Sunday, November 28, 2010

My Advice on Immunizations

Here is the blog I've been dreading, avoiding, and wishing I didn't have to write. It SHOULD be an easy one for me because it is a topic I know well, discuss daily, and am quite clear on where I stand--which is YES, you should fully vaccinate your child, on time, using the schedule recommended by the ACIP (Advisory Committee on Immunization Practices), AAP (American Academy of Pediatrics), and CDC (Centers for Disease Control), and endorsed by me and my colleagues in my pediatric practice. In fact, I believe that immunizing children is one of the most important contributions I can make to maintaining, or even improving an individual child's health as well as a vital contribution to the health of my community.

To me, this is a "no doubt about it" kind of recommendation. It's not an easy subject to write about, however, because it has become controversial. I don't like to have conflicts with families in my practice, or even with parents trying to decide if they should choose me as their pediatrician. It's hard for me to have to disagree. I don't think I'm very good at presenting my opposing point of view in a tactful way. I don't want to offend anyone, or make them feel bad. Still, I am going to write this blog, and I am going to be very clear about my recommendations for vaccinating your child.

I am asked daily to comment on the following questions or statements:

To vaccinate, or not to vaccinate...? Which vaccines are "the most important?" Do vaccines cause autism? What about thimerosol? What about mercury? Tell me about aluminum in vaccines? We were told at our new baby class to ask prospective pediatricians about vaccinations... Don't babies get too many vaccines these days? I don't what to overwhelm their immune system... We aren't taking the baby to day care, so they won't get exposed to any of these diseases. Can you look at this "alternative" vaccine schedule and make recommendations? We are going to vaccinate, we just want to "delay" the vaccines. The diseases we vaccinate for are pretty rare, right? I don't want to do anything that might hurt my child.

These are only some of the questions that come up every day. And it's understandable. After all, you should be an informed health care consumer, right? You just want to do the right thing. And vaccines are a hot topic right now for new parents. Many parents would feel they are not doing their job if they don't ask about or question their pediatrician about vaccines. However, in having these discussions, and responding to all of these details, I think we can lose sight of our goal (which, in my opinion, is a healthy and safe child).

I often get the impression that parents believe I am blindly following vaccine schedule recommendations, just spouting the "party line." When this happens, I don't think I am being given enough credit for doing my job. It is my responsibility to know about each disease and each immunization given to prevent the disease. I take this responsibility seriously.

My colleagues and I have built a schedule of vaccines for our patients that will effectively immunize them at the time when they are at most risk for the diseases. We regularly review this schedule, the type of vaccines we provide, and the benefits versus risk of every vaccine. Our decisions are made based upon scientific evidence, meaning they are supported by deliberate testing and study of the effects of each vaccine. We then recommend a routine vaccination schedule that we have created or actively given our endorsement. This schedule takes into account which vaccines can be given at the same time (to ensure a good immune response while minimizing potential side effects), proper intervals between vaccines, appropriate ages to give vaccines, and the number of actual injections given each time a patient is vaccinated. It becomes a routine part of our well child visits. Having a routine schedule helps minimize the possibility of errors such as a vaccine given at the wrong interval, or age.

Benefit versus risk is an important concept to think about. There are very few things we do that are without risk. We get used to certain risks and simply live with them. Common activities that involve some degree of risk include transporting our child in a car (what if there were an accident?), living in our homes (potential exposure to lead, radon, or carbon monoxide, burns from the stove, hot coffee, or curling irons, cuts needing stitches from falls against coffee tables, falls down the stairs...), taking any kind of medication (acetaminophen carries the rare risk of liver damage, ibuprofen can cause anaphylaxis in those who are allergic, or rarely can damage the kidneys, amoxicillin or any other antibiotic can cause an allergic reaction in some people), and allowing our children to play outdoors or participate in sports (the monkey bars are one of the most common sources of fractures in children, trampolines can lead to neck and spine injuries as well as fractures in the legs, head injuries occur all the time in sports and from falls (especially when unhelmeted) off of bikes/skateboards/scooters). There must be some kind of benefit that outweighs the risks involved in these activities, or we wouldn't be able to allow our children to live a "normal" life!

In thinking about vaccines you should think about benefit versus risk. Like any medication there are some small risks, and for most vaccines these risks are fever and the possibility of an allergic reaction. However, the benefits of the vaccines far outweigh any risk they present to a child. In looking at risks and benefits I think it is important to look at scientific evidence, not anecdotal reports. Anecdotal reports are the reports of a few individuals who tell their own story, these people may or may not have any background qualifications to lend credibility to their claims. Scientific evidence, on the other hand, is the result of deliberate study of the effects of an intervention or treatment (such as a vaccine). Scientific evidence is subject to peer review (scientific experts evaluating the evidence and methods of study), and to statistical evaluation to determine if the results could just be due to chance.

I think your child deserves to be treated according to recommendations made using scientific evidence. As an experienced, board-certified, pediatrician it is my job to do the best I can to provide this kind of care. I also think that you should expect your pediatrician to provide, at a minimum, the same level and quality of care that she would want for her own children. And my children were fully vaccinated, on time, in accordance with our recommended schedule of vaccines.

In writing this blog I also have to say something about trust, and the doctor-patient relationship. Do you trust your pediatrician? Do you value her advice on growth, developmental milestones, sleep habits and position, feeding issues, how to start solid food, pacifiers, thumbsucking, stooling, urinating, behavioral concerns, potty training, car seat recommendations, among other issues often discussed at well exams? Do you call your pediatrician for advice on what to do when your child has a fever, is vomiting, or is otherwise ill? Do you take your ill child to be evaluated by your pediatrician, and place your trust in her to determine what is wrong and how best to treat it? Do you value all of your pediatrician's education, training, ongoing efforts to keep up with current science, and her expertise in helping you raise a healthy child? If you do, then why would you so easily dismiss your pediatrician's advice on immunizing your child? And if you don't trust your pediatrician, then why do you keep bringing your child to her office? Isn't preventing meningitis, polio, measles, and pertussis (among others!) more important that the correct order in which to introduce solid food?

If you are inundated with anti-vaccine messages, considering Dr. Sears' advice on delaying or altering the vaccine schedule, feeling overwhelmed and worried about vaccinating your child, and spending a lot of time researching the issue, then you should also look at the case FOR immunizations, and at sources that use scientific evidence to back up their claims. The following websites can be very helpful:

And, for an interesting article in the lay press (not a scientific journal):

Wednesday, November 17, 2010

Get Smart About Antibiotics

Did you know that this week has been deemed "Get Smart About Antibiotics Week?" As a health care provider I am supposed to help educate the public about the proper use of antibiotics. You might wonder why it's important to educate people other than health care providers about when to use an antibiotic. After all, isn't it up to me (and other prescribers) to decide when to write a prescription? As you will see, it's not always that easy. I need YOUR help to prescribe antibiotics appropriately!

First of all you need the basic information. Germs cause infectious illnesses like colds, flu, strep throat, pneumonia, sinusitis, conjunctivitis (pinkeye), bronchitis, croup, etc. Many of these germs are viruses, some are bacteria. Viruses cause most of the coughs and colds we see all winter. They are contagious, can cause fevers, coughs, runny noses, green and yellow mucous, sore throats, body aches, red eyes, and other symptoms. They are not treatable (except for a very few, specific, viruses--and these don't cause cold symptoms) with antibiotics. If you take an antibiotic and you have a virus it will not help you get better. It probably won't even help prevent you from getting a bacterial complication later. In fact, an unnecessary antibiotic is more likely to cause problems for you later by making the bacterial organisms already living in you more able to resist the effects of an antibiotic.

Wow, that sounds really good, even easy. Don't take an antibiotic if you have a virus. Don't prescribe an antibiotic if your patient has a virus. Simple. Done. No worries.

It is up to me to decide, and at the same time, sometimes it isn't. You might be surprised to learn that there are some grey areas when it comes to prescribing antibiotics. Some illnesses are clearly bacterial. Others are clearly viral. And then there are some which could be either, or are probably from a virus, but could be from a bacteria. And, because of these uncertain types of illnesses, there are some situations in which it can be just easier to write a prescription than to explain why one might not be needed, or why the parent will have to bring the child back in a few days if things get worse. Don't be too shocked. Did you really think we (doctors) are beyond influence?

So what should I do in the following situation? My patient has missed several days of school. Dad had to take time off work to bring her to the office. They have a $30 copay for an office visit. She has been sick for at least a week with a cough and low-grade fever. I diagnose bronchitis, because I can hear the phlegm and mucous in her lungs. Yet I don't think it is pneumonia because most of this clears with her cough. I know that about 85% of the time, bronchitis is likely to be caused by a virus (this is true). There is nothing I can do to determine if I am dealing with a virus or bacteria. It could develop into pneumonia, but usually doesn't. Still, there is no way to tell if it will, or not. This is a grey area!

I can hear my professors in medical school saying "NO ANTIBIOTIC is needed in this situation. Have the patient return in a few days and recheck her. Educate the family about the proper use of antibiotics." Then I look at my patient and her family and explain my dilemma. They might say "What do you recommend, Doc?" Or "What would you do if it were your daughter?" Or "We'll take the antibiotic, because we can't afford to miss more work or school." Or "Can we just have the prescription? We can't afford another copay." Or "Last time this happened you didn't let us have the antibiotic and we ended up in the ER because she developed pneumonia." And then, the unspoken reproach, not said but seen in the family's facial expression, "We've been waiting for you for an hour and you're going to send us home with nothing?"

Another common scenario is that of a toddler who has had a runny nose and cough, and now a low-grade fever plus difficulty sleeping. Examination reveals some fluid behind both ear drums. This is called serous otitis media, and is not usually caused by a bacteria. It is just fluid in the middle ear, building up because of all the congestion. It probably has an 80% chance of clearing on its own, without ever needing antibiotics. However, let's say in this case the little one has already had six full blown ear infections in the last eight months. We could just be days away from another one. Ideally I should not prescribe an antibiotic, but should have the patient return for rechecks (as a toddler he won't be able to let us know in a reliable way if he is feeling worse) and give the antibiotic if I start seeing pus in the middle ear. Then I am obligating the family to take more time off of work, pay additional copays, and possibly have difficulty scheduling the follow-up appointment(s).

I'm here to tell you that sometimes, as the one prescribing the antibiotic, faced with the above scenarios, it's easier just to write the prescription.

I try to do as much education as I can--about the strong possibility that what I am looking at is a virus, my uncertainty that an antibiotic would be helpful, the possible need for a follow-up appointment. If I don't give an antibiotic prescription I am often asked "Can I just call back for a script if things get worse, or will they make me come in?" Sometimes I can agree to just call something in if things get worse--but in the case of a small child or infant I can't safely do that. Occasionally I will give a prescription and extract a promise from the family not to fill it for 48 hours, then only if nothing has improved. I have started to write an expiration date on those prescriptions as I have noticed they sometimes get filled a month later, for a totally different illness! I don't think that's a good idea at all--at that point how do I know an antibiotic is needed, let alone if it's the right one?

An antibiotic is not a back up plan or a safety net, "just in case." Antibiotics don't "ward off" complications of viruses. They have no magic. An antibiotic will work only in a very specific situation: when the infection is caused by a bacteria and the antibiotic is the correct one for that particular bacteria.

As a parent you can help by not asking for, expecting, or even wanting an antibiotic when your child has a virus. That could mean waiting a little longer before making an appointment to check out minor symptoms like a runny nose or slight cough. It could mean a statement when you come in for an appointment such as "I know it could just be a virus, but we wanted to make sure we weren't missing anything." It could mean educating yourself a bit about common cough and cold viruses, understanding that symptoms from these viruses easily last two weeks (and sometimes three!), mucous color doesn't mean much in terms of diagnosing a virus versus a bacterial infection, and being willing to simply comfort your child as the cold symptoms run their course.

Hey, look--I know it's frustrating to have a sick child and not have anything you can do to make it get better faster. I have three children of my own, remember? I know the grey areas make it even harder to know what to do. I can offer you my pledge--to treat your children the way I would want my own children to be treated, to communicate to you what I am thinking, and why, and to try my hardest to do what is best for your child. I need your pledge that you will try to want what is the best thing for your child, to understand and listen to what I am saying, and not just to extract an antibiotic prescription from the appointment. I want you to trust me, work with me, communicate with me. I will work with you!

The CDC has a website about antibiotics. I can't get the linking option to work on my blog--but you can type this in yourself.

Saturday, November 13, 2010

Hypoglycemia is a myth?

Parents worry their child might have hypoglycemia (or low blood sugar). They notice that when their child has not eaten for a while they get really mean and cranky. Or their teenager (who skips breakfast and lunch) becomes low on energy, possibly even feeling dizzy in the afternoon. Parents worry that this could mean their child has diabetes. It looks the same as when the child's diabetic grandparent seems "out of it" when their blood sugar level drops. Then they have to get the grandparent to drink orange juice to bring the level back up.

This concern brings itself to my office with a parent asking that their child's sugar be checked, or asking for a diabetes check, or simply with questions about hypoglycemia. Many believe this is a very common condition, and some think that it is a sign of diabetes.

My goal in this blog post is to dispel the myths--the myth that hypoglycemia is a sign of diabetes (it definitely is NOT), and the myth that hypoglycemia is a common and likely explanation for children being mean, cranky, low on energy, or dizzy.

First lets talk about diabetes. The main problem in diabetes is either lack of insulin, or decreased ability to respond to insulin. Insulin is a chemical that is made in the body by the pancreas. Its purpose is to make glucose (sugar) available and usable as a source of energy. Without the important, life-sustaining effects of insulin the result is HIGH blood sugar, or HYPERglycemia. In that case there is lots of sugar circulating in the blood, but it is useless to the body as energy. If a blood test is done, the blood sugar level will be very high.

Diabetes comes in two forms. Type I is insulin dependent--meaning that insulin must be injected into the body--and usually starts at a young age. Type II is not usually insulin dependent, is often controlled with diet or pills, and is traditionally thought to start in adulthood. The SIDE EFFECT of insulin or pills used in diabetes can be HYPOglycemia. If a diabetic person has low blood sugar it is usually an undesirable, and sometimes unavoidable, side effect of the medication they are using to treat their diabetes.

Is that point clear? Having diabetes means you will have HIGH blood sugar levels. Treatment of diabetes could have the occasional side effect of low blood sugar (hypoglycemia), but this is a result of the treatment, not the diabetes itself.

But, now that you know that hypoglycemia (or low blood sugar) does not suggest your child has diabetes, I must go on to dispel the myth that hypoglycemia is a common symptom.

Blood sugar levels are very tightly regulated by your body. Think of this as an algorithm: Levels get high and more insulin is released so the sugar can be processed as energy. Levels start to drop and natural body chemicals stimulate your body to release glucose from various places where it is stored (the liver is a big storage center for glucose). If blood sugar levels are starting to drop there might be a feeling of hunger or thirst as your body is stimulating you to replace your energy stores.

We could not live without this tight regulation of blood sugar levels. If our blood sugar levels were constantly getting low we would be passing out, having seizures, becoming brain damaged, and having terrible things happen to us. Our bodies are so sensitive and so good at preventing low blood sugar that we can often feel the effects of just a slight drop in an otherwise normal blood sugar level. This might be a feeling of hunger, crankiness, headache, or jitteriness. If we tested our blood sugar at that time it would likely be in a "normal" range! Yet the slight drop stimulated the symptoms we are having.

Similarly we might respond to rapid metabolism of simple sugars by feeling a quick boost in energy, followed an hour later by the "crash" as the sugars are absorbed from the blood stream. However, if we test the blood sugar level during the "sugar high" and the "crash", it will most likely fall into a medically normal range. We feel the tiny changes as the sugar is used and then leaves the blood stream, but these changes do not show up on a blood test. And, these adjustments are a NORMAL part of the process of using the energy we put into our bodies. Your body makes you hungry and cranky so you will EAT, and replace the energy you are using.

Is your child feeling jittery, hungry, cranky, low on energy, and mean? Obviously these are unpleasant symptoms. Possibly they are related to the body's metabolism of sugar, but they almost never translate into hypoglycemia that we can identify on a blood test. Other explanations for these symptoms could be fatigue, poor sleep, sensory overload, need to exercise or play, thirst, hunger, illness, or need for some quiet alone time.

It is definitely possible to smooth out the feelings we have as our body makes slight adjustments in our blood sugar levels. Protein, especially, helps even out the ups and downs of otherwise normal blood sugars. The body will first use the simple sugars in the blood, as they are the easiest to digest, then move on to other sources, such as protein, to help maintain smooth blood glucose levels. Some protein at breakfast, lunch, and snack can go a long way toward helping your child feel better throughout the day. An all carbohydrate diet (such as a breakfast pastry in the morning, followed by graham crackers for snack, and then a granola bar at lunch) sets your child up to feel bad, noticing all those little ups and downs as the body tries to maintain normal blood glucose levels.

You don't believe me? You were diagnosed with hypoglycemia, you say? I'm not saying it's impossible to have hypoglycemia--I'm just saying it's much more likely that your child is feeling the effects of normal body metabolism, and that if we check the blood sugar levels they will look normal!

As a physician, I have had patients and parents who did not believe me, who needed proof their child was not hypoglycemic. I have sent blood glucose monitoring units home with families, to check blood sugars throughout the day and record symptoms. Years ago one teenager did a beautiful job with this. He monitored his levels throughout the day, recorded his cranky, weak, and hungry symptoms, checked levels before and after eating, upon getting up in the morning, after exercise, etc. Despite having many symptoms he thought were attributable to hypoglycemia, ALL of the blood sugar levels recorded were in the medically normal range!

So, when you think about it, were you really diagnosed with hypoglycemia? Or did someone offer that diagnosis to you as an explanation for the symptoms I have described, without explaining in detail how the body works to maintain normal sugar levels? It would be easy for a health care provider to offer hypoglycemia as an explanation for such symptoms (it's hard to explain, after all), and then put the focus on improving the diet to help minimize those unpleasant symptoms.

Now that I have hopefully dispelled the common myths around hypoglycemia, I do have to mention some true examples of hypoglycemia! Newborn babies are at risk for hypoglycemia. Through the pregnancy the fetus makes its own insulin to respond to its mother's blood sugar levels. So the newborn baby sometimes comes out of the womb making much more insulin than it will end up needing, and there will be low blood sugars for a period of time. These levels can be very low, and sometimes need to be treated for a few days after birth.

There is also a condition that can affect young, usually tiny, toddlers and preschoolers. They might have true hypoglycemia after a long fast (often over night). Their symptoms are pretty dramatic--a seizure or loss of consciousness, inability to wake up--not just cranky. There are some rare conditions that can affect older kids, as well. Again, the symptoms will be dramatic--loss of consciousness, seizures, inability to wake up. Usually these symptoms are on a level that an ambulance must be called to take the patient directly to the hospital.

And, by the way, symptoms of Type I, childhood, insulin dependent, diabetes (which is HIGH blood sugar, remember?) are excessive thirst, excessive urination, excessive appetite, and weight loss.

Please keep in mind that the comments in my blog are meant to provide you with useful information and things to think about, but not to diagnose or rule out any particular medical condition in your child. My blog is not meant to be a comprehensive analysis of any particular condition. For that you need the personal attention of your child's own doctor.

Friday, November 12, 2010

Fatigue, Teens, and Tweens

I see many tired teenagers in the office every day. They take naps after school, can hardly get out of bed in the morning, sometimes sleep half the day on weekends, and generally are low on energy. They always seem low on energy when it is time to get up to go to school, do homework, or do chores. They often revive in an amazing way when it is time for sports practice or competitions, or time to engage in some way with peers.

Their sleep habits are often poor--bedtime of 10:30 or later, then up at 6:30 on school days (teenagers should be getting about 10 hours of sleep at night, averaged over the week, without counting naps). Their phones, computers, TVs are in their rooms to distract them as they try to fall asleep. They often skip breakfast, or have a high sugar treat on the way out the door. Lunch is fast food, or the equivalent in high fat and low nutritional content. Or they don't eat lunch. Fluids can be minimal throughout the day. Some teens barely exercise. Most spend lots of time in front of a screen (TV, computer, games, phones).

Then there is the stress of being a teenager--six or seven teachers making demands, tests, homework, sports, clubs, applying to college (fatigue is VERY common for seniors in high school!), lack of spending money, or the added pressure of a job, relationships with family and friends, a boyfriend or girlfriend, fitting in socially...Actually listing this makes ME feel a little tired and stressed. Wouldn't YOU want a nap after school, too?

There are many causes of fatigue, both physical and emotional. Of course there are important medical causes of fatigue, and mental illness (such as depression) can lead to fatigue. However, fatigue is a common symptom, and MOST OF THE TIME it reflects common, ongoing, physical and emotional stress in a teen or tween's life.

My medical training leads me to think of the most likely things first. There is a kind of medical school joke about zebras and horses. You need the background information that in the United States of America you would be more likely to see horses than you would zebras. In fact, you would probably have to go to a zoo to see zebras, while you could just drive out to the country to see some horses.

So, in south west Michigan, if an animal looked and smelled like a horse, was the same general size as a horse, walked and sounded like a horse--but you just couldn't see its hide to tell if it was striped or plain--would it be more likely a horse or a zebra? The right answer here, of course, is that a HORSE would be more likely than a zebra. It would not be impossible to see a zebra (I guess a farmer could have one as a pet, or one could have escaped from a zoo), but out in the country in south west Michigan you are probably looking at horses.

That means, that when I am assessing someone for the cause of their fatigue, I keep the possibility of zebras (or less common illnesses) in mind, but I do NOT usually end up seeing stripes. I am going to ask general questions about the patient's life, and these answers will factor in an important way into what I think is causing my patient's fatigue. I might ask any or all of the following questions, or even think of other questions that are centered around lifestyle, home, and school:

1. How is school going? Grades, attendance, completing assignments, behavioral concerns at challenges, perfectionism, getting behind in school?
2. How are you getting along with your family? Who do you get along with best? worst?
3. How are things at home?
4. Anything changed at home? Divorce, separation, illness, pets, job loss, troubled sibling...
5. How are things with friends?
6. Dating? How is that going? How long? Physically involved with this person?
7. Are you in trouble with anyone? Suspended? Grounded? Have a probation officer?
8. Substance use/abuse? Tobacco, alcohol, illegal drugs, prescription drugs...
9. What is your daily schedule like?
10. When do you have free time? What do you do with it?
11. What are your eating patterns like? Do you eat three meals? Drink enough water? Take a vitamin?
12. Are you happy with your weight? Dieting? Losing or gaining weight?
13. When and how much do you exercise?
14. Are most teenagers happier than you?
15. Are most teenagers having more fun than you?
16. Do most teenagers have more friends than you?
17. Are most teenagers more popular than you?
18. Are most teenagers thinner than you?

I think this list could be endless. Hopefully you see my point, that any number of these factors could be important considerations in figuring out why your child is tired all the time.

Of course there are the so-called "red flags" when it comes to fatigue. Here I am thinking about signs of depression, deliberate self-harm ("cutting"), thoughts of suicide, a suicide plan. I am also looking for excessive, paralyzing anxiety or panic.

And finally, last on my list, still important but much less likely, the reason most parents bring their fatigued teen or tween to see me, PHYSICAL ILLNESS as a cause of fatigue. Here is where I see parents worry. They believe their teenager has hypoglycemia, or diabetes, or a thyroid condition, or anemia. Now I am asking about weight loss, blood in stools, diarrhea, urinary frequency, excessive thirst, excessively heavy periods, palpitations, dry skin, constipation, night sweats, absent or fewer periods, joint swelling or pain, and other physical symptoms. I always ask about headaches and stomachaches as well, but many people have these symptoms so it doesn't usually help me narrow things down.

Follow all of the above by a physical exam, and sometimes blood work (often just general screening for anemia, hypothyroidism, and a general metabolic panel that includes a blood sugar level), and I am usually left with a physically normal appearing teenager who has normal blood tests. Parents are relieved. BUT THE TEENAGER IS STILL TIRED!

In my respectful, and humble opinion, the blood tests have contributed very little to the evaluation of the fatigued teen/tween. The physical/medical disorders that could have led to abnormal blood tests just aren't that common in comparison to the psychological, lifestyle, and mental health issues that can lead to fatigue. And while it may relieve YOU, as the parent, to know the blood tests are normal, it didn't help your teen overcome his fatigue!

I am not advocating skipping the medical work up for a fatigued teenager. What I want is for parents and teens to take a close look at their lifestyle, diet, sleep habits, stress, and mental health, and to consider these issues as a possible important cause of fatigue. MOST OF THE TIME these issues will be THE cause of the fatigue, so I don't think we can ignore them.

I don't want to miss an important physical cause of fatigue any more than you do, but I do want to help your child feel better. That will probably take us looking at the whole picture, not just ordering a blood draw. And it may involve a solution that is not as easy as taking a pill. It could include changes in lifestyle, diet, nutrition, sleep habits, exercise. Or a recommendation may be made for counseling or family therapy.

You might also be able to tell from this blog that an evaluation for fatigue deserves its own appointment in my office. This is not a work up I can easily add on to the end of a visit for a cough, strep throat, or wart, or piggy-back on to a sibling's appointment. We need to give this symptom the time and attention it demands. After reviewing the information above, however, you may have more insight into the problem and have some ideas for helping your teen. It's usually ok to try some things before making the appointment.

As I always say, this blog is intended to provide general information for situations that are not specific to any patient or family. My blog is not meant to be medically comprehensive and cannot take every situation or symptom into consideration. Every one deserves to have their concerns personally addressed by their own doctor, and the information in my blog is not a substitute for that kind of attention.

Friday, November 5, 2010

Norovirus in Kalamazoo

Our office received a "Health Advisory" from the Kalamazoo County Health & Community Services this week. It announces laboratory-confirmed cases of Norovirus in Kalamazoo County. Norovirus is the new, official name for viruses previously known as Norwalk viruses. Noroviruses have been responsible for relatively large outbreaks of vomiting and diarrheal illnesses on cruise ships, in schools, and in day care centers.

My factual information in this blog comes directly from that Health Advisory, and a fact sheet about Norovirus from the Michigan Department of Community Health, Communicable Disease Division, 201 Townsend Street, CVB-5th floor, Lansing, Michigan. The advice on oral rehydration is the general advice I and my colleagues at Trestlewood Pediatrics give to parents whose children are suffering from a vomiting and diarrheal illness.

Noroviruses are contagious viruses that cause stomach and intestinal illnesses in people. These kinds of illnesses are often incorrectly referred to as "stomach flu" or "flu". Actually, the correct term is gastroenteritis. Gastroenteritis has no relation to influenza (correctly termed "flu"), which is primarily a respiratory illness.

The most common symptoms of a norovirus infection are nausea, vomiting, diarrhea, and abdominal cramps. They occur 10 to 48 hours after exposure to the germ. Other symptoms can include fever, chills, headache, muscle aches, and fatigue. The symptoms last 1 to 2 days, and can be very severe for some people. Dehydration is the most worrisome problem that can result from a Norovirus infection. This would occur if the sick person cannot drink enough fluids to replace what they are losing in vomit and diarrhea.

Treating Norovirus infections means replacing fluids and waiting for the symptoms to subside. There are no antibiotics or vaccines for Norovirus. Fluid loss should be replaced with clear liquids. The best fluids, especially for children five and under, are oral rehydration solutions such as Pedialyte. Sports drinks are not a good substitute because they have too much sugar. Diluted juice or water could also be given, but preferably to an older child. Infrequently a child may need to see a doctor to determine if intravenous fluids are needed.

When orally rehydrating an infant or young child you may need to give them the oral rehydration solution in a syringe. Wait one hour after the last vomiting episode, and then syringe feed Pedialyte 1 to 2 teaspoons (5-10 ml) at a time every ten minutes for two hours. Set a timer on your stove so you can stay on track.

If vomiting starts over, wait an hour and start the oral rehydration process again. If your child tolerates 5 to 10ml every ten minutes for two hours, you can then let them have more at a time (maybe 20-30ml every 15 minutes). Continue with only clear liquids for at least half the day. If everything is going well after that you could try a little milk, or one small cracker or piece of cereal. Start over if they vomit again. Don't let your pathetic little sick child sweet talk you into giving them food or milk until you know they are tolerating the clear liquids quite well. If you introduce food or milk too soon you will set everything back by hours because it will almost certainly induce more vomiting. Crackers do NOT settle the stomach of a vomiting child. First go slowly with oral rehydration solutions such as Pedialyte. Don't let your child refuse the Pedialyte, give it to them in a syringe, as if it were medicine.

The nice thing about Pedialyte is that it can be partly absorbed from the stomach (instead of having to travel all the way to the intestine first)--so even if some of it gets vomited back up, some will still be absorbed. This is not true of sports drinks, water, or juice.

The most interesting thing about Noroviruses is how very contagious they are. They are quickly spread from person to person, by ingesting contaminated food and drink prepared by infected food preparers, by touching contaminated surfaces and then touching the mouth, or having direct contact with an infected person and then touching the mouth before washing hands. Stool and vomit from an infected person is definitely contaminated with norovirus. In some cases undercooked oysters or drinking water contaminated with sewage have been the cause of an outbreak.

If you have norovirus, you are contagious from the time you start feeling ill or nauseated until at least 3 days after recovery. The contagious period after recovery can last as long as two weeks for some people.

Good hand washing with SOAP AND WATER is important to prevent further spread of the virus. Infected people should not prepare food, work in nursing homes, or take care of patients while they have symptoms, and for three days after the symptoms are gone. Children may return to school and daycare when the diarrhea and vomiting is gone. Then hand washing with soap and warm water must be strictly enforced. Alcohol based hand sanitizers do NOT work against norovirus. Soap and warm water is the best way to eliminate the germ from your hands. A household chlorine bleach-based cleaner should be used to disinfect contaminated surfaces.

So, wash your hands with soap and water, disinfect your surfaces with some kind of bleach solution, don't go to work or school if you become nauseated, vomit, and/or have diarrhea, and don't return to work for three days after you are better if you have a job preparing food or taking care of patients. Don't return to school until vomiting and diarrhea have stopped, and then use careful handwashing methods with soap and water. Have some Pedialyte on hand, or know where you can get it. Stock up on medicine syringes in case you must force feed the Pedialyte. And wash your hands again.

Please call your own personal pediatrician for more specific advice for your child. My blog is meant to provide you with general information, and is not a good substitute for the personal attention your own doctor can provide.

The Michigan Department of Community Health norovirus cleaning and disinfection guidelines, as well as other information, are available at the following link. Once at the main web site, click on the icon for Health and Services, then type Norovirus into the search box.

Saturday, October 30, 2010

Halloween Candy

How does Halloween candy fit into my obesity prevention strategy?

Well, it doesn't. Really, it's disgusting when you think about it. The epitome of American excess, in the extreme. Fat, sugar, and no nutritional value makes for rotten teeth, hyper kids, and added pounds. What could be worse?

But I think Halloween is fun! It's a little nostalgic for me, remembering all the pumpkins my siblings and I designed (and my Dad carved) lighting up my sister's 16 pane bedroom window in our little cape cod style house. Yes, there were 16 pumpkins carved every year. And I loved almost all of the candy. Remember wax lips? There were, and still are, some candies I don't like. For example, I hated the Boston Baked Bean candy. I always tried to trade that one. I still have some of the Halloween costumes my Mom made for me, and once in a while I can get one of my kids to wear one. This year one of my high school prom dresses has been incorporated into a Queen of Hearts costume for my eleven-year-old. And there was a lot of Daddy/daughter bonding time this month making matching robot costumes out of cardboard boxes.

So, what to do about the candy? I've tried different ideas to deal with it. First, I don't want the supply of candy to last forever. As a kid I can remember still having Halloween candy to eat in the car on the way to Florida for Spring Break! Yuck! I say be done with it in a week, maybe two, but don't let it last. You could have a little splurge of candy eating on the night of trick-or-treating, and just get it over with, then share the rest with Mom and Dad, and their friends at work. You can have kids trade in candy for a different reward--a movie night, laser tag, Bounce Land, a water park, a trip to the mall. You can keep the candy in a public area (not your child's bedroom), and reduce its visibility (start putting it in the cupboard)--lots of kids will forget about it.

Just have some kind of plan that doesn't involve daily candy eating from now until the New Year. Make candy be a little splurge that happens as a special treat. Consider it a privilege, not a right. Incorporate your child's favorite treats into the plan, but discourage them from eating the stuff they don't love. Encourage sharing. Emphasize teeth brushing. Require an apple, banana, or something GREEN be eaten in addition to the treat. Don't put candy in a packed lunch.

Have a parent "tax" on candy. Use this as an opportunity to explain how income taxes work--if your child collects 10 pieces of candy they have to give you one piece, but if they collect 100 pieces of candy they have to give you 30 pieces! I haven't tried this one yet, but my husband is an economist, so I'm sure this is going to happen some time at our house.

Here is an interesting idea--talk to your child before they trick-or treat about what they think is a good way to handle all the candy. You might be surprised at the ideas they have, and you can review good nutrition at the same time.

You can also intervene by limiting the amount of candy your child collects. Go trick-or-treating with your child. Start a little late. Relax, don't run. Have them use a small bag to collect candy, not a pillow case. Stop to socialize with others along the way. Take your time! Insist on good trick-or-treat manners (I think the rules of trick-or-treating are to wear a costume, say "trick-or-treat" and then say "thank you"). Let your child stop and take time to choose and eat a few pieces along the way. Show off your costumes, take pictures. Spend some time decorating your house that night. Maybe your kids would like to pass out candy to others for a while. Do anything you can to slow down the candy collection process and emphasize the fun and fantasy of the night.

Most of all I would suggest having some kind of plan that cuts off the candy after a week (or two). Think about it before you trick-or-treat. Tomorrow I'll be angling for my share of Heath Bars, Almond Joy, Starbursts, and Dots. Then we'll eat a bunch of candy that night, and keep the rest in the kitchen for about a week. And that will be it for Halloween candy at our house.

Good luck to you, and remember to have fun!

Tuesday, October 12, 2010

Flu and Flu Shots

Hey, I got my flu shot today! Tina (one of Trestlewood's nurses) gave it to me in my left arm about an hour and a half ago. I feel fine. I could hardly tell the needle went in, and my arm doesn't hurt a bit. I don't ache, I don't have a fever, I didn't catch flu from the vaccine, and I am so happy to be protected from this season's flu viruses. I am sure to be exposed to them many times this year.

My girls had their flu vaccines on Sunday, just two days ago. They prefer the FluMist (a flu vaccine that is given via drops squirted in the nose). My husband will probably drop by my office soon and surprise one of Trestlewood's nurses to get his vaccine. Everyone in my family gets a flu vaccine every year. We started this tradition after my oldest got the flu in first grade. It was quickly followed by pneumonia, and then in her weakened state, strep throat. It was awful, and I never wanted a child of mine to go through that again. Unfortunately, my middle daughter had the flu a few years ago. She was coughing, had fevers upwards of 104, and was utterly miserable for a week.

I also take flu shots to Indiana to give to my parents and my mother-in-law. I think giving out flu shots each year is one of the biggest contributions I can make to the health of my community and my loved ones. The other big impact I have on public and individual preventive health is the rest of the recommended childhood vaccines--but that's for another blog.

Flu, at least the flu we vaccinate for, is NOT the stomach flu! I am told daily how this or that family had "the flu" last week, or last month, or last year. Or how they never get "the flu." Or, how the flu vaccine didn't work for them because they still got "the flu." When pressed for details it is clear that most people mean gastroenteritis when they say "the flu." Gastroenteritis is an illness that is very contagious, lasts a day or two, and involves vomiting and diarrhea. The flu I am talking about is influenza, a RESPIRATORY illness.

The symptoms of influenza are fever, severe muscle aches, coughing, sore throat, runny nose, extreme fatigue, chills, with occasionally some stomach symptoms. It lasts for about a week. It is also very contagious. Flu weakens and can kill its victims, especially those who are already debilitated. It can lead to complications, such as pneumonia. At the very least it is a miserable week to spend in bed with a box of tissues, cough drops, and other cough/cold/anti-fever medicines.

Flu vaccine is recommended yearly for everyone who is six months or older who does not have an allergy or other contraindication to the vaccine. While it is especially important for people with chronic illnesses such as asthma or diabetes, it is recommended for all of us. We can all benefit from a yearly flu vaccine.

Have you and your children had your yearly seasonal flu vaccine? Get yours as soon as you can!

The following are some links to reliable information about the flu and flu vaccine. This year's vaccine includes the H1N1 subtype, so a separate shot for that one isn't necessary. Children under age nine who are getting the flu vaccine for the first time, or who have not had at least two previous seasonal flu vaccines plus one of last year's H1N1 vaccines, will need two doses of flu vaccine spaced one month apart to be completely immunized.

Croup and a Croupy Cough

It's easy to be scared when you wake up in the middle of the night to hear your baby or young child coughing with a deep, loud, barky cough and making raspy sounds when she breathes. Chances are this is croup!

It's important to hear what croup sounds like. The following videos are from YouTube. All give a pretty good idea of the distinct barky, croupy cough. It sounds like a barking seal.

A croupy cough sounds loud and barking, like a seal's bark:

Raspy breathing, also known as stridor, is another characteristic of croup:

This next link is to a video that demonstrates a significant case of stridor, just click on the link to go to YouTube (the video did not allow itself to be embedded):

Croup is usually caused by a virus (a common one is parainfluenza virus). It causes cold symptoms (runny nose, stuffy nose, cough, fever) and it likes to settle in the upper airway. It causes swelling in the upper airway and vocal cords, giving the funny sounding cough, causing raspy breathing, and a hoarse voice (laryngitis). The barky cough and raspy breathing are always worse at night.

Croup often sounds much worse than it is. In two of the videos above, the ones demonstrating stridor, you can see completely happy babies who have raspy breathing. They look pink, are smiling or talking, and are not bothered by the "trouble" they are having with their breathing. Croup can be serious, and require a trip to the emergency room. However, usually it is manageable at home.

For a croup attack, first sit your child up, and then calm him down. Sitting up usually helps the airway stay open. Crying and panicking tend to make the airway close even more. Take your child into a steamy bathroom. To do this--run the hot water in your shower and don't turn on the fan. Sit in the bathroom and sing to your child, rock her, read to her. Try this for about fifteen minutes at a time. If it works, you can put your child back to bed--then repeat the treatment as needed through the night.

Another home treatment is taking your child outside into the cold night air (assuming it is cold outdoors!). The point is to try the opposite of hot steam, if the steam wasn't working for her. You can also put a cool mist vaporizer into your child's room.

If a croup attack is very severe, your child can't breathe despite home treatments, or is looking quite pale, bluish, or lethargic, you should go to the emergency room. There your child can receive breathing treatments (to temporarily open the airway), oxygen (if required), and steroids (to reduce swelling in the airway). Remember, however, that croup can look and sound much worse than it really is--so if your child is happy and playful, able to nurse or drink from a bottle or sippy cup pretty well, it's unlikely that you need to go to the emergency room for croup.

If you make it through the night, but had a rough time getting to morning (needing recurring steam or outdoor treatments) you should bring your child to the office the next morning. Symptoms may appear to be gone in the daytime, but croup comes back each night for a few nights before it turns into a regular cold.

After a few days of the croupy stage the cough will change into a phlegmy, wet cough. This almost always happens with croup, and is a sign that the croup is starting to clear up. However, when the cough changes into something else, every parent worries that it is turning into something more serious. When it changes, watch your child closely. If she is sleeping better, is more playful, more hungry, and the fever is mostly gone, then your child IS improving and you can handle the rest of the croup illness at home, like you would for the average cold virus.

Croup is contagious in the way a regular cold is contagious. It is spread by respiratory droplets (mucous, cough, sneezing), and is most contagious in the first 2 to 3 days of the illness. If there is no fever, and the child is sleeping pretty well at night, croup is not a reason to keep kids out of daycare or school.

As always, my blog is designed to give you general information about your child's health and illness. One of the main reasons I posted this topic is to provide the links to videos of a croupy cough and stridor. My advice here is not meant to replace the more personal advice you can receive from your child's own pediatrician.

Lots of information about croup is available on the web. Here are some possible links, if you want more information:

Post updated 1/26/2014 (a new video added to replace one no longer available, two links replaced with embedded videos).

Friday, September 24, 2010

Obesity Part II: Early Prevention (Prenatal through Preschool)

Is there anything you can do to prevent obesity in your child? YES, YES, YES!

First, look at your child's risk factors. Family history is important. One study showed that a child born to an obese parent (or parents) has an 80% chance of becoming obese herself. There could also be diseases in the family which are influenced by obesity. These would include diabetes, high blood pressure, cardiovascular disease, and stroke.

Conditions during pregnancy, such as gestational diabetes and maternal smoking, may contribute to a child's difficulty maintaining a normal weight. Babies born small for gestational age may have a predisposition to glucose intolerance. Breastfeeding may help reduce the chance of obesity.

By assessing risk factors I don't mean to introduce more guilt in your life as a parent. We all have a family history, we all have our own health issues, complications occur in pregnancies, and not everyone can breast feed their baby! I know all of this. However, in preventing obesity and its related diseases from happening it is important to know what the risk is from the beginning.

Early in infancy it is important to feed your baby when he is hungry, and allow him to stop when he is full. Watch for signs of hunger such as rooting and crying. Listen for the cry that means hunger, versus the cry that means irritability or sleepiness. Feed your baby "on demand." If the baby just ate and seems to be acting hungry again try cuddling, soothing, swaddling, or a pacifier before offering another feeding. If your baby is bottle feeding, watch closely for signs of her being full. Don't try to get her to just finish that last ounce. If she stops sucking, lets milk pour out of her mouth, or pulls away and turns her head, recognize these as signs she has had enough. Hold your baby when you feed her a bottle. Never prop a bottle for a baby.

As your baby gets older and learns to smile and interact socially, you can try toys and other distractions to keep her happy when she is fussy but not really hungry. The more you interact with your baby, the more you will get to know her and understand what she needs. Often it will be hunger, but sometimes it will be boredom, fatigue, or loneliness that needs to be addressed.

TV is a very poor substitute for interaction with you. Children grow up in the presence of lots of media. They learn to be entertained, rather than to entertain themselves. They learn to be inactive, and to stop using their brains. Developing minds and bodies do not need TV. It does not benefit young children at all. Yes, babies will watch videos, and appear mesmerized and happy, but they aren't learning anything that will help them later. Instead they are learning from an early age to be what we all don't want to be--couch potatoes! Add snacks and beverages consumed while watching TV and we are thoroughly indoctrinating them into the inactive lifestyle led by many Americans. No TV at all until age 2 or older is the best way to go.

In the toddler years trouble spots for weight control seem to center around excessive juice, excessive milk, and "grazing." Grazing is allowing your child to nibble on things throughout the day. Usually these are foods like fishy crackers, cereal, fruit snacks, puffs, pretzels, and other foods that are mostly made up of carbohydrates. Sippy cups allow toddlers to walk around all day sipping on milk or juice. These practices cause lots of eating problems. Children can get too many calories from this constant sipping and nibbling. They never feel hungry, so then they don't eat well and are very picky at meal times. As soon as they are the slightest bit hungry they whine and cry about wanting food. To top it off, they even are learning to treat boredom (and possibly negative emotions) with food.

You can help your toddler control his weight, be less picky, and be hungry for meals by feeding three meals and two or three quality snacks ONLY per day. At other times the kitchen is CLOSED! Also, limiting milk to 16-20 oz. per day, and juice to 4-6 oz per day will help your cause. Make snacks count--serve fruits, cheese, yogurt sweetened with applesauce or fruit, vegetables, hard-boiled eggs, and more at snack time. Don't give your child anything else to drink other than milk, water, and a tiny bit of juice. Pop? Do you have to ask?

Allow your child to become hungry before meals, then serve the stuff that's good for him first! My sister-in-law always dished out big bites of broccoli to her kids and mine while they complained of hunger and the rest of the meal wasn't quite ready. Guess what? The broccoli (or peas, green beans, or carrots) was devoured by many picky little people who were also quite hungry!

Save the empty calories (fruit snacks, fishy crackers) for an occasional little treat, or a difficult part of the week (the check-out line at the grocery store). Allow your child to freely drink water from their sippy cup, and give the milk and juice at meal and snack time. Teach your child to drink milk and juice from a regular cup and ditch the sippy cup as soon as possible.

As your child gets older--into the preschool years--keep up the practice of three meals a day, and two snacks. Make your child what she likes to eat at breakfast and lunch. Then, at dinner (if this is your family meal) serve one meal to your family. Do not make your child a separate meal. A few items in your meal should be kid-friendly. You can always set out some fruit, or a bowl of applesauce. At first, aim for good table manners--no saying "yuck" or throwing or pushing the food off the plate. Your first goal is to get your child to tolerate the presence of the food in front of him. Then you work towards a taste of everything, and then a few bites (cut them very small and ask for three bites from a three year old, four bites from a four year old...) of a less desirable food. If your child leaves the table hungry, there is always tomorrow and a good breakfast around the corner. No guilt here--you served the food, it was your child's choice not to eat it.

Please consider avoiding fast food restaurants. If you can get the food at the drive through window I would really question its nutritional value. Watch the video Super Size Me. I have not taken my own kids to that fast food restaurant (and most others) since I watched that movie! Most toddlers (and definitely preschoolers) recognize the golden arches, and will happily eat a meal consisting of chicken nuggets and fries. But why develop those taste buds when you could be working on the taste buds that some day will hopefully enjoy salad, whole grains, fruits, and vegetables? Why cultivate a taste for fatty, high calorie, high salt food that is low in nutritional value?

Encourage free outdoor play. Allow your young child to run, climb, dig, race, throw and kick balls, twirl, swing, slide, swim, and be free outdoors. Limit time in front of the TV or any media screen to one hour a day on most days, and definitely no more than two hours a day. Try to have twice as much outdoor play time as time in front of the TV. Children under the age of two should not watch TV.
Children should have a minimum of one hour a day of very active play.

Take care of yourself, too. Are you eating healthy food? Exercising? Limiting your time in front of the TV? It is much easier to help your child be healthy if you are also living a healthy lifestyle.

I am trying to give you ideas to help keep your child at a healthy weight with a good level of fitness, to minimize the risk of obesity related diseases, and to promote better self-esteem and enjoyment in life. All of us are a work in progress, and this goal is something to work toward. I hope I have given you something to think about, and some practical ideas you can put to use. As always, the advice in my blog is quite general, and is not meant to substitute for more specifically tailored instructions from your own personal pediatrician! Good luck.

As far as resources I used--the same ones I sourced in my first Obesity blog (Part I) were used here, as well relying heavily on my own experience as a pediatrician in general practice.

Sunday, September 12, 2010

Obesity: Part I

Big boned, husky, chunky, chubby, overweight, obese...we all know it's something we want to avoid. Many adults struggle with their own weight, and all of us worry about our children. We feel better when we are fit, when our clothes aren't too tight, and when we can move and breathe easily.

Screening for overweight and obesity is now a routine part of a pediatric check-up. A Body Mass Index (or BMI) can be calculated for children ages 3 and older. Just like a growth chart, children are compared to others of the same age and gender using percentiles. A BMI that falls into the 5th to 85th percentile is considered a normal weight. A BMI in the 85th to 95th percentile is overweight, and over 95th percentile is obese. If you aren't sure what a percentile is, check the end of this post and I'll do my best to explain it.

To calculate your child's BMI I would suggest a website that lets you plot it on a graph, gives you percentiles, and tells you what kind of calories per day your child needs: (just click on the BMI calculator when you get to the site)

A healthy weight is important not only for a positive self-image, but for the body's current and future health. With one out of three children weighing in with a BMI of 85th percentile or higher our society is seeing problems with high cholesterol, high blood pressure, pre-diabetes, type II diabetes, orthopedic problems, non-alcoholic fatty liver disease, and more--both in adulthood AND DURING CHILDHOOD.

A child who is overweight or obese should have a medical evaluation. Usually this will mean a check-up that will include a detailed history, checking height, weight, and blood pressure, calculating BMI, and a complete physical exam. Blood work is not a routine part of an obesity evaluation in a child, and would be decided upon individually. Family history is important in the evaluation of obesity.

There are some rare genetic syndromes and medical conditions that can make it more likely that a child will become obese, however, it is more common for obesity itself to CAUSE medical problems than the other way around.

The first step in dealing with obesity is recognizing it as a problem. I certainly see it daily in my office. I also see normal weight children who have a family history of obesity, or who have eating and activity patterns that put them at risk. There is much we can do to prevent and deal with obesity. But there is no easy answer, no pill, no surgery. The long-term, sustainable solution involves a change in attitudes, habits, and lifestyle. And solutions like these are always the most difficult.

In future posts I hope to touch on prevention and treatment, as well as recommendations for feeding your child. Dealing with this problem for your child and yourself could be one of the most important, life-changing things you can do as a parent.

I have used the following resources in preparing my blog:

Pediatric Obesity: Prevention, Intervention, and Treatment Strategies for Primary Care, Sandra G. Hassink, American Academy of Pediatrics, 2007.

Pediatric Obesity Clinical Decision Support Chart 5210, Sandra G. Hassink, American Academy of Pediatrics, 2008.

Addendum: Regarding percentiles: If your daughter has a BMI that is at the 50th percentile, this means she is right in the middle for her age (50% of girls her age would have a lower BMI). I also look at it like this: If there were one hundred girls her age and height, 50 of them would weigh less. If your son has a BMI at the 95th percentile, this means that 95% of boys his age have a lower BMI (I like to think of it this way: If there were 100 boys his age and height, 95 of these boys would weigh less).

Sunday, September 5, 2010

Calling the Doctor After Hours

Every time I am on call I answer after hours calls from worried parents. I have been on call, on average, 7 days a month for the last thirteen years. That would be 1092 call nights/days since I joined Trestlewood. If I average 10 calls a night (weekends more, weeknights less, winter more, summer less, but averaging it all out) that means I have answered over 10,000 calls from worried parents so far in my career! I have a lot of experience answering after-hours questions from parents via my cell phone. I know what are the most common reasons people call and what advice to give them. I know what really scares parents in the middle of the night, and how to tell parents what to look for if the illness is getting worse.

Still, after all these years, I greatly prefer that face-to-face contact in the office. It is still sometimes hard for me to figure out how sick a child is when I am talking to a parent over the phone. A description of a rash, swelling, injury or bug bite by the parent, using their frame of reference and experience, may conjure up a completely inaccurate mental picture in my mind when I try to match it to my frame of reference. Thermometers are broken, degrees are added or subtracted from temperatures, weights are not known, allergies are not remembered. Sometimes the person calling me isn't even with the child, so they are themselves telling me information they received from a third party.

And I often think my goals for the phone call and the parent's goals for the call differ wildly. My primary interest is to quickly and accurately provide an assessment of the nature and severity of the illness and whether it is possible to use home/natural methods to provide comfort until the child can be seen in the office. I think many people want more out of the phone call than that--it would be nice to be able to go back a month, or year, or years in the history to be able to arrive at an exact diagnosis, prognosis, and prescription, and possibly a note for school or daycare, and sometimes even a refill on another medication that has run out.

So with that preface I will provide you with my perspective, as an experienced after-hours phone call answerer, of what a parent should expect from the doctor answering the phone after hours.

What to Expect From After-Hours Phone Calls

If your child is an established patient at Trestlewood Pediatrics we want you to feel confident that, even when the office is closed, there is a physician available to help you with urgent questions about your ill child. We wrote these notes thinking it would be helpful for families to understand how our after-hours phone system works. The after-hours phone number for established patients of Trestlewood Pediatrics is available on our office answering machine, and is on our business/appointment cards. As of 2010 there is no charge for an urgent, brief, after-hours phone call. Most calls of this type take less than 3 to 4 minutes.

Office Cell Phone
When you call you will be pleased to notice that we do not use an answering service. Instead you will speak to the doctor on call directly on our office cell phone. If the doctor cannot take the call immediately (perhaps while driving, or taking another call), then the call will be returned using information you have left on our voice mail. We strive to return calls within 30 minutes. Sometimes we are at the hospital or answering other calls, however, and a return call is delayed. You should call back if you have not heard from us within 30 to 60 minutes.

The most important information to leave on the voice mail is your name, your child’s name and age, and your phone number. A few words about the problem can be helpful (“she is wheezing,” “I think he broke his arm.”). If the message is too long it will delay us in returning the call.

Our Goals in Answering Calls
When the doctor talks to you about your child he/she is trying to determine how serious of a problem this is and what needs to be done for it right now. This is called “triage.” For example, is it best to treat this problem at home with over the counter medications or home comfort measures and see the child in the office tomorrow, or should the child go to the emergency room now?

After hours the doctor does not have your child’s medical record, information about medication and allergies, and other important data needed to provide a thorough assessment and treatment plan. While a worried parent might understandably hope for a complete evaluation, diagnosis, plan, and prescription, this is actually very difficult for the doctor to do over the phone. In most cases the doctor’s goal after hours is to get your child through the night in the safest, simplest way we can until we can provide more thorough and personal care in the office.

It would be unusual for the doctor to call in a prescription, such as an antibiotic, without seeing your child in the office.

Calling About Specific Problems
Our web site might be helpful in addressing some simple questions, thus making some phone calls unnecessary. Also, the patient folder has information about common illnesses (fever, vomiting, diarrhea, sore throat, ear pain, pink eye, constipation, coughs, colds). The fever information includes a dosing chart for children under 35lbs. for acetaminophen (Tylenol) drops and suspension, and for ibuprofen (Motrin, Advil) drops and suspension.

Because we can’t see the child, rashes are very difficult to diagnose over the phone. With a rash we will attempt to determine if it represents a serious illness (the child would appear extremely ill in that situation) or if it is an allergic rash (such as hives). To receive a diagnosis beyond this the child would need an appointment in the office.

Saturday, September 4, 2010

Please Wear Your Helmet!

Every day I tell kids they should wear helmets. They should wear bike helmets whenever they are on something with wheels (bikes, skateboards, scooters, rip-sticks, roller-blades...) or ski helmets if skiing or snowboarding. They should wear the appropriate helmet for a motorized dirt bike or for off-road vehicles, as well.

Every day I have small children tell me they don't need a helmet because they never fall. Then I realize I have to convince both child and parent (mostly parents in this age group of kids) that the point of a helmet is to protect in case of an accident. I don't doubt the child's skill on the bike, or the quiet cul-de-sac the family lives on. I say that a helmet is like a seatbelt in the car. You always wear your seat belt in the car, right? But do you really think your Mom or Dad will get in a crash? No! So why wear the seatbelt? Just in case of an accident, in case something happens that we didn't know would happen. Helmets are the same kind of thing. They protect you in case of an accident, and we wear them because we don't know when accidents will happen.

I also tell kids (getting to a little older group now) something Dr. Van Es told one of my girls during her check up with him. I loved this explanation, and now I use it all the time. Doctors are good at fixing broken arms and legs, we just put them in a cast and a few weeks later everything is as good as new. Also, we can put band-aids on scrapes, and sew up cuts with stitches. But doctors are not good at fixing brains. If your head cracks open and you hurt your brain, there isn't much that we can do other than wait and see what kind of damage was done (and I add my own spin on it here, especially for adolescents). For example, a bad brain injury can take away your ability to talk, you might not be able to walk and have to use a wheelchair, you might not be able to control yourself to get to the bathroom and therefore need to wear a diaper, you might not be smart anymore...etc. So the helmet is extra important when you are on your wheels because it gives your brain an extra hard layer of protection in case of an accident.

And after feeling really good about how I have educated everyone I drive home for lunch in the summer and see lots of kids (many are my patients) in my neighborhood biking, skateboarding, rip-sticking, and scootering around with NO HELMETS. And they are in the street!

But street versus sidewalk is worth mentioning when it comes to helmets. The worst head injury from a device in this category of someone in my pediatric practice was a six year old girl who lived across from the elementary school and was a friend of my oldest daughter. She was on her little scooter on the sidewalk in front of her house, unhelmeted. Mom was gardening in the yard, right there to supervise. She hit a little crack or rock, fell off the scooter and hit her head hard on the pavement. Forty-five minutes later she was vomiting and very drowsy and lethargic, and within another hour or two was in the operating room having the bleed into her brain drained by a neurosurgeon. She is ok, but fortunate to have such a good outcome. Probably this was preventable if she had been wearing a bike helmet.

It is not enough to just tell kids to wear their helmets. They don't believe they need helmets because they don't think they will fall. As parents it is our responsibility to make our kids wear their helmets, with consequences if they do not wear them. We need to get all the parents in the neighborhood in on this rule, so one child doesn't have to feel the stigma of being the only one who has to wear a helmet. And we as parents have to set a good example! We need to wear helmets, too. It's a little funny to see families riding around town with three helmeted kids on bikes, but the parents on bikes have bare heads. How long do you think those kids will be wanting to wear helmets?

The Great Outdoors versus Turtle Salmonella

For me growing up and playing outside was all about seeing what was out there. We caught fireflies, minnows, toads (remember that warm wet feeling on your hand?), beetles, ants, frogs, and turtles. Today the emphasis is trying to get kids "back to nature." Get them playing outdoors, in nature, whenever possible. Give them free time to just play, make daisy chains and houses for fairies, use a dandelion to make wishes or check to see if you like butter (rub the yellow dandelion on someone's chin, if their chin turns yellow, they like butter), gather acorns and make houses for the acorn family, find bird nests with evidence that chicks have hatched (or have the mama bird swoop at you and scold you to keep away from her babies).

We are also told by health authorities that we shouldn't have our kids touch these animals (especially turtles) because they could be carriers of salmonella. Salmonella is a nasty gastrointestinal illness, and definitely worth avoiding. However, didn't anyone ever think of washing your hands? I think we should tell our children to go ahead and observe and even carefully catch turtles, frogs, toads, and garter snakes! It's exciting to do this and it makes nature more real. Kids can learn about nature and how to be kind to animals by creating their own relationship with them. They can learn about habitats and lifecycles. Protecting the environment becomes more important when we see who lives in the marsh, or even on the side of the road. What is all the trash we just picked up on the lakeshore doing to these animals? And it's all more real because of "Fenton and Frieda" (the frogs in the pictures), or Snakey the garter snake, or Percy the turtle--who all became "pets" for a few minutes before they were gently let go (and the child washed her hands).

Potty Problems: Number 1

I'll try a slightly different format for this one--kind of like Dear Abby. This is a real letter to me from a friend and former mom in my practice, and my actual answer to her (we used facebook!). I changed names (other than mine) to protect the innocent. As always please remember that the purpose of this blog is to provide you with more information and insight into how I personally think about health and illness. I am not trying to personally diagnose or treat your child. For that you need to discuss the problem with your medical professional. Other sources of information on the web could include, or

Hey Stephanie

I wanted to pick your brain a little. I hope you don't mind but I really trust your care for little ones and miss you as the girls' doctor.

So, our little sweetheart is a big three old, 40 lbs, 42 inches. She is potty trained day and night but has a huge problem holding her potty. When she has to go, she has to go NOW or potty comes out, she cries that she can't hold it, etc. At her well child in May I brought it up but she tested clear for urine and blood sugar. Took her in again in August b-cuz it has gotten worse but again nothing wrong with her urine. The doc here says she is just big for age and her bladder has not caught up. What do you think? My mommy intuition is telling me there is something else going on.

Please let me know your thoughts. Wish we could come up to MI and see you. It is very hard having new doctors for my girls.

Thanks, Sweetheart's Mom

Hi Mom:
Interesting problem. And a tough one to sort out. What I can tell you is what is usually the problem in this situation, and what else to look for.

The bladder is designed to be in a relaxed (empty) state. So when it gets stretched it has the tendency to spasm a little and give you the urge to urinate. If it gets overstretched, the problem will be worse, and the person will wet. Good bladder habits involve emptying the bladder regularly, or the bladder will stay kind of stretched out and having little spasms at unpredictable times.

Commonly there is a point in potty training where a child wants to experiment a bit with how long they can "hold it." Certainly the desire to not interrupt play, or stubbornness about doing what mom or dad want can play a part in "holding." You know how that looks--the bottom is wiggling, feet are moving, sometimes the hand is holding the urine in--but the child says "but I don't have to go." Maturity involves the child knowing themselves and how long it takes to get to the bathroom as well as the bladder physically being able to handle a fuller state.

So when there is a problem like you describe it is BY FAR most commonly resolved with a behavioral approach. Small, immature bladder or not, the behavioral method is most likely to work and doing testing is hardly ever helpful. And, thankfully, there is physically RARELY anything wrong (and if there is, behavioral approaches are usually best!).

What I normally tell a parent in your situation is that you have to go back to potty training (but now it's RE-training). The bladder needs to be emptied at regular intervals. It will have a harder time producing spasms that way and make accidents less likely. At first, the intervals need to be close enough together to capture the accidents (keep her dry). Set a kitchen timer, or your digital watch for 60-90 minutes. When it beeps you tell Sweetheart that the timer says it's time to sit on the potty.

Initially you might say something like "Sweetheart, we are proud of you and you must be so proud of yourself when you go potty like a big girl, and keep your underpants dry. We think there is a way we can help you get even better at staying dry. The doctor said there is a special way you can do that and we want to tell you how that will work..."

You might need rewards at this stage (something little--a sticker, a cracker), or praise might be enough. Sitting on the potty might have to be timed, or enough distraction provided to get her to relax and actually urinate (read a short book, listen to a song, sing a little song). She might have to think about whether all the urine actually came out.

When this becomes successful in controlling accidents, you attempt to increase the intervals to a more normal level of frequency. That's what I call "potty manners." Potty manners are going potty at regular, convenient times in the day (Pick some of the following: when you get up in the morning, before meals--combine with handwashing before eating, or after a meal, before leaving the house, before or after a nap, as soon as you arrive at a large store where the bathrooms are inconveniently located, as soon as you get to a friends' house--so you know where the bathroom is, bedtime, before you go outside, before you leave in the car on a trip, when you stop for gas, etc.). The point of potty manners is to normalize going potty throughout the day so there is a good habit and little resistance, and to keep the bladder empty.

When you are working on potty manners, EVERYONE makes a show of doing it too. For example, "Sweetheart, it's time for everyone to go potty before lunch, do you want to go potty first, or should I go?

Pitfalls in potty retraining:
1. Letting your child know how important this is to YOU, and how disappointed YOU are when they don't succeed is a pitfall. If your child realizes how they can use this to manipulate you, you'll have a tough time. Bowel and bladder control are something your child should be proud of, for themselves, for growing up. You should be happy for her as she achieves control. ("You must be so happy that you stayed dry on your playdate!).
2. Offering big tangible rewards is a pitfall. The beautiful Halloween costume hanging in the bathroom that she can have if she stays dry all day will quickly become something unattainable to her, or something she decides (after looking at it all the time) that she doesn't really have to have. Potty rewards seem to work best if they are tiny tokens of success (stickers, sugarless gum, a cracker), OR if there is an element of surprise (the potty prize box has 4 or 5 little but exciting rewards in it, and at each success the child opens the box and gets to choose--the key is that after the child chooses, the parent exchanges out some of the items, so the child never knows what will be in the box).
3. Constipation is a pitfall. Being really constipated makes it hard to empty the bladder, so it's constantly partly full. The bladder stays stretched out and spasming off and on, and accidents keep happening. This situation can lead to bladder infections too--and if this is part of your problem, then you should go back to the pediatrician. Stools should be daily and soft in consistency. Stools should not be huge, plugging the toilet. Nor should they be round balls or dry logs with cracks in them.
4. Not being consistent is a pitfall. Training is the key word here.

So what if I am wrong? The big sign would be that you can't get her to be dry even if you reduce the intervals down to 45" to an hour (assuming she is compliant with going potty then). The amount of urine that comes out doesn't necessarily help decide anything. Sometimes the bladder will spasm and just produce a little squirt, and sometimes it releases it all. If it all just doesn't work, the next step would be back to the pediatrician with a discussion of all the effort you put in behaviorally--and consideration of limited testing (maybe just an ultrasound, to stay noninvasive) and possibly a urology referral. But this, again, is hardly ever necessary, and even at the urologist's office you might get similar advice.

I hope I'm not missing anything, since my advice has been somewhat generic--so let me know if there are important details that I haven't considered. Also--you didn't tell me what happens at night (pull-up?).

Would you mind if I used my answer to you on my blog? I'll take out all personal info from you--but I think this might be a good one to post for others since it comes up so often.

I miss you too! Nice to hear from you.


Thank you so much for getting back with me in regards to Sweetheart's potty problem.
We are going to do the re training like you suggested and hopefully it will get her back on track. She has been potty trained since the spring and still could use reinforcement for keeping dry and making it to the potty on time.
I took her diapers away at night about a month ago and she does good but I wake her up before I go to bed and she also wakes up 1-2 times to go. She has also had her share of night time accidents. I will start rewarding her for staying dry at night.
You absolutely can use the question for your blog! I truly appreciate your wisdom. Thanks a bunch.
Have a great long weekend.
Sweetheart's Mom

Wednesday, August 18, 2010

Sunlight, Milk, Vitamin D

Vitamins! What a boring topic. I used to think so--in fact, a year or two ago I rarely recommended vitamin supplementation for my patients. My previous mantra was "Eat a healthy diet and you won't need vitamins." Then the new vitamin D supplementation guidelines were published in 2008. Study after study confirmed that children (and adults, actually) do not get enough vitamin D on a regular basis to reliably prevent problems with bone health. Some studies show that adequate vitamin D consumption is linked to lower levels of autoimmune diseases and helps fight infections.

In fact, I have been so convinced by this information that I actually take a vitamin D supplement myself! If you knew me well you would understand how amazing this is. I have always had trouble swallowing big pills, such as vitamins. Prenatal vitamins were impossible for me, and I actually took children's chewable vitamins during my pregnancies. However, I have gotten used to the vitamin D and I take it each night.

I have brought my kids along on this vitamin ride, too. They prefer gummy vitamins, and are supposed to take two each day. Sorry, Dr. VanEs--I know you don't like the sugar in these sticky vitamins--but I promise that they brush their teeth! My children will be the first to tell you that sometimes I forget to get a new bottle of vitamins for them when they run out. I resolve to do better, but I am a busy mom, and not perfect even in regards to my own medical advice.

The vitamin D recommended daily allowance for children from birth to age 18 is 400 IU (or international units) per day. Supplementation starts at birth. If a baby is formula fed, then after they reach one liter of formula per day they are getting enough vitamin D. Infant vitamins are usually given in drops, while children's vitamins are chewable or gummy. You should read the labels, especially in the infant drops. Normally 1 ml would give 400 IU, however some drops are super concentrated and provide 400 IU in a single DROP. It is possible to overdose on vitamin D and cause vitamin D toxicity, but there is a fairly wide margin of error. Most vitamin D supplements are in the form of vitamin D-3 (not 2).

It is possible to get vitamin D from sun exposure, and the lighter your skin the less sun exposure you need. The sun activates vitamin D that is inactively resting in your skin, making it possible for your body to use what is already there. In the United States, on average, it has been shown that we spend more than 90% of our time indoors! Top that with using recommended sunscreen during sun exposure and it doesn't add up to enough sun exposure to be sure you have enough vitamin D.

I have seen attempts to calculate how much sun exposure is needed per day on skin that is not treated with sunscreen, taking into account the degree of pigmentation in the skin. This seems too complicated and unreliable to me, plus I doubt most people will be pushing their kids out the door in just a bathing suit in the dead of winter. What about a break from vitamin D supplements in the summer? Are you organized enough to get your children to sunbathe without sunscreen for a set period of time each day in the summer, and then remember to apply the sunscreen right away when the timer goes off? How will you handle cloudy days? Will you remember to restart their vitamin D during the colder months of the year? I think you should just have them take the vitamin and use sunscreen liberally to prevent sunburn and skin cancer.

It is possible to get vitamin D through breast milk. However, mothers must take very high doses of vitamin D (much more than is in a prenatal vitamin) to achieve adequate levels for their babies. Even then the levels in the milk may not be consistent and the mother may be at risk for vitamin D toxicity. Not enough is known about this to recommend it.

It is possible to get vitamin D from formula and from vitamin D fortified milk. You must consume a liter (about a quart, or 32 ounces) per day to get enough vitamin D. So if kids are big milk drinkers (4 8oz cups per day) they probably don't need extra vitamin D. Newborns don't drink that much formula right away, so technically they should receive a supplement until they do. However, they will come pretty close to the recommended daily allowance in just a few weeks, and almost certainly by 4-6 months of age, so I don't usually recommend the supplement for a formula fed baby.

What about measuring levels of vitamin D? This is tricky, because the level in the blood at any particular point in time does not always reflect overall body stores of vitamin D. Except in cases of chronic disease with malabsorption of nutrients (such as children who have had large sections of their bowel removed) checking vitamin D levels is not very helpful in determining vitamin D status. Most insurance companies won't pay for this test anyway, and if I would order it for a patient I would have no idea what it really means. Please don't ask me to order a vitamin D level for your child. Why poke your child (causing pain and stress) and run a test that is imperfect, difficult to interpret, will cost you money, and won't change my advice to you? There are limits to technology, and this is one of them. Take the vitamin, life goes on.

Vitamin D supplementation is one of those recommendations where the intervention (taking the vitamin) doesn't have very many down sides, and the benefit is potentially pretty big. So I am recommending that all my pediatric patients take 400 IU of vitamin D3 per day, with less or no supplementation needed for formula fed babies and big milk drinkers (4 cups milk per day).

My primary source of scientific information for this blog was the following publication:

Prevention of Rickets and Vitamin D Deficiency in Infants, Children, and Adolescents--Wagner et al.122(5):1142--AAP Policy

The publication is available online at the American Academy of Pediatrics web site (, and it has a large list of references/scientific studies on which the recommendations are based. As a member of the AAP I have no trouble accessing this study online, I don't know if it is accessible to a non-member.

Please remember that the purpose of this blog is to provide you with more information and insight into how I personally think about health and illness. I am not trying to personally diagnose or treat your child. For that you need to discuss the problem with your medical professional. Other sources of information on the web could include, or

Friday, July 23, 2010

Why Bother with a Regular Check-up?

It's summer! In my office there is less coughing, and more bug bites. Poison ivy, sunburn, heat rash, cuts, scrapes, swimmer's ear, allergies, and swimmer's itch all make themselves known again. While in the winter months I have to move fast in order to tend to a larger group of younger sick children, in the summer I have more time scheduled to devote to physical exams for school-age children and teenagers.

Regular check-ups are important. They establish a good doctor-patient relationship, empower children by helping them understand their bodies, screen for important health problems, monitor ongoing illnesses, and address new concerns.

I love having the opportunity to spend more time with my patients and listen to their concerns. I think that seeing usually healthy children and teens regularly (at least every two years after age five) gives me the chance to establish a solid, health-enhancing relationship with my patients. A relationship like this is based on familiarity, good communication, accurate expectations of what will happen in the office visit, and trust.

For a perfectly healthy child a physical exam can be a boost to her self-esteem by showing how well she grew and gained weight over the last year or two. It can be interesting to find out what the blood pressure means, and that a normal blood pressure is a good sign that her heart is healthy. These very personal bits of data can make a child feel strong and healthy, proud of himself and his ability to take care of his body. I believe that regular, positive interactions with his own doctor can be empowering for a child, laying the footing for him taking responsibility for his own health for a lifetime.

At a regular check-up I can reinforce what many parents are already telling their children. I emphasize the importance of eating fruits and vegetables, and of limiting time in front of a TV or other "screens". I talk about safety, such as wearing a bike helmet or seat belt. For older children and teens I might discuss how the choices they make and the influence of their peer group can affect their health. I also talk about hygiene! Including deodorant, showers, washing hair and faces, and shaving.

I talk about puberty at check-ups. Most pre-teens and teens want to know if their body is developing normally, how it compares to other kids their age, whether things are too big or too small, if it's starting too early or too late, or when certain events are likely to happen. Normally, for girls, I talk with parents at their daughter's age of seven about the eventuality of breast development--something that can start to happen close to age nine. At nine I start talking to girls directly about this topic, at whatever level they might need (maybe their friends are wearing bras, maybe they need a bra, maybe they don't know where to get a bra, why they might want to wear one, etc.). And my discussion becomes more advanced as the patient gets older.

A check-up involves checking all parts of the body. If a child has been having regular check-ups with me from the beginning, this is not a surprise to them. After all, I've been checking their private parts since they were born, why would I stop checking once they are five, or seven, or nine, or eleven, or thirteen..? They know I will make sure they have privacy, are covered up, and have only agreed-upon family members in the room. They know how I will check them, how long it will take (usually seconds), and they probably know exactly what I will say. If puberty has started I can also give them an idea of how far into it they are and what will come next.

At my office a check-up includes an external genitalia exam only. Girls would be referred to a gynecologist for a pelvic exam and pap smear if there are problems identified, within two years of becoming sexually active, or by age twenty-one.

One important screening that takes place at a regular check-up is the examination of the spine for scoliosis. Ideally we should identify scoliosis before a child's rapid growth spurt occurs. If I see a child at age five, and then not again until they need a sports physical for high school, it might be too late to treat scoliosis. Screening for normal blood pressure, vision, and growth can identify problems early, as well. Starting at age three we calculate a body mass index (BMI) for every patient during their well visit. This can identify children at risk for obesity. The child's immunization record is reviewed, and anything needed will be given at the end of the check-up.

For a child who has a chronic illness, or takes regular medication for a condition, a check-up will include a review of that condition. I will look at the impact of that condition on the child's health over the last year, evaluate the severity of the condition and the need for any further evaluation or adjustment in treatment. I will refill necessary medications.

Sometimes a patient has a new problem being brought up during a regular well exam. The detail involved in the well exam helps establish a better context for the problem. Sometimes the regular questions and information provided in an otherwise healthy child well exam must be abbreviated to properly address the new problem. There is no specific formula for this, we will do what we must do to address the most important concerns. The complete physical exam would still be performed.

Sports physicals are done along with a regular physical exam. I do not have a separate appointment for a sports physical available. If a teen is there for a sports physical we will do the whole physical exam. Parents and patients will notice that the checklist on the sports physical form is quite comprehensive, and includes all body parts, anyway! If needed, I will complete the forms at the time of the check-up, or up to twenty-four months after the check-up if there have been no changes in health or injury status during that time, and there are no chronic illnesses we have been monitoring.

I have one more thought for you as a parent helping your child on his or her journey to a lifetime of personal responsibility for good health. When do you think you should encourage your child to have a few minutes to talk to the doctor on her own? Usually I have initiated this at age 13, encouraging parents to wait in the waiting room (not just the hallway) while I do the physical examination part of the visit.

By high school I really think it is a good idea for the teenager to have a little time with the doctor without a parent present. Teenagers, who are now thinking for themselves, need to learn how to talk to, and listen to a doctor. Parents, this means you might have to trust me to talk to your teen alone. Why would you bring your child to me if you don't trust me? When I talk to your teen the discussion will be focused on establishing rapport, on physical and mental health, on making good choices, and on bringing family and parent-teen relationships together. By having you (the parent) out of the room it is very likely that I will be reinforcing things you have already discussed with your teen. You will look much smarter and more reliable to your teen if he realizes the same information is coming from the doctor!

So, call and schedule your child's well exam soon. Get on at least an every other year schedule (every year for monitoring chronic conditions). Let's think long term about promoting a healthy life for your child. And yes, I will read those little notes you pass to me secretly before the check-up and along with my usual advice I will emphasize whatever health rule you think needs a little extra reinforcement at home.