Saturday, January 21, 2012

When To See Your PCP?

We have many kids who come in for what I consider "band aid" medicine. We only see them when they have a problem. They never come in when well so we can know more about them: what they enjoy doing, what good (and bad) habits they have, if they are growing properly... you get the idea.

I understand that it is time and money to visit the doctor's office, but it is time and money well spent.  Sometimes it isn't obvious that this is an investment that benefits in the long run, but preventative care has been shown to be worthwhile!  I typically feel that I give inferior care to kids I rarely see because I only see them when they are sick, and can only focus on the current problem, not the overall health. You can't use a band aid to fix a broken bone or high cholesterol.  Without proper evaluation, you don't even know you have some health problems.  Even our cars get better care: people do routine maintenance checks on their car every 3-5 thousand miles, they don't just call the service station when it won't start.

Many problems have few or no signs or symptoms until they become severe. Anemia, elevated lead levels, high blood pressure, growth problems, and behavior concerns are some that we typically only see when critical if kids don't come in for recommended visits or do recommended testing.  Some parents fail to bring kids to the lab or other facility for recommended evaluations. This can delay diagnosis and puts kids at risk.

There are kids who visit urgent cares often, yet never come in for routine care.  It may be years between visits with the primary care provider (PCP).  "PCP" is used broadly here, since the primary care isn't done.  I understand that sometimes it is because kids wake in the middle of the night and the parent wants a quick fix, parents don't want to take off work so go on weekends, or the drugstore with a clinic is on the way home, but this isn't good care on many levels.
I don't always trust an outsider's assessment of certain physical signs.  Studies show parents are much happier with a diagnosis of "ear infection" and a prescription than an accurate assessment of a viral respiratory infection and instructions on home remedies.  Many ear infections are over diagnosed, leading to inappropriate antibiotic use, despite better parental satisfaction.  It benefits a practitioner who will be evaluated with patient/parent surveys to provide a prescription rather than an accurate assessment and instructions.  It also takes less time to write a quick script than to discuss the diagnosis, when to follow up if worsening, what to do to help symptoms, etc. Less work and more satisfaction, sounds good, but...
I don't know if the provider has enough experience with infants/young children to recognize what is really going on. I'm sure some of the people working urgent cares are really good at what they do, but many have little experience when they start working without supervision. They have no one to ask for a second opinion, so even after years of working they haven't developed the same skills as a practitioner working with more experienced providers who are able to help when needed.  Bad habits can be reinforced because they simply have no way to learn better skills.
Quick treatment of some infections that really do need treatment leads to poor immune memory, increasing the reinfection rate.  Strep throat recurrences have been shown to happen more when kids start treatment with less than 2 days of symptoms. There is benefit to waiting!  Strep should be treated within a week to prevent complications, but allowing the body a couple days to fight it off first builds the immune system!  It is okay to wait until office hours for many (if not most) problems. 
Difficulty breathing, dehydration, altered mental status, many injuries, and other things do require emergent care. If your parent alert system is telling you your child needs to be seen, then an ER visit is appropriate.
Keeping a good timeline of infections helps the PCP know when it is time for more intervention, such as ear tubes or prevention medications. If quick fixes are always at another location, we might not recognize the frequency. Even when parents bring kids in with a history of frequent infections we can't make appropriate recommendations because we might not trust the diagnoses.  Parents might not ever be told that their child has asthma that needs a prevention medication, so they simply keep using the quick relief inhaler, which puts the child at risk for serious complications.  Asthmatics who have regularly scheduled asthma visits when they feel well have fewer wheezing episodes requiring emergent visits and admissions.  Improve management of frequent or chronic illnesses by visiting with the primary care provider for illnesses and when your child feels well to optimize medication use, make appropriate referrals, improve safety, and spend overall less time and money.
Recommended routine maintenance is spelled out clearly in a book that comes with every car, yet a maintenance book doesn't come with kids. Yearly exams for those over 3 years (more for infants and toddlers) are recommended at a minimum.  Routine care also means regular visits to check on chronic conditions, such as asthma or obesity.
Preventative Care Guidelines are developed by people smarter than me by reviewing statistics including risk/benefit ratios, cost analysis, and more.  These aren't perfect and are regularly reviewed and often change. Some recommendations are simply not followed because insurance companies don't cover the cost. Pediatricians and many others are fighting for better coverage.  Examples of things recommended at various visits (depending on age):

  • height/weight measurements
  • blood pressure screenings
  • lab screenings (anemia, lead, cholesterol)
  • vision and hearing screenings
  • development assessments
  • mental health screens
  • more...    

I'd like to think that I can make a difference with healthy lifestyles by providing regular routine care. Sleep habits, screen time, exercise, safety, and more are discussed at various well visits. This might uncover issues that need additional visits to be properly addressed, but early recognition helps improve outcomes.

I know my own kids take what others at the office (other doctors, the midlevels, even the nurses) say about safety, nutrition, and sleep more seriously than when I say it. (Never mind that I have qualifications to discuss and advise on this topic, I am just Mom to my kids!)  I also recognize that I see my kids daily, but don't know their growth parameters, blood pressure, heart sounds, etc from day to day living.  I bring my own children in for routine well care and follow up of health issues so that they can be the healthiest they can be.  It has become routine for me to schedule their summer physicals every Spring Break.  This routine helps because:

  • it gives plenty of time to find a time/date that fits our busy family calendar and the provider's schedule. 
  • it is a routine, which helps me remember... yes, I forget to make appointments just like everyone else! (Others use birth dates to remember, but I prefer summer visits for many reasons.)

It is not uncommon to uncover a problem during a well visit that needs to be addressed more completely but wasn't recognized ... even by smart, educated, attentive parents.  Please join me in healthy parenting and schedule routine checks for your kids!  Do the tests, treatments, and follow up recommended by your provider or speak up during your visit if you don't plan on doing them, which allows for open discussion about why they should or should not be done.

Use band aides when appropriate, but treat overall health with routine visits!

Monday, January 16, 2012

Red Dye #40

Image: meepoohfoto/
A recent facebook post asked about the link between red 40 dye and hyperactivity.

Would love to see an article on red 40 dye and thoughts from a professional medical standpoint. As the mom of a very strong-willed child, I've gotten advice from other moms who swear this is the "poison" that creates so much difficulty in kids. Wondering how you feel..... So"What's up, doc?"

Tolerability and safety of food additives and their influence on behavior have been questioned since the 1970s after a pediatric allergist alleged that there was risk of hyperactivity due to food additives. This allergist, Dr Feingold, supported the Feingold Diet.  Scientists reviewing his studies found he had no control group, limiting the validity of his study. Several other well designed studies have not found a risk except to those allergic to the food dye (FD&C Yellow No.5 leads to hives in 1 out of 10,000).

Studies attempting to show a link between food additives (including Red dye #40) have been inconclusive, inconsistent, or inadequate.
In 1982, a Consensus Development Panel of the National Institutes of Health concluded that for some children with ADHD and confirmed food allergy, dietary modification provided some benefit to behavior. They did not recommend all children alter their diet since there was no proof that it helped anyone but the small group with ADHD and food allergy.
In 1997, a review of several studies on this topic showed minimal evidence of benefit and extreme difficulty getting children and adolescents to adhere to a restricted diet.
In 2007, color additives specifically were questioned in relation to hyperactivity in a study by the UK Food Standards Agency.  Both the FDA and the European Food Safety Authority independently reviewed the results and concluded that there is no substantial link between color additives and behavioral effects.
Parents could argue that simply omitting foods with additives wouldn't hurt their child, and on many levels they are correct.  But...
We should all attempt to eat a nutritious diet rich in fruits and vegetables and minimize processed foods.  Unfortunately, that becomes very difficult in our society.  Many foods, including dairy, breads and cereals, and more have food additives.  It is difficult to eliminate these entirely and continue to get a balanced diet.  
Kids with true food allergies who must avoid certain foods often feel singled out and "different" or "fragile".  While this is very important for kids who have direct health risks to foods, it is psychologically difficult and if not a real risk/benefit, do we really want our kids suffering psychologically?  
Avoiding these foods also might allow the child to place blame on an external factor, leaving less responsibility for their action.  "I ate jelly beans, that is why I am out of control today.  It's not my fault."  
Trying an elimination diet also might delay the initiation of seeking professional help to try things that have been shown to work, such as behavioral modification, improved sleep, routines, and sometimes medication.
I believe in recognizing real risks, looking at the risk benefit ratio, and then making a decision.  If you have not noticed a difference with your child's behavior when eating only real whole foods (not from a package) then food additives likely aren't the culprit.

Behavior is very complex and is related to the child's temperament, sleep effectiveness, environment, hunger, emotional support, and more.  If there was one easy solution (ie removing food dyes) parents would all be doing it!


Friday, January 6, 2012

New Look! New Title!

My blog has a new look!

And a new title... Quest for Health

I have changed the title of my blog to further identify my mission to spread information, offer my reflections on news related to child health, and to tell of personal experiences relating to the practice of medicine.

This blog was started over the summer as a collaborative effort of the pediatricians at Pediatric Partners.  Busy lives and writer's block have kept all the physicians from contributing.  As a previous medical school yearbook editor and current family historian / scrapbooker, I have found a new voice and love in blogging, so will continue the endeavor on my own.  Though I still plan to ask for guest bloggers... hint hint, wink wink.  You know who you are!

The new format allows readers to see previous post titles at a glance and open any interesting topics easily.  The background is clean and sharp, allowing an easier view on the eyes.

I am still accepting topic ideas and feedback!  Post to the Pediatric Partners Facebook page if you have suggestions!

Here's to your health!


Tuesday, January 3, 2012

New Year's Reflection

I was fortunate to be able to spend New Years with my extended family in the St Louis area.  Conversation led to my mother remembering old family videos in the basement. After a little digging around, my brother found the never before seen footage!

We had a blast watching videos of past holidays and vacations.

Some things were fun to compare. My daughter is better at ballet than I was at her age.

Other things were simply laughable.  Although I was impressed at my grandmother looking fit and trim in short shorts, most clothing choices of the 70s should never be repeated.  What will they think of our current clothes in 30 years?

One thing that struck me sadly was the average weight of people at all ages in the 70s seemed to be less than the average weight of people the same age today.  I'm not saying my friends and family have gained weight ~ I would get into trouble for that!  It was simply noticeable that people of today are heavier when comparing large groups.

I've read the statistics before...

Self Reported Weight up Nearly 20 Pounds Since 1990
Mean Body Weight, Height, and Body Mass Index, US 1960-2002

... but it was interesting to see large groups of people from my past vacations and comparing to what I see daily when out and about.  It made it real.

If the US is such a great nation, how have our individuals as a group gained weight in this unhealthy manner?
Is it the convenience of pre-packaged foods, many of which are processed and/or high in fat?   More women work now than previously. Does this contribute to less home-cooking and more fast foods?
Is it that the meal size increasing?  Large sodas of my childhood are now the smallest size available.  Who needs 64 ounces of acidic bubbly sugar?  We eat larger servings both at home and at restaurants. 
Are we less active than we used to be?  I can easily see how today's kids are tempted with tv, video games, and other sedentary activities.  As a child, I only had one tv channel, and most often it had adult programming. (There were no recordings available!) I had many other things to do both in the house and outside.  We didn't have many structured activities, so we just made it up as we went along.  And we had a blast!   What about adults? Are they less active? Do we work more hours than our parents?  Do we spend more free time in front of the tv/computer than our parent's generation? What did they do for fun?  Was it out of a chair?
Do we sleep enough? With many tasks to do and distractions, such as tv programming and internet available all night, do people stay up too late to get a good night's rest?  More and more research supports that sleep is needed for concentration, endurance, immune functions, as well as weight control and more.  How often do we feel tired?
I suspect that there are many reasons for our generalized weight gain, which means that there are many potential fixes, and not one alone will help.  I have tried to limit processed foods at home, but they are convenient and easy, so I sometimes splurge.  We try to eat as a family at home most nights, though activities sometimes interfere.  Portion control is relatively easy for my kids: they eat minimally by nature.  My husband and I need to check ourselves.  My kids are much better at exercise than I am, mostly because they have time and they love to move!  I don't want to forego sleep to fit in exercise. No one gave me time for Christmas... but I'm working on finding some free time!

What do you find helps keep your family healthy?