be addressed, even if you are talking fast!

It doesn’t matter what aged child I am seeing, there are just so many issues to be covered.  High on the list is anticipatory guidance. It is a look ahead at how your child will be changing and developing.

For a first time parent this may mean a discussion about their child beginning to crawl and the need to childproof the house. For a parent of an older child, it may be a discussion about a new driver and driving contracts, or a college bound student and the risks of binge drinking. The list of topics is enormous and the topics to be discussed continue to grow!

I try to cover the “list” of topics that I want to cover in each well child visit and then leave time for parents/children to ask questions or address any specific issues that they might have.  In most cases it is not possible to accomplish this in the scope of a 10 minute exam.

As a child gets older, and many of the issues become more complex than “what is the first food I should feed my baby”, the time crunch is even more evident. I only wish that I could spend 45 minutes to an hour with each teen that I exam as there are just so many topics to cover, and most teens will talk if you just give them the time. Therein lays the rub; not enough time!

Unfortunately for both the patient and the pediatrician, medicine is becoming more and more about the insurance company, time and billing. Many insurance companies do not cover the time spent for preventative care and the numerous screening services that are recommended.

There is nothing more important than preventative care, especially in the pediatric population. The time (and therefore money) spent now may be the solution to more costly heath care issues at a later date. How can you discuss obesity, food choices and type 2 diabetes with an overweight 13 year old, whose parents are also overweight, yet they continue to buy fast foods.  

The visit should also include discussing the child’s learning issues at school, throw in rules surrounding social media, sleep needs for teens, and round it out with gun safety in a 10 minute time span? Oh yes, you need to do a thorough physical exam too.  I find these conversations hard to do with my own children during a dinner conversation, yet alone during 10 minutes with the doctor.

Next time you go in for your child’s check up, make sure your questions are all answered and see how long your average visit takes. I wonder why I am always “behind”; I just can’t do it in the 10 -15 minutes allotted. I want to answer all of my patient’s questions and concerns and if it takes a bit longer, so be it! 

That’s your daily dose for today.  We’ll chat again tomorrow.

Daily Dose

The Difference Between A Viral Sore Throat & Strep Throat

It only takes getting the kids back in school for the pediatrician’s office to see an upswing in illness. But this year it came on particularly early and we are definitely seeing more illness in the first week of fall than is typical.

Most of the illness being reported around the country is due to Influenza A, H1N1 (swine flu) and the majority of cases seem to be occurring in the five to 24 year old age group, in other words the school aged, elementary through college aged kids. To review again, flu like symptoms for all influenza strains are typically similar with fever, sore throat, cough, congestion, headaches and body aches. Occasionally there may be some nausea or vomiting but that is not seen as often. Flu like symptoms seem to begin with general malaise and then develop over the next 12 – 24 hours and you just feel miserable. Some of the confusion now is about sore throats and the difference between a sore throat with the flu, which is due to a viral infection, and strep throat, which is a bacterial infection. As for most things in life, nothing is 100 percent and the same goes for viral and bacterial sore throats. But, with that being said, there are certain things that might make a parent think more about a viral sore throat than strep throat and vice versa. Viral sore throats, which we are seeing a ton of with the flu right now, are typically associated with other viral symptoms which include cough, and upper respiratory symptoms like congestion or runny nose. A viral sore throat may or may not be accompanied by a fever. In the case of flu, there is usually a fever over 100 degrees. With a viral sore throat you often do not see swollen lymph nodes in the neck (feel along the jaw line) and it doesn’t hurt to palpate the neck. If you can get your child to open their mouth and say “AHHH” you can see the back of their throat and their tonsils, and despite your child having pain, the tonsils do not really look red, inflamed or “pussy”. Even though it hurts every time you swallow, to look at the throat really is not very impressive. Strep throat on the other hand, typically occurs in winter and spring (that is when we see widespread strep), but there are always some strep throats lurking in the community, so it is not unusual to hear that “so and so” has strep, but you don’t hear a lot of that right now. As we get into winter there will be a lot more strep throat. Strep throat most often affects the school-aged child from five to 15 years. Children get a sudden sore throat, usually have fever, and do not typically have other upper respiratory symptoms (cough, congestion). This is another opportunity to feel your child’s neck and see if their lymph nodes are swollen, as strep usually gives you large tender nodes along the jaw line. When you look at the throats of kids with strep they usually have big, red, beefy tonsils (looks like raw meat) and may have red dots (called petechia) on the roof of the mouth. The throat just looks “angry”. Sometimes a child will complain of headache and abdominal pain with strep throat. Some children vomit with strep throat. The only way to confirm strep throat, again, a bacterial infection, is to do a swab of the back of the throat to detect the presence of the bacteria. There are both rapid strep tests and overnight cultures for strep. Most doctors use the rapid strep test in their offices. If your child is found to have strep throat they will be treated with an antibiotic that they will take for 10 days. Again, antibiotics are not useful for a viral sore throat and that is why strep tests are performed. I’m sure we’ll talk more about sore throats as we get into winter. But in the meantime, get those flashlights out and start looking at throats. That’s your daily dose, we’ll chat again tomorrow.

Daily Dose

Baby Naming in the Hospital

1:15 to read

An interesting article was published this week in Pediatrics. If you have had a baby or visited the newborn nursery you typically see that a newborn is named “Babygirl or Babyboy Smith” on their crib and chart.  These are the temporary names given until the baby is named and the birth certificate is filled out. Well, it seems that these temporary names can cause quite a bit of confusion and may also contribute to medical errors, especially when there are babies with the same last name.   

These temporary names are even more problematic when a newborn is admitted to the neonatal intensive care unit (NICU), which was the case for my grand daughter last summer. While there may be few orders in the regular newborn nursery which are used for every baby, in the NICU each baby has many different orders and issues.  

A study was done looking at ways to cut down on medical errors in orders written in the NICU by using more distinct temporary names for newborns. In the study they incorporated using a mother’s first name into the newborn’s first name (for example, Susansgirl Smith). By changing the manner in which temporary names were used there was a 36% reduction in orders being placed in the wrong chart and then having to be retracted.

So, the next time you head to the NICU or newborn nursery for a visit you may soon notice a difference in the way temporary names are used. I can see how this would really make a difference as we often have several newborns in the nursery with the same last names and it can be confusing, even when the chart is labelled “name alert”. I like this idea and I would think it would be easy to implement this change without needing a lot of new training or computer programs.  We will all just get used to seeing longer temporary names on those baby cribs!

Daily Dose

Your Baby's Umbilical Cord

1.15 to read

I get a lot of phone calls several days after parents head home with their newborn regarding their baby’s umbilical cord.  The umbilical cord really is the lifeline for the baby for 9 months, but once the baby is delivered, and the cord is clamped, it becomes a nuisance and “grosses” many parents out.  So often parents don’t even want to touch the cord and one of my patients told me....”why can’t it just dry up and fall off immediately?”. My only answer to that is, “God did not make it that way?”.

So, in a nutshell the umbilical cord is made up of 3 blood vessels, actually 2 arteries and one vein.  When the cord is cut and clamped the vessels begin to clot and eventually the cord detaches, typically in 7-14 days and then falls off.  

In the interim the cord is developing a scab so it may “ooze” a bit and there may even be dried blood on the baby’s diaper or around the edge of the cord.  A tiny bit of blood is to be expected, and parents don’t need to be worried that the baby is bleeding!!!  I like to explain that it is the first time as a parent that you might need to clean off a little blood, the same way that you will again when this sweet newborn becomes a toddler and falls down and skins their knee.

On occasion the hospital forgets to take the cord clamp off before the baby is discharged and the family comes in with the baby for their first visit with the cord clamp still on.  Poor parents have no idea that this is typically removed before discharge...somewhat like leaving the store with the magnetic tag on the outfit....just no alarm to let you know it is still there. In that case they are amazed when we pop off that yellow or blue plastic attached to their baby!

Lastly, the newborn baby can have some time on their tummy, if they are awake, even with the remnant of the cord still on. It will not hurt the baby at all and early tummy time is important...just NOT when a baby is sleeping!

I have to admit that I opened the baby book 30 years later and that dried umbilical stump was in there..Yes, I too was a first time mother.....don’t save it!

Daily Dose

Measles Exposure on an Airplane

Public health officials are warning passengers of possible exposure to measles on an airplane. Dr. Sue talks about how infectious diseases are just a plane ride away. I know you have read previous blogs on immunizations.  I have re-iterated many times, that despite the perception of some, many vaccine preventable diseases have not been eradicated from the United States and some may just be a “plane ride away”.

This is now the issue with a recent case of measles that occurred  in an unimmunized woman from New Mexico who was returning from a trip. The woman developed an illness, later confirmed to be measles, as she returned from London and subsequently travelled through no less than 4 different airports in the United States. The issue is that this one traveler, exposed many individuals on multiple airplane flights, as well as in 4 different airports.  As Dr. William Schaffner, an infectious disease specialist at Vanderbilt University stated, “the potential exposure of so many travelers in airport terminals is a cause for concern”. While most Americans have been immunized against measles (with the MMR vaccine), there are still those who remain unimmunized either due to the fact that they are too young, or because they choose not to be vaccinated (as had this woman who developed the “index case” of measles). Children do not receive their MMR vaccine until after their first birthday, and then receive a booster dose of MMR between the ages of 4–6 years. Therefore, a child who is less than 12 months of age, who may be up-to-date on all of their immunizations but is too young for MMR, may have been exposed to measles if they had been sitting within 5 airline rows of the woman who had undiagnosed measles. The same holds true for infants who might have been next to the woman in a security line, or at a Starbucks, or in the newsstand as she passed through these 4 various airports. It is also possibly an exposure for anyone of any age, who has never been immunized against measles, or who has not had the disease (older individuals). All of these exposures would have been accidental and never even noticed unless an exposed person subsequently develops measles. The incubation period for developing measles after an exposure is between 8-12 days, and measles will present with symptoms of fever, cough, runny nose, red eyes, and a body rash. So….here is just another example of the spread of an infectious disease.  This case involves travelers in airports from London, England, to Washington D.C., to Baltimore, to Denver, and ultimately to Albuquerque.  Now we need be alert for any further cases of measles in next several days and weeks.  Remember, measles is a respiratory virus, and it is spread via coughs and sneezes, and the virus may last in the air for up to 2 hours, without any one suspecting they are being exposed. If your child has not been immunized, this is a good reminder, run don’t walk, and get that MMR. That’s your daily dose for today.  We’ll chat again tomorrow.

Daily Dose

Earaches Are Painful

1:30 to read

I just managed to catch yet another cold from my cute, little patients who felt that they could “squeeze in” one more cold before officially closing out the sick season!  Parents are so SICK of their children being SICK and I must agree...it is time for everyone to stop coughing and sniffling and get well, and that means fewer ear infections as well.

Ear infections are one of the most common reasons that a parent brings a child to their pediatrician.  But, not every child that has a runny nose, cough, fever, or pulls on their ear will have an ear infection. In fact, most will not.  

Several important facts about an ear infection: a child’s ears typically do not get infected on the first day of a viral upper respiratory infection, most ear infections occur between day 3-7 of a cold. Most children who will develop an ear infection will have a runny nose, congestion, cough and often develop a fever.  It is not unusual for a child to have a fever for the first few days of a cold, but a fever that develops 3, 5, 7 days after the beginning of a cold may be a red flag for an acute ear infection.

The newest guidelines on ear infections are quite clear and state that the pediatrician needs to distinguish between an acute otitis media (AOM), with a bulging and opaque ear drum versus those children who simply have serous otitis media (fluid behind the ear drum).  Antibiotics are only recommended for those children with and acute ear infection who are symptomatic.   

For children under the age of two years, especially those in day care or school situations who have a first AOM, amoxicillin is still the recommended drug of choice. It is inexpensive and well tolerated (and tastes good too). For children with recurrent ear infections second line drugs will be used.

For a child over the age of two years who is not running a high fever or in exquisite pain, the newer guidelines advise “watchful waiting” with treatment beginning with topical ear drops for pain and acetaminophen or ibuprofen.  In the older child the infection is less likely to be bacterial and more likely viral and therefore will not respond to antibiotics.  I will give the parents a prescription for an antibiotic with instructions to begin it if the child seems to be worsening over several days, and to call me to let me know they started the antibiotic. In over 75% of my patients, they never begin antibiotics and the symptoms improve and the ear infection resolves on its own.

Discuss options for treatment with your own pediatrician and remember, judicious use of antibiotics is very important.  Not every child who pulls on their ear or who has a “bad night” of sleep will require an antibiotic. All children must be seen to decide who has an ear infection. it is not a telephone diagnosis!

 

Daily Dose

Sleep & Your Baby

1:30 to read

Once a new baby joins a family one of the first questions I am often asked is, “when will my baby sleep thru the night?”.  SLEEP is one thing that all parents crave and for one reason or another many parents with infants over 6 months of age, complain that their baby is still not “sleeping through the night”. If your baby or child is not sleeping well, that typically means that parents are having disturbed sleep as well.   

By 6 months of age a baby should be able to self soothe and fall asleep on their own and the majority of babies are sleeping 10-12 hours thru the night as well.  After many years of practicing pediatrics and dealing with my own children’s sleep issues, I spend quite a bit of time with my patients discussing healthy sleep habits.  Like most things, it is easier to start off with good habits and bedtime routines.

So….when parents come in at the 6 month visit and are concerned about their baby’s sleep and awakenings I typically discuss “letting their baby cry it out”. This advice is met with varying responses.  Some parents are ready to get a good night’s sleep and will do “anything”, while others think I am “a mean doctor” and would “never let their baby cry”.  Like most things it is not always black and white and that is why we have chocolate and vanilla.  But, in my experience, the sooner you deal with sleep issues the faster they seem to resolve…

A recent article in Pediatrics should now reassure parents that they are not “harming their baby” by letting them “cry it out” which is called graduated extinction.  The study done in Australia found that infants whose parents let them “cry it out” fell asleep 13 minutes sooner than a control group and woke up less often during the night, and had no significant differences in stress levels (based upon salivary cortisol levels). The study also found no long term effects on parent-child attachment.  All good news for some sleepless parents who are considering this method to get their baby to sleep through the night. 

The researchers also looked at another behavioral sleep training intervention called “bedtime fading” which some feel is a “gentler” method of sleep training. In this case a baby’s bedtime is delayed with the thought that a sleepier child will fall asleep faster and may not cry as long.  This may be an easier method for some parents who continue to be anxious about “graduated extinction”.  This too showed that infants fell asleep sooner than controls but they showed no change in the number of nighttime awakenings.

Bottom line, sleep is important for the entire family ….all ages.  This article should hopefully go a long way in reassuring sleep deprived parents that a baby’s cries are not harmful and may actually get everyone to sleep faster, longer and more peacefully….you just have to believe the research and hang in there. 

Daily Dose

It's Croup Season!

1.45 to read

It is definitely fall and all around the country, the temperatures are cooling off and the chill is in the air at night. With the cooler temperatures more of those pesky viruses come out and once again I am seeing croup.

Croup is a viral upper respiratory infection that causes swelling of the trachea and larynx (voice box) which causes young children to cough and at times to bark like a seal. This hoarse raspy cough is most problematic in younger children who have smaller airways.  

Children often go to bed at night with nothing more than a little runny nose, and then suddenly awaken with this barking cough. Many times the noise emanating from the child’s room sounds more like a sick animal than your previously healthy toddler and may be alarming to both parents and the child.  

Whenever you awaken to a croupy child, the first thing to do is turn on the hot shower and shut the bathroom door as you head down the hall to your child’s room.  After getting your child, grab several of their favorite books and head back to the steamy bathroom. Sit in the bathroom and try to calm your child down and let the steam work.

Typically in several minutes (or until the hot water runs out) their coughing should improve and they will relax. Remember, they have suddenly awakened and are trying to figure out what is going on as well so they may appear to be tired and anxious as well.

In most cases the steam and humidity will help to relax the airway. If the steam doesn’t seem to be working after 5– 10 minutes try going outside into the cool night air. Many times a frantic parent will put their child into the car for a trip to the ER, only to find the child perfectly calm and no longer coughing on arrival to the hospital. The reason being, the cool air has also helped to calm the coughing.

If your child is having stridor (a high pitched squeal) when they breath in and appears to be having any respiratory distress with pulling of their ribs when they are breathing (called retractions), then you need to call your doctor. If they are coughing and turning bright red while coughing be reassured that they are still moving air well. You should not see any duskiness or blue color and if you do call 911. (Remember the adage blue is bad, and red is good).

If by morning your child is having continued symptoms you may want to see your doctor as steroids (given orally or by injection) may be used to help shrink the airway swelling. Most cases of croup do not require hospitalization. After several days of croup your child will probably be well.  

Lastly, older children and adults may also get the virus that causes croup, but with larger airways will simply show signs of laryngitis and being hoarse.

That’s your daily dose for today.  We’ll chat again tomorrow.

Daily Dose

Skin Lesion: Staph or Pimple?

1:30 to read

I just received an email question from a teenager who happened to attach a picture of a skin lesion she was worried about. I think it is great that teens are being proactive about their health and are asking questions about issues that are concerning to them.  BRAVO!!

So, this “bump” sounds like it started out as a possible “zit” on this 16 year old girl’s neck.  She admitted to lots of “digging” into the lesion and then became concerned that it didn’t seem to be getting any better.  She said that friends told her that it could be scabies, or possibly staph.  Leave it to friends to make you more apprehensive about the mystery bump. Looking at the picture it looks like it could be a simple pimple and in that case the best medicine is to LEAVE IT ALONE. The hardest thing to get teens to do (and also adults) is not to pick at pimples or bumps on their bodies, as this could lead to a skin infection. Many times just washing the “zit” and leaving it alone, it will go away.  When you go “digging” into it you break the skin and allow bacteria to enter the now open wound and you can get a skin infection. 

In many cases this may be due to staph or strep from your hands.  This may sometimes require a topical or oral antibiotic to treat the infection, when it may have been something that should have been left alone. There are skin infections that we are seeing in the community that are due to MRSA (methicillin resistant staph) which have become quite frequent in the last several years. In this case that small “bump” usually arises quite quickly, often times it is confused with an insect bite. But very quickly the bump becomes more inflamed, tender and often quickly grows in size. Many times there will be drainage from the bump which now resembles a boil.  In my experience the hallmark of MRSA infections is how quickly they arise and how painful they are.  They have a fairly classic appearance (see old post on Staph).

MRSA infections often have to be drained and require different antibiotics than ”regular” skin infections. In most cases it is necessary to obtain a culture of the drainage so that the appropriate antibiotic may be selected. In some circumstances the infection is quite extensive and may even require surgical drainage and IV antibiotics, requiring a stay in the hospital.  MRSA is a serious infection and is often seen in teens who share articles of clothing or participate in sports where they are showering, using equipment etc that is shared. Remember to use your own towels, and athletic equipment when you can.

This teen also asked “if you have staph would you have it forever?” In actuality, many of us harbor staph in our noses and we all rub our noses throughout the day and then touch other parts of our body as well as other objects. This then passes the bacteria from person to person, sometimes via another object. If you are not symptomatic, don’t worry about whether you have staph in your nostrils, but do adhere to good hand washing and try to keep your hands away from your face. For patients who have had recurrent skin MRSA infections, I often prescribe an antibiotic cream to be put in the nostrils as well as in the nostrils of all close contacts (family members). I also recommend that the patient bath in an anti-bacterial soap and take a bleach bath every week to help decrease the bacterial colonization with staph. It seems that this has helped prevent reoccurrences of staph for the individual as well as for other family members. Lastly, this is certainly not scabies, but we have an older post on that too with pictures!

That’s your daily dose for today. We’ll chat again tomorrow. Send your question or comment to Dr. Sue!

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