Cold and Flu Season is Upon Us!

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As cold and flu season approaches, I have been thinking about how our kids are managed when they become sick.  Not only what we do to treat symptoms, but how, when, and where patients get medical advice and care.


We are a busy society.  We want things done now.  Quickly. Cheaply. Correctly.  Resolution so we can get back to life.


Illness doesn't work that way.  Most childhood illnesses are viruses and they take a few weeks to resolve. There's no magic medicine that will make it better.

Please don't ask for an antibiotic to prevent the runny nose from developing into a cough or ear infection.  

Don't ask for an antibiotic because your child has had a fever for 3 days and you need to go back to work.  

Don't ask for an antibiotic because your teen has a big test or tournament coming up and has an awful cough.  

Antibiotics simply don't work for viruses.  They also carry risks, which are not worth taking when the antibiotic isn't needed in the first place.

Many parents in this community have grown accustomed to using after hour urgent cares  because they are convenient.

Convenient isn't always the best choice.  Many times kids go to an urgent care after hours for issues that could wait and be managed during normal business hours.  I know some of this is due to parents trying to avoid missing work or kids missing school, but is this needed?  Can it hurt?

Some kids will get unnecessary tests, xrays, and treatments at urgent cares that don't have a reliable means of follow up.  They attempt to decrease risk often by erring with over treating.  Our office does have the ability to follow up with you in the near future, so we don't have to over treat.  

Urgent cares don't have a child's history available.  They might choose an inappropriate antibiotic due to allergy or recent use (making that antibiotic more likely less effective).  They might not recognize if your child doesn't have certain immunizations or if they do have a chronic condition, therefore leaving your child open to illnesses not expected at their age.  We know that parents can and should tell all providers these things, but our own new patient information sheets are often erroneous when compared to the transferred records from the previous physician... parents don't think about the wheezing history or the surgery 5 years ago every visit.  It is so important to have old records!

There is some evidence that treating things too soon does not allow our bodies to make immunity against the germ.  A great example of this is Strep throat.  Years ago we would go to a doctor when our sore throat didn't get better after a few days.  They would swab our throat and send the swab for culture, which took 2 days. We would treat only after that culture was positive.  That delay in treatment allowed our bodies to recognize the Strep and begin making antibodies against it.  Now kids are brought in the day they have symptoms, and if the rapid test is positive, they immediately start antibiotics.  The benefit? They are less likely to spread Strep to others and they can return to school 24 hrs after starting the antibiotic.  The negative? They might be more susceptible to recurrent illness with Strep, so in the end are potentially sick more often and end up missing more school.

Receiving care at multiple locations makes it difficult for the medical home to keep track of how often your child is sick.  Is it time for further evaluation of immune issues?  Is it time to consider ear tubes or a tonsillectomy?  If we don't have proper documentation, these issues might have a delay of recognition.

Urgent cares and ERs are not always designed for kids.  I'm not talking about cute pictures or smaller exam tables.  I'm talking about the experience of the provider.  If they are trained mostly to treat adults, they might be less comfortable with kids.  They often order more tests, xrays, and inappropriate treatments due to their inexperience.  This increases cost as well as risk to your child.  We have been fortunate to have many urgent cares available after hours that are designed specifically for kids, which does help.  But this is sometimes for convenience, not for the best medical care.

Cost.  As previously mentioned, cost is a factor.  I hate to bring money into the equation when it comes to the health of your child, but it is important.  Healthcare spending is spiraling out of control.  Urgent cares and ERs charge more.  This cost is increasingly being passed on to consumers.  Your co pay is probably higher outside the medical home.  The percentage of the visit you must pay is often higher.  If you pay out of pocket until your deductible is met, this can be a substantial difference in cost.  (Not to mention they tend to order more tests and treatments, each with additional costs.)

What about our urgent care in our office?  We offer a walk in urgent care as a convenience for parents who are worried about their acutely ill child.  It is within the medical home, which allows us access to your child's chart. We can keep all treatments within this medical record so it is complete.  Our staff follow the same protocols and treatment plans as scheduled patients, so your child will be managed with the protocols our physicians and midlevel providers have agreed upon.  Essentially we have a high standard of care and want your child to receive that great care.

So what kinds of issues are appropriate for various types of visits?  
(note: I can't list every medical problem, parental decisions must be made for individual situations)

After hours urgent care or ER:

• Difficulty breathing (not just noisy congestion or cough)
• Dehydration
• Injury
• Pain that is not controlled with over the counter medicines
• Severe abdominal pain
• Fever >100.4 rectally if under 3 months of age
  

Pediatric Partner's Urgent Care:

• Fever 
• Ear ache
• Fussiness
• Cough
• Sore throat
• Vomiting and/or diarrhea
• Any new illness

Issues better addressed with an Appointment in the Medical Home:

• Follow up of any issue (ear infection, asthma, constipation) unless suddenly worse, then see above
  
• Chronic (long term) concerns (growth, constipation, acne, headaches)
  
• Behavioral issues
  
• Well visits and sports physicals (insurance counts these as the same, and limits to once/year)
• Immunizations - ideally done at medical home so records remain complete 

If your child gets a vaccine at any other location, please send us documentation (including the date, brand, lot number, and place administered) so we can keep the records complete.

Remember our website offers answers to questions and many treatments to try at home for various illnesses and conditions!

Starting Solids-- The Old and the New and the Myths

Many parents are excited yet apprehensive to start foods with their infants.  So many questions, so many fears.  So much food introduction guidance has changed in recent years, that what you did with your older kids might not be current.  Change takes time, so not everyone agrees on the "new" rules.  Talk to your own pediatrician to see their take on it all!

The older "rules" for starting foods were so confusing... different sources will vary on these rules.

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• don't feed before 6 months is now ok to feed at 4 months if baby's ready

• don't give nuts, eggs, and other "allergy" foods until ____ (2/3/5 years, varying by expert) is now it is okay to give allergy foods unless there is a family history of food allergy

• don't start more than one food every 3-5 days is now  introducing multiple foods at one time is ok

• start with rice, then add vegetables, then meat., wait until last for fruit is now begin with any foods, but try to make nutritious choices, such as meat which is high in iron and protein

Variations of this were plenty, depending on the provider's preferences.  

No wonder there is so much confusion!!!!

New rules are much easier.  I like easier.

• Start new foods between 4 and 6 months, when your baby shows interest and is able to sit with minimal support and hold the head up.
• Don't give honey until 1 year of age.
• Don't give any textures your baby will choke on.

Done.  

That's it.  Nothing fancy.  Any foods in any order.  Multiple new foods on the same day are okay. Common sense will hopefully guide types of foods.  Nothing too salted. Try nutritious foods, not junk.  

These minimal rules can make parents weary.

What about food allergies if foods are given too early?

Research does not support the thought that starting foods earlier lead to allergies.  In fact, there is research to support that starting foods earlier might prevent food allergies.  A full 180 degree change!  Pregnant women and breastfeeding mothers no longer have to avoid nuts or other allergy foods in most cases.  If there is a close family member with a food allergy, it might still be beneficial to wait to introduce that food.  Talk with your pediatrician in that case.

I admit that I was initially nervous about telling parents it was okay to give nut products in infancy.  Not just the allergy aspect, but also choking risks.  ~ Back to the no textures your baby will choke on... nuts are hard and round-- two no-nos, peanut butter is thick and sticky-- another choking risk.   

Any of the more allergy prone foods should first be offered in small amounts at home.  These foods include nuts, egg, and fish.  Do this only if there is no one in your house who is allergic to that food.  Have diphenhydramine allergy syrup around just in case, but remember most kids are NOT allergic, and starting younger seems to prevent (not cause) allergy.  In the case of nuts, since there is also a choking risk, you can try a food cooked with nuts or nut oil.

What about saving the fruit for last so they don't get a sweet tooth?

Babies who have had breast milk have had sweet all along! Breast milk is very sweet, yet babies who are graduating to foods often love the new flavors and textures with foods.  Formula babies haven't had the sweet milk, but they can still develop a healthy appreciation of flavors with addition of new foods. Saving fruit for last simply doesn't seem to make a difference. Adding fruits alone is not very nutritious though, so fruits should be added along with other more nutritious foods.  The more colors on our plates, the healthier the meal probably is!

I thought they couldn't have cow's milk until after a year?

Cow's milk is not a meal in itself (like breast milk or formula). It is missing many vitamins and minerals, so babies need to continue breast milk or formula until at least a year.  Cow's milk may lead to allergies or eczema, including formulas made with cow's milk.  Milk products, such as cheese and yogurt can be given to babies as part of an otherwise well rounded diet as long as they don't show any allergy risks to milk.  Regardless of dairy intake, it is recommended for infants under 6 months to have 400 IU Vitamin D/day and those over 6 months to take 600 IU Vitamin D/day as a supplement.

I thought they should have cereal first...

Rice cereal has been the first food for generations, probably because grandma said so.  There has never been any research supporting giving it first.  With white rice and other "white" carbohydrates under attack now, it is no wonder the "rice first" rule is being debated. Despite being fortified with vitamins and iron, it is relatively nutrient poor, so choosing a meat or vegetable as first foods will offer more nutrition.  

Shouldn't we wait on meat?

Waiting on meat due to protein load was once recommended, but no longer felt to be needed. Pureed meats (preferably from your refrigerator... baby food meats are not very palatable!) are a great source of nutrition for baby!  Some experts recommend meat as the first food due to its high nutritional value and low allergy risk.  

How do we know what they're allergic to if we start several new things at once?

First, most kids are not allergic.  

Second, if they are allergic to a food, it is often days/weeks/months before the allergy is recognized. Waiting 3 days between food introduction simply doesn't allow recognition unless it is hives or anaphylaxis, and there are a small number of foods that account for most of these reactions. If your child has one of these reactions we can test to see what the offender was.  This is recommended with severe allergies since people with one allergy might have other allergies, and identification for avoidance is important.  

Allergy symptoms can be broad and often are not specific: dry skin (eczema), runny nose, hives, swelling of lips, difficulty breathing, vomiting, diarrhea, or blood in the stool.  If you think your child is allergic to a food, discuss with your doctor.  Severe symptoms (anaphylaxis) demand immediate attention!

How do we know when to start foods? I wanted to start to help baby sleep through the night, but I heard starting too soon increased obesity and diabetes.

When babies are able to sit with minimal support and hold their head up and when they show interest in food by reaching for it they might be ready.  They can wait until 6 months to start foods, but some studies show poor weight gain and nutritional balance as well as resistance to foods if started after 6 months.  

In formula fed babies it has been shown to increase the risk of obesity at 3 years (6x!) if foods are started before 4 months of age.  That risk is not seen in exclusively breast fed infants or those who begin foods after 4 months of age.

It is still an old wive's tale that starting solids will help baby sleep through the night.  Babies tend to sleep longer stretches at this age, so it is no wonder that this myth perpetuates.  Start foods because you see signs that baby is ready, not because you want longer sleep patterns!

How do I know how much to feed my baby?

Babies will let you know when they are full by turning away, pursing their lips, spitting out food, or throwing foods.  As they eat more food, they will need less breast milk or formula.  In general a baby who is gaining weight normally will self regulate volumes.

What's better: baby foods bought at the store or home made foods?

Marketing and ease of preparation has made pre-prepared foods for us all common place.  It does not mean they are any better.  They cost more than home made foods.  I didn't make baby foods when my kids were babies because I thought it would be too hard, but now I puree foods to put into recipes (my kids are like many who aren't fans of veggies and I want to improve their nutrition).  It really isn't hard.  You can take whatever you are cooking for your family and put it in a food processor or some blenders and with a little water to get it to a texture baby can eat: voila!  Home made food.  There are of course many baby food cook books and ideas of how to freeze meal-sized portions so you can make multiple meals at one sitting. There is help for parents who want to safely prepare baby food at home on How to Make Your Own Baby Food from What to Expect. (link updated 9.16.17)

My baby only wants table foods. Is that okay? Don't they need pureed foods first?  He doesn't have many teeth!

Pureed foods are what most babies start with due to the easy texture, but some babies quickly develop the ability to pick up small pieces of food with the pincher grasp (finger/thumb) and want to feed themselves.  If they are able to get the food in their mouth, move it to the back safely with their tongue, and swallow without choking, they are ready to  feed table foods... at least with some textures. Beware of chewy or hard foods as well as round foods ~ these all increase the risk of choking.  

Most babies will be able to eat table foods between 9 and 12 months.  They tend to not have molars until after 12 months, so they grind with their gums and use all their saliva to help break down food.  They need foods broken into small enough pieces until they can bite off a safe bite themselves.  

Don't put the whole meal on their tray at once... they will shove it all in and choke! Put a few bites down at a time and let them swallow before putting more down.  Rotate food groups to give them a balance, or feed the least favorite first when they are most hungry, saving the best for last!

This is a great time for parents, sitters, and other caregivers to take a refresher course on CPR in case baby does choke.  Infants and young children are more likely to choke on foods and small objects, so it is always good to be prepared!  

How much juice should my baby drink?

In general I think babies don't need juice at all. They can practice drinking from a cup with water.  Juice adds little nutritional value and a lot of sugar.  Eating fruit and drinking water is preferable.  If they do drink juice, it should be 100% fruit or vegetable juice, not a fruit flavored drink!  No more than 4 ounces/day of fruit juice is recommended. 

What about organic? 

There is not enough evidence to recommend organic food, since the nutritional components of the foods are similar regardless of how they were farmed.   

Organically grown foods do have lower pesticide residues than conventionally farmed produce, but it is debated if this is significant or not to overall health.  Conventionally farmed produce have the pesticide levels monitored, and they fall within levels that are felt to be safe.

Organic farming rules also dictate no food additives or added hormones, which is also an area of study for health risks and benefits, but not enough data is available to give an educated opinion yet.  

Organic farming is generally felt to be better for the environment, but the sustainability of that is questioned.  

Organic farming might increase the risk of bacterial and fungal contamination or heavy metal content, so it is very important to wash fresh fruits and vegetables well prior to cutting or eating (as you should with all fresh foods).  

For more information, see the USDA site.

A backyard garden can be inexpensive, organic, and a great way for your kids to learn about growing and preparing healthy foods!  

Food Strike!

A recent facebook question: Any articles out there about what to do when your child goes on an eating strike? My son, who's five (soon), has these occasionally, and he's already thin as a rail to begin with :)

My answer became much too long, as this is a very common concern and there are so many aspects, so it turned into this blog.

This question (very common) always reminds me of the Judy Blume book, Tales of a Fourth Grade Nothing.  (One of my favorite books growing up.)  The younger brother in the book, Fudge, refuses to eat.  After many failed trials of forcing food, and bribing, his Dad finally loses patience and says "eat it or wear it."  Needless to say, Fudge ends up with the bowl of cereal on his head and goes around for days saying "eat it or wear it!"

Food Strike!  This is a common concern of parents.  But kids are smart, they won't let themselves starve.

Of course there are some instances that are cause for concern.  Red Flags include kids who are sick, recurrently vomit or ruminate, seem dehydrated, have problems with food allergies, are very limited in foods over an extended time, experience swallowing problems or choking, or who are not following their growth curve.  Red flags are another topic entirely!  Work with your physician in these cases.

If hungry, he will eat.  Just don't let him fill up on things that aren't giving a nutritious balance. Even just milk all day can be harmful because it lacks many vitamins and minerals, so a little milk with other foods is better!

• Offer veggies, fruits, cheese, nuts, etc at scheduled snack times. 
• Limit pre-packaged foods and snacks.
• Limit drinks other than water and low calorie milks.  These fill kids up and don't offer balanced nutrition.
• Put only a small amount on his plate... it might be overwhelming to have a full plate.
• Turn off the tv.  Have a dinner conversation with the family.  This not only sets up healthy eating habits, but also healthy family dynamics. Teens who eat with their families are less likely to have risky behaviors!
• Set a good example!  Talk about how much you are enjoying the healthy foods at the table. (Not how healthy they are, but rather how good they taste.)
• Keep foods separate on the plate... they might eat one food if not touching another.
• Set a time for meals and stick to it.  If your child doesn't eat, still clear the table.  When they complain of being hungry, don't be condescending.  Simply say, "I know how you feel.  I'm hungry too when I don't eat.  Dinner is coming up soon. I'm sure you'll be ready!"  Don't offer filler foods. Don't yell.  Don't over-discuss.  Kids are smart, they'll pick up on the fact that they need to eat at meal time or be hungry.  (They won't starve to death!)
• Hide healthy foods in casseroles, sauces, etc.  I love my blender... the food processor was too much for me to clean, but my blender works just as well!  Many vegetables have little flavor, which makes it easy to "hide" them in things.

• I put a can of beets in with the spaghetti sauce --makes a cool color without changing the flavor.    

• I put carrots, spinach, or cabbage in my smoothies without changing the flavor.  Strawberries, bananas, kiwi, and other fruits are much more flavorful than many veggies and kids tend to like their tastes.  I just try to match color to hide the vegetable. 

•  Puree onions, carrots, zucchini, spinach, and other vegetables in recipes rather than chopping them... kids won't pick them out!  Chances are they won't even know they're there.

• Try foods in different forms: 

• frozen peas are crunchy-- maybe they don't like the squishy texture of cooked peas
• raw broccoli is much different in taste and texture than cooked broccoli
• many kids love cheese over vegetables or foods dunked in catsup or yogurt
• it is fun to eat with fingers for a change... let them get messy!
• try cutting things into pieces and serve with toothpicks
• make a kabob of fruit and cheese pieces... it's always more fun to eat off a stick! 
• cut sandwiches with a large cookie cutter for fun shapes
• use small cookie cutters for bite sized sandwiches or fruit pieces 

• Try not to use food as a reward. This can set up unhealthy eating habits.
• Don't reward for eating.  Most kids will get the intrinsic reward of satiety.  They don't need stickers or dessert for eating a meal.
• Praise small steps.  If kids try a new food (whether they like it or not) praise the fact that they tried!

Set your expectations realistically.  Don't expect kids to eat as much as infants/toddlers or teens/adults.  Calorie needs go down when not in growth spurts.  Just make the nutrition needs balance.  Don't worry as much about volume as variety of healthy foods!  Most kids don't need supplemental meals in a can (Pediasure and other brands) ~ they are getting the nutrition and calories they need, there is just an imbalance of perception of what they need.  I always prefer a healthy, active, thin child over a child who is overweight and not active (and often undernourished due to poor quality foods).

Vitamin supplement use and need is debated (except Vitamin D, which is recommended for all).  In general, I think it is a good idea to give a multivitamin with iron if kids aren't eating well.  Iron deficiency actually causes anorexia-- increasing the problem!   Just be sure to lock up vitamins as if they are medications, so kids don't accidentally ingest too much. 

Most kids grow well during their picky eating and food strike phases!  Just be patient and aware of any red flags that need to be evaluated.  If you are concerned, schedule an appointment to discuss foods, growth, nutrition, and concerns.  Bring a typical food log of foods and drinks (with approximate volumes) for at least one week.  We can either identify a concern and develop a plan of action, or reassure you that your child is normal!

Middle Man Payment Plan?

Healthcare billing is a very complex issue, mostly because people are familiar with purchasing things with money or credit in full disclosure of costs, not the complex system of insurance billing.  


People pay a lot for insurance, and then expect insurance to cover the cost of care, but they often do not realize the details of their contracts with insurance - AKA the Middle Man.  

Patient <--> Insurance <--> Doctor Office

This is  a long post, so bear with me... it is such an important but complex issue. I am only touching the surface here.  If you can't read the whole thing, at least hit the highlights at the bottom!

Typical purchase:  Buying a shirt. 

• I select my favorite store. 
• I look through the rack of shirts and pick one that is the right size and color.
• I look at the price tag and decide if I want it.
• Maybe I have a coupon or it's on sale - I can calculate the discount!  
• If it is the right cost and meets my needs, I make the purchase. I can choose cash, check, credit card.  Maybe I have a gift card! 
• If it isn't right for any reason, I keep shopping.

Healthcare purchase: Full of Unknown costs... making the decision to "purchase the product" much more difficult.  

Product? What product?

• "Product" is the expertise and knowledge of the healthcare professionals. 
• There is nothing to take home to show.  
• Time spent with the provider may or may not end up with a prescription or other identifiable thing that shows what the money was used for.  
• You might leave the office with as many (or more) questions because final diagnosis of a problem can be a process that takes time.
• You might disagree with the diagnosis or treatment given.  You don't have the option to choose another shirt. You already bought this one when you signed in.  You could buy another (2nd opinion) but you'd have to pay for both.  I hope you talk about these concerns at your visit... don't just worry that we "missed" something or did it wrong! 

Costs are becoming more important to the consumer as many insurance companies are putting more financial responsibility on their policy holders and covering less medical costs.  So it would be best if we let you know our fees and your payment amount before we see your child, right?  Well, there's a catch to that.  

The catch?  I don't know what your insurance contract requires of you, so it is impossible to accurately tell you what your real cost will be until after my office gets the insurance adjustment.  I don't know exactly what the insurance company will pay and what they'll discount ... my billing staff can make an educated guess based on past experience with a company, but it varies from case to case.

In this difficult economic time this places financial stress on families. I understand this and am happy to work with families on payment plans if they let me know their hardships, but often they simply yell that I billed it wrong. Because of contracts between my  office and the insurance company and the patient and the insurance company, there are many rules and laws regarding how to bill and collect payment.  


Back to Healthcare "purchase":

• Patient/consumer uses a service.
• Place of business (ie doctor's office) submits a bill based on well defined codes.  This bill doesn't go to the patient.  It goes to the Middle Man.
• Middle Man (insurance company) reviews the bill submitted.  
• Middle Man discounts each item to what they believe is a reasonable fee.  
• Middle Man pays the part of the adjusted fee that they are contracted to pay. 
• Middle Man sends us this information and we write off the discount they applied and bill the patient/consumer the difference.  
• We have provided a service and it is several weeks to months before any money is collected. Anyone in business knows the consequences of this timeline of money collection. 
• Payment collected from the doctor's office depends more on what the insurance company adjusts the bill to rather than the original bill itself. 
• Note: although the bill comes from us and is due to us, it is a result of your insurance plan/contract!  In general, the less expensive your plan for monthly health insurance, the more you are responsible to pay with each use.

Let's run through a couple scenarios of this Middle Man payment plan.


First scenario: Well visit plus additional concerns. A child is scheduled for a well visit but woke with a fever and cough.  He has an insurance company that requires a copay for each issue seen in the office.  We provide the care for a complete well visit (monitoring growth, development, nutrition, safety, reviewing vaccinations, etc) and bill for that service. We also ask further questions regarding this illness and symptoms and discuss management for the fever and cough.  Addressing and Documenting these issues (after all, the kid isn't well) is important.  When the bill is submitted to the Middle Man, the insurance company sees that the child is sick, so tells us to bill the family for a 2nd copay.  Our contract with this insurance company requires this, so we must bill to the family.  By law we must follow our legal contract.  To fail to do this is insurance fraud.  I'm not willing to go to jail to save a family a few bucks.  Sorry. I love my patients and want to help, but I don't want to have to go to jail for trying to do a good deed.


Second scenario: Screenings and tests sometimes, but not always covered. Another child is in the office for a 3 year old well visit and is due for a vision screening.  We know that most people either don't have vision coverage or their insurance only covers one vision test every 1-2 years.  The standard of care (ie what should be done if we want to provide the BEST care) is to do the vision test at this age.  This causes many possible scenarios, most of which equates to a headache for pediatricians:

• If a patient passes a vision screen done at our office and the insurance pays:  great. Rare, but great.
• If a patient's parent refuses the vision screen in our office (or fails to take the child to the specialist when we refer) because they feel the eyes are normal and don't want to pay, but later learn there was a problem that should have been addressed earlier for better outcome: parent is upset with us that we didn't insist on screening. The child also suffers from an undiagnosed vision problem.  
• If a patient passes a vision screen and insurance applies the charge to the deductible: the parent is upset at us for charging something "that wasn't needed. I knew the eyes were fine." (Note: we are the bad guy because the bill comes from us, despite the fact that it is their insurance company that chooses this payment method.)
• If a patient fails our vision screen and insurance pays us: parent is upset because we used up the once/year (or every other year) coverage, and now they pay out of pocket for the ophthalmologist.
• If patient fails our vision screen and insurance doesn't pay: parent is VERY upset because they must pay twice! (us and ophthalmologist) Why is this? Screenings by nature pick up some normals so they don't miss any abnormals. If a child fails at our office, they need to be seen by a specialist to confirm if there is or is not a problem.  Two visits by two providers with two fees.  Ugh!  

So... how many of these vision screening scenarios ended up with all happy?  ONLY ONE RARE CASE!

Please read your policies and ask questions to your insurance company before visiting the doctor so you know your financial responsibility.  Plan accordingly to save some money for healthcare needs.

One major issue we are seeing is described in scenario #1 above.  We follow the use of CPT codes as published by the American Medical Association. To bill both a sick and well visit on the same date of service, we add a Modifier -25 to identify separate preventive medicine service (well child exam) and a problem-oriented service (ear infection, hurt foot, earwax removal, etc) on the same date of service. This is the national standard, but not all insurance companies cover it the same.  Middle Man may tell us to charge the insured family a second co pay.  Why?  Because they want their members to pay their contracted portion of each visit.  Simply saving up multiple issues to be seen on the same visit day does not result in a person being less responsible for their portion of medical costs agreed to in a contract.  You are responsible for what your contract states.


Or maybe you simply have a high deductible plan.  You will be responsible for payments until you reach the magic number in your contract.  You have the benefit of lower monthly premiums, but expect to pay more each time you need medical care.


Another issue is labs.  Some insurance companies ONLY pay for labs done at their contracted lab. This means that quick Strep throat test we did gets charged to you.  Unfortunately we didn't know this from your insurance card.  Is it worth it to you for the convenience of knowing results right away to pay for the rapid strep, or would you prefer to wait for the lab to give culture results in a couple days? If this is important to you, call your insurance company.  Tell us before we do the test!


Billing codes separate out parts of services/product. Immunizations are a great example of this. There is the vaccine component, and there is an administration cost to cover costs associated with a vaccine:

• vaccine insurance -- they are expensive and need to be covered!
• temperature control of the refrigerator--did you know if the temp gets too high or low it alarms so our vaccine doesn't become ineffective? After hours one of us is automatically paged and we have to go in to see what is wrong?
• incidental supplies like syringes, needles, bandaids-- all the little costs add up!

Some insurance companies pay only the vaccine component, but not the administration fee. It goes toward the deductible.  Do you know how your plan works?

What does this all mean?

• We would like to provide the best care to our patients in a timely and economical manner, but we need your help identifying what you want done and not done due to costs before your visit. 

• If we address well and "not well" issues on the same day, it might mean a 2nd co pay or deductible for you to pay.  Some issues deserve a separate visit due to the nature of the concern.  

• We encourage you to do the recommended follow up labs and tests discussed at visits for the best medical care of your child.

• If your insurance company tells us to write off a portion of your bill, we do.  It is illegal to balance bill a patient.

• If your insurance company tells us to bill you for a service, we do.  It is illegal to write this portion off.   

• If you have a high deductible plan, save the money you save on premiums monthly in a special account for use when needed. 

• If you have any questions about your bill, please feel free to call our billing department to discuss. Please choose nice words with our staff. They are only the messenger!

Humility: the Anti-Bully

October is National Bullying Prevention Month, a topic that is important to me because it affects most of us at some point or another.  I will post information all month on our facebook page about bullying.  I don't want to repeat details of recognizing and stopping bullying -- there will be lots of great information posted, keep watching our wall!

I want to talk more about learning how to prevent bullying from a different perspective.  The slippery slope of when friendly banter or bragging turns into hurt feelings.  The way kids treat family members can reflect on how they will treat friends and classmates. The way kids are treated by family members also shapes their behaviors.

Bullying varies in severity and type.  We all recognize severe verbal bullying and physical bullying, but there are shades of grey. When is it bullying and when is it just kids being kids?

Bullying is when kids hurt other kids on purpose, but what if it isn't on purpose?  Kids still feel hurt.  How can you tell if it was with intent to hurt or just a blunder?

• My team is better than your team.  Bullying or just a friendly competitive spirit?
• I got an A on my test!  Pride or making another feel small without knowing it?
• You got your hair cut? (in that voice)  Surprise reaction -- or does hurting feelings mean bulling?

Kids don't always recognize when they say something hurtful. They haven't learned to always think before speaking or acting.  This doesn't make the action acceptable, but it offers a teaching moment.

• Tell them when you hear words that can be hurtful. Ask how they would feel if someone said that to them.  
• Discuss how the look on the friend's face lets you know something is wrong.  Talk to kids about how to understand when another person looks hurt or changes their mood suddenly  it might be due to what was said or done.  When they see face changes or moods fall or become angry, they need to quickly think back to what was said.  They can ask the friend if they said something wrong.  They should apologize if the friend's feelings were hurt, whether the friend admits hurt feelings or not.
• Teach kids to speak up for themselves when someone says something hurtful.  Until their friends learn to recognize what they say is hurtful, they need to be told.  A friend will stop.  Hopefully the friend will apologize, but maybe they haven't been taught that yet.  Teach your kids to accept apologies and offer forgiveness. 

A bully will keep doing the same behaviors even after the behavior has been called to their attention.  Bullies tend to pick on kids who have less self confidence, so build up your kids. Let them know they are loved.  Teach kids that it is okay to ask an adult for help.

I believe that teaching core values and showing a child love can help prevent bullying.  This is counter to many of societies goals.  It involves a tricky balance between building self esteem with praise without over-inflating the ego or demanding perfection.  Love kids for who they are, not what they do.

Bullies are self-indulgent and impatient. They try to feel better or inflate their self esteem by putting others down, but don't feel happiness.  They blame others or the system for problems.  They often feel unfulfilled and need more out of life but they don't know how to achieve these needs.  They probably don't even see that they are unfulfilled.

Kids who know that they shouldn't lie, cheat, and hurt others because it is wrong might think twice before intentionally hurting someone's feelings or spreading lies.  Young children must learn this.  We need to talk to them about how their words make others feel.  How would they feel if someone said that to them?

Don't tell them how they would feel.  Ask them, guide them.

I think humility is the anti-bully.  Humble people put others first and treat others with respect.  They are not weak and they are not step stools.  They have self confidence and inner strength, but are happy when others are happy.  They don't need to prove themselves to others.  Kids who put others first will be less likely to try to put others down to make themselves feel better.  A mistake should not break their whole self esteem because they know they are loved for who they are, not what they do.  They shouldn't have to defend themselves.  They can admit their mistakes and not lie to cover them up.

Do not confuse humility with humiliation. Humiliation is of course bullying and the opposite of being humble and helping others.  

The best way to teach humility is to be a humble example.  Serve others. Volunteer.  Give praise freely and unconditionally.  Show caring and respect to all.  Give credit where credit is due.  Accept responsibilty.  Ask for forgiveness when needed. Offer forgiveness to others.

Teach kids to give out praise often to others.  Who doesn't love it when others notice them? What can we say to people with genuine heart felt praise?  Think of ideas together and praise them when you see them hand out praise!  This builds confidence all around.  Confidence protects against bullying!

Teach kids how to respond truthfully without making others feel put down and without seeming over-confident.  (No one likes the kid who brags...)

• "You scored the most goals.  Great job!"  

Reply: "The whole team was great. I couldn't score if they didn't pass the ball."

or "Coach taught me a great move.  I couldn't do it without his help."

• "Wow! You got an A on the test.  I tried so hard and got a C."  

Reply: "The way the teacher explained it really made sense to me. I couldn't do it without good teaching."

or "I had to study really hard too.  Maybe we can quiz each other next time."

or "Math might be easier for me, but you are great with music!"

Teach kids to apologize when needed.  No one is perfect, and there is always a need to know when and how to apologize.  Words must sound sincere.   Don't allow kids to work around the situation or lie to get out of trouble.  Don't allow them to put blame on anyone or anything else.  

Teach kids they can only control what they say and do.  No one can control what another says or does.  How can they change their words or actions to change the outcome of a situation?  

Have you ever read one of those books that have multiple endings?  The ones that say things like, "If you want to go into the house, go to page 43. If you want to go to the park, go to page 46." 

Have kids pretend that their life is one of those books.  

Tell him to pick a time that someone's feelings were hurt, a fight started, or he got in trouble.  

Now have him change one thing he did or said.  Play out the rest of the situation.  

Ask: How would the other person respond to your new action? How does that change the end of the situation?   

This takes some practice, but we can all learn from this type of reflection.

Adults need to model these behaviors.  Kids can't learn humility just from being told. They must be shown these behaviors daily.    

Kids who know what to do if they see bullying behavior or feel bullied can help stop the cycle.  Many schools have anti-bullying programs in place.  

Does yours?  

Do you model anti-bulling values at home?

Too Little Sleep in Athletes

I am very concerned on many levels about late nights required for local sport programs from a parent perspective and as a pediatrician.

Many physical and emotional problems have been linked to sleep deprivation.  I see many kids who struggle in school and at home with behavior and learning problems that are directly related to loss of adequate sleep.  Poor sleep is also related to obesity, poor growth, depression, anxiety, poor school performance, and so many other issues.  Sleep is needed for release of growth hormone, which is needed for bone and muscle growth, muscle repair, fat burning, and learning.  Sleep loss leads to poor attention spans, inconsistent performance, decreased aerobic endurance, delayed response times, and increased illness, and will therefore affect their game!  There is increased risk of injury in these tired athletes.

You can argue that one late night a week will not have devastating consequences, but I disagree. We have all heard that consistent bedtimes are important for sound sleep.  Ironically sleep deprivation often leads to insomnia and more sleep problems. You cannot sleep "extra" to bank sleep hours.  Kids will often sleep in on weekends to attempt to catch up on the sleep hours missed during the week, but that means a week of struggles emotionally and physically.  It also gets their sleep routine off balance, which again contributes to poor sleep.

It is recommended to exercise at least 2-3 hours before bedtime because exercise is stimulating, making it difficult to fall asleep after exercise until the body temperature and metabolism return to normal.  Yet I find that many school aged kids have practices and games in the late evening into night hours.

School aged kids up to 12 years of age need 9-11 hrs of sleep per night to function adequately.  Practices and games late in the evening shortchange their night's rest by far too many hours.  Don't forget to consider that the time to settle down after the game is up to 3 hours. The following day they are likely to have problems at school.  An overtired child often has MORE problems getting to sleep, which affects the rest of the week.  These younger kids tend to have a lot of noticeable behavior and learning problems. Many are misdiagnosed with ADHD and treated with medication, when all they really need is better sleep. It is simply not acceptable to set them up for this failure.

As kids enter middle school they often need extra sleep due to puberty.  (Growth hormone is released during sleep.)  Unfortunately, school tends to start earlier and their game/practice times are often later, meaning they might be getting up just a few hours after they are falling to sleep.  Do we really want to affect their growth during these important years? 

No wonder many middle and high schoolers fall to sleep in class and struggle with falling grades, irritability, depression, and more.

Kids shouldn't have a hard time getting up in the morning.  If they are, it's a sign of not enough sleep!

I should also include coaches and parents in this, since we will be required to teach and transport these kids. Adults will fall short of their recommended 7-9 hrs of sleep, which affects mood, weight gain, and attentiveness.  This affects not only health, but also home and office life.  Can you wake up before your alarm?  If not, can you get to bed earlier?  That is a healthier choice than adding an extra cup of coffee or energy drink to your day.

We as parents and coaches want our kids to succeed in all areas of life. We want to give them the tools they need for this, which must include proper sleep.  Practice and game times on school nights must take into consideration the sleep requirements of these kids.  I do not want to be responsible for allowing  my child to be out late on school nights, therefore contributing to increased risk of poor school performance, behavior issues, immune deficiencies, depression, growth and obesity, and all the other known consequences of poor sleep. Once these issues surface it is too late to prevent them and the snowball effect begins!

The question: What can parents do?????