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Play it Safe!

As the Spring sport season approaches, it is a good time to review the importance of playing safe to prevent injuries.  Parents want their children to grow up to be well rounded academically and physically.  A great way to be physically fit is to participate in sports, but often kids do too much too soon or play with an injury- which can lead to worsening the injury and removal from the game.  Unfortunately by 13 years of age many kids leave sports due to feelings of inadequacy or burnout.  They lose the many benefits of athletics, including physical exercise, mental well being, drug abuse prevention, and more.  Most young kids should not play at an elite level.  Not all will be natural athletes, but all can and should participate in life long sports to varying degrees.  Emphasizing having fun while improving performance can help kids feel less pressure to win and be the star athlete, but even the star should emphasize fun at younger ages!

In general there are two types of injuries: acute and overuse.  Overtraining syndrome is a mental as well as physical issue that can lead to decreased performance and sports burnout. Acute injuries are commonly recognized, and include things such as sprained ankle, wrist fracture, or concussion.  Overuse injuries are less often identified and are more difficult to diagnose.  They occur subtly over time from repetitive trauma to the bones, joints, and tendons.  Examples include little league elbow, gymnast wrist, or stress fractures.

Acute Injuries:  Although not all injuries can be prevented, you can decrease the risk of acute injuries  by adhering to the rules of the sport and the sport-specific safety measures recommended.  If injury is suspected, removal from the sport until injury is healed is important to prevent further injury.

Overuse Injuries:  In the child and adolescent, overuse is the cause of up to half of all pediatric sports injuries.  It is bone, muscle or tendon microtrauma caused by repetitive stress without adequate healing time.  It begins with pain after activity, then pain during activity without affecting performance, followed by pain during activity that affects performance, and finally pain even at rest.  Children are at increased risk because of their growing bones and inability to recognize or describe symptoms.



Overtraining Syndrome (“burnout”) is the psychologic, physiologic and hormonal changes that lead to decreased performance.  Symptoms include chronic muscle or joint pain, personality changes, increased heart rate at rest, decreased sports performance, fatigue, lack of enthusiasm, and inability to complete usual routines.  Prevention includes encouraging a variety of sports throughout the year, making workouts interesting and fun and having athletes take 1-2 days off per week, plus 2-3 months off per year for other activities.  Overtraining can lead to burnout in the early years, which can cause a child to end participation in sports altogether, which may cause inactivity and contribute to the obesity epidemic in our country.

In general, injury prevention begins with making sure your child is playing in a safe environment with a knowledgeable coach and well fitted safety gear.  My favorite tips:

• Remember that many coaches are volunteers with little (or no) specific training.  Don't assume the coach knows how to prevent or treat injuries... you should ask what their experience is!  Be sure there are always at least 2 adults around (this is abuse prevention... another topic entirely, but important!) 
• Encourage athletes to take the time to warm up and cool down.  
• Make sure athletes drink plenty of water, especially in warm weather. 
• Be sure they are playing at a level that meets their skills. 
• Let them know that they should enjoy playing for the fun of the game, not to win.  
• Be sure to remind them that you enjoy watching them play ~ not watching them win!  
• Have kids take time off a favorite sport to try something different for a season.  This not only keeps the game fun, but it works different muscle groups and improves overall fitness.  
• I am also a firm believer in sleep for kids of all ages! Sports practices and games can interfere with an appropriate bedtime and adequate sleep, so make sure your child doesn't suffer from sleep deprivation. 

American Academy of Pediatrics Guidelines and Recommendations Include:

• Athletes should take 1-2 days off per week from competitive athletics and competitive practice to allow physical and psychological recovery.
• Athletes should be a member of only one sport per season.
• Athletes should take at least 2-3 months away from a specific sport during the year.  During this time another fun activity can be done to prevent loss of skills or conditioning.
• The focus of participation should be fun, skill acquisition, safety, and sportsmanship.
• Weekly training time, number of repetitions or total distance should not increase by more than 10% per week.
• Watch for possible burnout if the athlete complains of nonspecific muscle or joint problems, fatigue or poor academic performance.  Consider time off at that time to allow physical and psychological recovery.
• Use caution for younger athletes who participate in multiple games during a short time period.
• Children should participate in a sport at a level consistent with their ability and interest.
• Single sport specialization should be avoided before puberty.  Young athletes who participate in different sports at various seasons have less burnout and fewer overuse injuries.
• Parents should be aware of the coach’s knowledge of proper training techniques, equipment and training of a particular age group.  Parents should encourage organizations to mandate coach training in these areas.
• Never allow an injured athlete to participate in activities until completely healed or cleared by a physician.
• Children are more at risk for heat injury.  Proper hydration should be encouraged.  Avoidance of prolonged activity in moderate temperatures or any activity in extreme temperatures should be enforced.  
• Ensure proper nutrition:         

Proper caloric intake is based on body size and growth rate in addition to calories burned.  Monitor for signs that the athlete is trying to lose weight to benefit performance (to the detriment of overall growth).

Balance nutritional elements based on the Food Guide Pyramid.

Adequate iron is needed.  The amount of iron needed in the diet is highest during the growing years and sports may contribute to iron losses.  Athletes need adequate iron to bring oxygen to tissues in the body.

Calcium intake is important for normal bone growth and possibly to help prevent and heal stress fractures.

Resources and References:


PEDIATRICS Vol. 106 No. 1 July 2000, pp. 154-157, AMERICAN ACADEMY OF PEDIATRICS:  “Intensive Training and Sports Specialization in Young Athletes.”  Committee on Sports Medicine and Fitness.


PEDIATRICS Vol. 119 No. 6 June 2007, pp. 1242-1245, “Overuse Injuries, Overtraining and Burnout in Child and Adolescent Athletes.”  Joel S. Brenner, MD, MPH and the Council on Sports Medicine and Fitness.

Stop Sports Injuries

Teen Dating Violence Awareness Month

February is Teen Dating Violence Awareness Month, so it is a great time to learn about this all too common problem.

Teen Dating Violence is a very difficult and complex topic.  Teens might share friends with their abusive partner. Their friends might think the abuser is wonderful, lending to peer pressure to stay together. They typically go to school together, so it is difficult to avoid each other entirely.  Teens might fear trying to leave the relationship safely.  If teens have lived with domestic abuse at home, they might even think the abuse is normal.  The abusive behaviors tend to lower the victim's self esteem, making leaving feel less desirable since they feel no one else will ever care about them and a bad relationship is preferable to being alone.  They often have feelings of love and attachment to the abuser, and hope that behaviors will change.  Online teens can experience cyberbullying even when not with their (ex-) partner. There are often no physical signs, but the emotional scars can last a lifetime. Learning about abuse characteristics can help save someone you love from a dangerous relationship!

Nearly 1 in 10 high school students report being physically hurt by their boyfriend or girlfriend in the previous year.  (CDC 2009 Youth Risk Behavior Survey)

1 in 10 = TEN PERCENT of high school kids in the past year were hit, slapped, or otherwise physically hurt by their date!

The Liz Claiborne Inc.'s Love is Not Abuse 2011 College Dating Violence and Abuse Poll showed that 43% of dating college women have experienced violent and abusive dating behaviors.

That's nearly HALF of college dating women who have been victims!  

I remember as a medical student working ER shifts or in the STD clinic and seeing several college girls come in for suspected sex while drunk (they never called it rape) or after unplanned/undesired sex with a "boyfriend".  They typically just wanted testing for disease, but what they really needed was much more!  They had mixed emotions and were confused about who was at fault.  They had a lot of guilt that really was misplaced (in my opinion).

Though females are more likely to be the victims (1 in 4 women have been assaulted by a partner), 1 in 14 men report being victims.  Regardless of sex, it is likely that abusive relationships are underreported due to the nature of the problem.

We see news stories of abusive relationships but it doesn't always seem real. A new bride murdered.  A teen raped.  A sports figure accused.  Unfortunately we don't even know about most abusive relationships. People suffer silently.  How is a parent to know?  Can a teen see risk factors before becoming involved with a risky personality?

Parents might look for the "type" of teen that they want their child to steer away from, but unfortunately, the abusers are not easily identified.

They typically are very smart, personable, likable people.

They manipulate others.

They gain trust.

They weave deception.


What it might look like: 

The relationship typically starts out well.  A lot of laughs, good times.  If it didn't, people would leave.  Abusers have a power and control cycle that builds over time. They gain a little trust, then test with a little control.

Bit by bit they become more controlling and abusive.  It builds so slowly many people miss the early warning signs and then are so swept by the cycle that it is hard to leave.

Abusers want to know your every move, which at first might even seem flattering, but it is a control tactic. They might chose what you wear or where you go. They monitor your phone calls to see who you talk to.  They isolate you from your friends and even family so you lose your support group.  They put you down so you feel no one else would like you or want you.  They make you feel less of a person and they are "good" to put up with you.

They get jealous (again, flattering on the outset because they "care").  They often apologize for hurting you, but then claim it is your fault that they behave that way. In truth, they blame others for most of their behaviors and only take credit when things make them look good.

What to do?

There are many levels that need to be addressed to prevent and recognize abusive relationships, starting with how we raise our children from infancy and continuing throughout their lives.

Children who are raised in homes with abusive behaviors are much more likely to grow up to be in an abusive relationship.  If your home is not safe make every attempt to make it so.  Stop the cycle!

Abusers often monitor your computer and phone use, so use caution.  

From a safe computer, click here if you are in the KC area.  From a safe phone call 913-262-2868 (phones answered 24/7 confidentially at SafeHome).

We need children to feel loved and secure.  Children who feel unloved might look for love in all the wrong places, trying to please others and end up being taken advantage of.  Love unconditionally!

Kids need defined limits, but an ability to learn and grow into independence with experience.  Being firm and setting boundaries is an important part of being a loving parent.  You are NOT their friend. You don't need to be a friend to be an effective, loving, parent who is well loved and respected.

Kids need help learning to stand up for themselves and to deal with anger and disappointment in a healthy way.  Set an example for this.  Life typically presents many opportunities to model these behavior.  If you have not learned to control your temper, learn.  Ensure enough sleep for everyone at home, as we are all more short tempered when tired. Choose words carefully.  Remain calm.  Of course you can't be a pushover either.  There is a way to stand firm in your position without yelling and losing your temper.  There are many self-help books on this topic and counseling is available.  It is that important!

Kids need to learn to accept responsibility.  Responsibility should grow as kids grow.  They should have appropriate consequences that teach lessons along the way.

Remind teens that they are never to blame if someone forces them to do something sexually they don't want to do. They need to feel open to share this pain with you or another trusted adult so they can get the help and support they need.

Kids need respect.  Do unto others as you would have done unto you. These words of wisdom have passed through the generations, and are needed as much now as they were generations ago.

They should be taught to respect themselves in all they do: eat nutritionally, exercise, get enough sleep, wear helmets, buckle up, stay away from drugs, etc.

They should be taught to respect others: say nice things, don't ask others to do things that might cause them harm, respect their personal space and things, etc.

They should enforce that others treat them with respect. If a friend does not treat them with respect, they can try first to talk with the friend about it if they feel safe doing so. If the friend does not change behaviors, they should leave the friendship. 

How can parents and teens recognize signs of potential abuse?  Use your instincts. If you suspect something is not right, act on your hunch and take action to address issues and leave the relationship early if problem behaviors persist.  Get help from local resources as needed.

Things to watch for with an abusive relationship:

• Relationship moves quickly to "serious"
• Jealousy in the relationship 
• Frequent calls, texts, and other contacts  
• Control issues in the relationship
• Isolation from family and friends
• Mood swings, anxiety, or depression
• Physical signs: bruises, cuts, scrapes, showering immediately when coming home
• Verbal criticisms are overheard: stupid, fat, ugly, no one else would put up with you, etc
• Abused feels guilty and "at fault" and makes excuses for their partner
• Personality changes in the abused
• Drug or alcohol use
• Multiple sexual partners

What are signs of an abusive personality or one who is likely to abuse? Abusers do not look like drug dealing, tattoo covered, pierced people in tattered clothing. They are difficult to recognize on first glance because they tend to be popular, good looking, and personable.  They are often *good at reading people and responding to other's desires, making them seem "perfect" initially.

Traits to watch for in an abuser: 

• One who blames others for all problems
• One who wants to move quickly into a relationship
• One who does not respect personal boundaries
• One who is easily jealous 
• One who is insulting (you're fat, you're stupid, no one else would love you like I do)
• One who has a history of hitting or hurting others
• One who criticizes others
• One who takes little personal responsibility for actions
• One who tries to monopolize your time and life
• One who seems perfect initially (no one's perfect!)
• One who has mood swings or can't manage anger or frustration well
• One who takes big risks and is impulsive
• One who wants to control what you wear, who you are with, and what you do

Where to go for more help:

Be Smart. Be Well

Centers for Disease Control and Prevention

Love Is Not Abuse

National Network to End Domestic Violence

Safe Home

Teen Dating Violence

Recurrent Strep Throat

Rapid Strep testing

Recurrent strep throat is a problem for many families.  Some kids seem to catch strep the minute it enters their classroom or neighborhood.  Their parents recognize the symptoms and bring the child in immediately for diagnosis and treatment so they can get the child back to school in 24 hours (and parents can get back to work).

The problem with this rapid treatment approach is it doesn't allow the child's immune system to rev up against Strep. The antibiotic kills it off, and doesn't leave "memory" of the Strep bacteria. If given a few days, the body's immune system builds fighter cells to kill off the Strep bacteria.  Some of these cells hang around as "memory" cells so that with the next exposure, they round up the troops and kill off the Strep before it becomes a big infection.

It's a matter of short term versus long term solutions.  The short term solution is to quickly treat so everyone can get back to their routine lives, but leaves opportunity for recurrence. The long term solution is to treat symptoms to maintain hydration and comfort for a couple of days and then to treat with antibiotic. This requires more time at home and delays return to school.  Which option is better for your child depends on your current needs and long term goals.

Parents chime in: Knowing the short term/long term issues with rapid treatment of Strep throat, will you take your kid to their doctor or walk in clinic at the first sign of sore throat or wait?

Remembering Vitamins and Medications

Compliance taking a daily medication (or vitamin) can be troublesome for many.  I find myself counseling parents and kids how to remember medicines often.  Here are my favorite tips:

• Use a pill box for pills. They come in various sizes and either single daily dosing or am/pm dosing, depending on your needs.  Pill boxes allow you to: 

1. be sure you have enough for the upcoming week,
2. remember if they were taken today,
3. keep several types of pills for each day together if taking more than one pill.  

• Liquid medicines: Wash the syringe after each use. Empty the dish drain of all contents daily so you find the syringe and remember to use it.  Or put a clean syringe in visible sight where you often look (tape it to the milk jug, in a glass next to the kitchen sink, in a glass near your coffee pot).  Remember the medicine needs to be out of reach from kids... not necessarily the syringe! 
• Refrigerated medicines: Put the medicine on a shelf that is eye-level, right in front. Don't let it get pushed to the back. Return the bottle to the fridge before giving the medicine to lessen the chance you leave it on the counter.  Remind older children that can access the refrigerator that the bottle is off limits!
• Keep medicine next to something you do daily (coffee, toothbrush). *Always keep out of reach of young children.*
• Use a specific glass that is unique that goes from table to dishwasher to table and never is put away.  Every time you empty the dishwasher, put water in the glass and set it on the table for medicine.
• Refill the medicine 1 week before you run out.  This allows you flexibility in case you forget to pick it up. It also allows recognition that there are no refills if that was missed, giving one week to see your doctor.  You can have enough for vacations if you routinely do this, since you can only fill one week earlier than the last fill... plan ahead if travelling!
• Keep tabs on number of refills left. The pharmacist should let you know with each refill how many are left. If there are none, call right then to set your next appointment if you haven't already.
• Set your phone or watch to alarm at the times the medicine is due.  Change the tone to one that is unique to remind you.
• Put a reminder on your calendar to call for refills and/or schedule appointments before the last minute.
• Leave sticky notes around the house or in your bathroom and kitchen if necessary!
• Keep some medication in your purse (or at the school nurse) to take if forgotten in the morning if this might still be a problem.  Remember to not leave your purse in the car or other places the medicine will get too hot or cold.  If the school nurse will keep some, be sure to ask for a nurse's note when getting the prescription.
• If you travel often, it helps to keep an empty pill box in your toiletry bag, so when packing it you see the empty box that needs to be filled.  Or you could put a sticky note in the toiletry bag reminding you to pack them.
• Grab a pen/marker and draw a "calendar" (Mon am/pm, Tues am/pm, ...) on the bottle with space to check off when you've given the medicine each day. 

Regular prescription medications goes hand in hand with regular follow up with your doctor to manage the medication dosing. This is important for many reasons, so I try to give as many refills that will be needed until the next visit.  Ask your doctor how they handle refills before the medicine runs out so there are no delays in treatment.  Remember to schedule your next visit!

• If able, schedule the next visit before you leave the doctor's office.  Bring your calendar to each visit!
• Call as soon as you can to schedule if you don't have your calendar available at the doctor's office or you were unable to schedule for any reason.
• If you notice no more refills on the bottle when picking up your medicine, call that day to schedule an appointment.  The later you wait, the fewer appointment times will be available. Early morning and later in the day fill first!
• If you are filling the prescription at a time that your doctor's office is closed, look for options for them to call you.  Some offer online appointment requests.  You can request appointments from our website at any time day or night. Leave the best numbers for us to call during business hours.  Many offices have a voice mail that allows leaving a message for them to call you to schedule an appointment.

Once habits form, it is easier to remember, but until then be sure to set reminders-- especially if the medication must be taken at a certain time each day or if missed doses can be dangerous.  Learn what to do if you forget a dose by talking with your doctor or pharmacist. Some medicines are fine to skip a dose, others are not so forgiving and must be taken as soon as remembered.  

I hope this helps!  What tricks have you learned to remember your medicines?

Walk In Clinic Etiquette

Cold and flu season always brings more people to the doctor or health clinic.  The pure volume can be overwhelming for any clinic, scheduled or walk in, but the nature of walk in clinics makes the volume unpredictable.   Sometimes no one in walks in, other times several come at once.  Walk in clinics are wonderful for the overall rapidness at which one can be seen, but how can you help streamline the process?

1.  Write down symptoms.  It sounds crazy to write down things since you know your child better than anyone, but if your child is sick you are probably sleep deprived and might forget important details.  Writing things down helps everyone summarize what is going on and get facts straight.  Very often the diagnosis lies in the history, and if the person bringing the child in does not know symptoms well, it is difficult to make a proper diagnosis.

2.  Expect to be seen for one acute problem.  Illnesses typically have more than one symptom, but they are a single illness.  It is appropriate to bring a child in for multiple symptoms, such as cough, fever, and sore throat.  It is not appropriate to bring them in for those issues as well as a wart and headache of 3 months off and on.

The nature of walk in clinics is that they move rapidly.  The number of patients checking in at any given time can be large, so each visit must be quick.  If you need more time with a provider, schedule an appointment.

3.  Do not attempt to get care for a chronic issue.  Chronic issues are always best managed by your Primary Care Provider (PCP).  This does not include sudden changes to a condition, such as wheezing in an asthmatic.  Your child can go to the walk in for the wheezing, but should follow up with the PCP with a scheduled appointment to discuss any changes needed to the daily medication regimen (Action Plan) to prevent further wheezing.  This is especially important if you went to another urgent care or ER for initial treatment so that your doctor knows about the recent exacerbation of a chronic issue.

4.  Do not add additional children to the visit. Many parents bring additional kids to the visit and ask if we can "just take a peek" in their ears. If you want them seen, check them in too.  Again, walk in clinics move quickly and the "quick" peek takes longer because the child is running around the room or fighting the exam.  The quick peek also does not allow for documentation of findings in the medical record, which might be helpful in the future.

5.  Have your insurance card and copayment ready at check in.  Streamline checking in by having everything ready.  It is amazing to me how many people must return to their car for their wallet.

6.  Try to bring only the child who is being seen.  It is difficult to focus on one sick child when another is running around the room, falling off the exam table, or constantly asking questions.  This applies to scheduled as well as walk in visits.  I know this becomes a childcare issue, but it can really help focus on the child being seen.

7. Bring medications your child has recently taken.  Often parents have tried treatments at home, but are not sure what was in the bottle.  Bringing all medications (prescription and over the counter) and supplements helps us advise on correct dosage and use of the medications.

8.  Go to a walk in clinic at your regular doctor's office if available.  I know not all doctor's offices have walk in hours and most are not open all night long, but most walk in type visits are not emergent, they can wait until the next business day.  Treating symptoms with home remedies is quite acceptable for most illnesses for a couple days.  This might even be beneficial to improve the immune system's ability to fight illnesses and to see how the symptoms change over time. Some kids are brought in at the first sign of fever, and look normal on exam, only to develop cough and earache over the next few days. When the symptoms change, so might the exam and treatments!

The benefits to going to your regular doctor's office to see your PCP or another provider with access to your child's medical record are many.  The record has your child's immunization history,  previous drug reactions, any underlying illnesses or frequency of illnesses (as long as you use them exclusively), as well as any other pertinent information.  Primary Care Providers and their staff also know your family and that alone can help!

Some walk in centers limit services or ages of patients.  The provider at the clinic may or may not have adequate training in pediatrics, and they often do not have others around who can help if a problem arises that is out of their comfort zone.   If a baby is crying, the eardrum gets red, but isn't necessarily infected.  A provider without a lot of experience will often err on calling it an ear infection. Giving a prescription for an antibiotic makes parents happy, regardless if it is necessary.  Better satisfaction scores for the clinic.  Faster turn around time since it takes longer to explain how to treat a cold than it does to write a quick script.  Everyone's happy, but antibiotics are overused.   They also do not offer follow up of issues to see if there is improvement.  They do not take phone calls if there is a followup related question.  You must call your PCP, but if we haven't seen the child for the issue, we are unable to give appropriate advice. 

There are gaps in care even at urgent cares where there is a pediatrician or midlevel provider with extensive pediatric training (there is more than one option in this area).  They do not know your child's full medical background and do not update your child's health record in the medical home.  Following in one office allows us to see the chronicity or recurrence risk of an issue.  If your child goes multiple places for every sore throat, the PCP only sees him for well visits and no one recognizes that a tonsillectomy might be beneficial. 

9.  Please don't use walk in clinics to have health forms filled out.  I know it is tempting to get a quick physical just to have the sports form or work physical signed, but this breaks the concept of a medical home.  Your regular doctor doesn't get to see you for a comprehensive visit, reviewing growth, development, safety, immunization status, and more. We lose the opportunity to share what has happened in the past year and continue our relationship.   If the medical home does all the well visits and vaccines, we have up to date records and can update as needed.  Some kids have missed school because vaccines were missed and they can't return until they get them.  Others have gotten extra doses of vaccines because a record of a shot was missing and parents can't remember where they got the vaccine.  We request a well visit yearly (after age 2) within the medical home.  If in need of a well visit, please call the office to schedule!