Saturday, March 31, 2012

Pre-participation Sports Exam

We are nearing the time of year we have kids lining up to do sports physicals.  When asked why they are in the office, many simply say: "to get the form signed".  I suspect they do not realize the importance of WHY the form must be signed.  I view the physical as a time to reinforce good habits: eating well, sleeping adequately, exercising, and making overall good choices.  

We review risks that might cause health problems with a sport, such as family history of heart problems or sudden death, as well as a personal history of passing out, chest pain, or concussions.

I have had a handful of patients that knowingly or unknowingly leave out pertinent information on these forms.  My two biggest areas of concern are sudden cardiac death and concussion. With both of these the exam might be normal, but the kids are not safe to play and can be cleared for play medically without the examiner knowing a complete history.

If you do not know a family history, as in the case of adoption, please write that on the form.

Please do not omit a previous concussion or injury.  

Please do not "forget" that you get dizzy with exercise. 

These are important! These questions are often the only clue that there might be a problem, since the physical exam is often NORMAL even with life-threatening conditions.  

My son plays hockey. There has been a great awareness in the hockey community about concussions. His club covered the cost of ImPACT testing for all players before the season started. This involves baseline testing to see what each player can do before a head injury to have a comparison. There is high hopes of this testing allowing better return to play guidelines, but its reliability has been questioned by some experts. 
Did I take my son for testing? You bet!  

Sudden Cardiac Death & Concussion Comments

  • Sudden cardiac death is caused by over 20 different problems but remains overall rare, between 10-25 cases per year of athletes under 30 years old. Another way to look at it:  6-15 SCD per 1,000,000 athletes per year.  If you have a family history of SCD or a sudden death from heart disease under age 50, or if you have ever passed out/blacked out during exercise or get chest pain with activity, you might be at increased risk and a further evaluation should be done. Bring these up at your exam!
  • 90% of SCD occurs during or shortly after exertion or exercise. 
  • Risk of SCD increases around 17-23 years of age, and college athletes have about twice the risk as high school athletes. 
  • Cardiomyopathies (damaged heart muscle), anatomic abnormalities, myocarditis (infection of the heart muscle), and arrhythmias (rhythm changes) can all cause SCD in young athletes. Often the exam is normal and the only clue to a problem is the family history or the personal history of pain or dizziness/passing out with exercise. Talk about these at your exam!
  • Concussions can happen from bumps, falls, or sudden movements of the head. Even mild concussions need to heal completely before resuming any at - risk activity.  Recognizing the risk and stopping play are important. Symptoms of concussion can be found here. Do not return to play if you suspect you have a concussion! It can be fatal or lead to permanent brain injury!
  • Both Kansas and Missouri have relatively new concussion rules. This is important because it involves education of the athletes and their families. We are seeing an increased number of kids with concussions due to the increased awareness. Next step: better prevention and treatment...
  • Kansas has a required form to be completed before sports at the high school level here.  By Kansas law, the physical must be done AFTER May 1st, but BEFORE the season starts, so please plan accordingly.
  • Missouri's form is here
Some quick well visit tips:

  • Yearly well visits are recommended for all children over 3 years of age to review growth, development, safety, nutrition, and more. (They are recommended more frequently prior to that!)
  • Most insurance companies only cover ONE well visit per year after 3 years of age. Sports physicals are not considered separately, so if you need the form signed for your high school athlete, plan ahead.
  • Well visits are a time to catch up on vaccines... please don't tell your child "no shots" will be done. The vaccine schedule changes yearly, and we might need to give vaccines!
  • Visit our website ahead of time to consider questions that should be answered and topics that will be covered.
  • To streamline the visit, bring all forms needed to your appointment pre-filled out.  This really helps, trust me!
  • Register each of your children on our website to get updates and announcements as well as an email reminder before your visit.

Please request an appointment on line or call (913-888-4567- leave a message on line 1 if after hours) to schedule your child's annual check up for the summer. Spots fill quickly!

Monday, March 26, 2012

Toddler Talk

Any parent knows that raising toddlers takes a special kind of patience and can lead to parental exhaustion. There are challenges to all ages, but toddler moments tend to be memorable!  Tantrums can explode and totally change the look of your little angel.

Some kids are mild mannered and people pleasers by nature and are relatively easy to discipline.  Strong willed kids can be among the most challenging, but with proper guidance can grow up to be great leaders.  So how do you guide them?

The basics of discipline are similar regardless of a child's age or temperament.  Consistency among all caregivers is important. Consistency with routines, especially meal times and sleeping, is also very important.  Never underestimate how much damage being tired, sick, or hungry can do to any person's behavior~ especially toddlers!

Praising the positive is a great way to improve the odds that they will want to get that positive attention again.  Catch kids being good.  As they grow and mature, make the stakes higher, but early on praise every small good deed.  
Remember when your rambunctious toddler was a newborn and you were so proud when he simply peed or pooped? Slept 3 hours straight? Very little expectations from a newborn.  As they grow you expect more, but don't expect a toddler to sit still for an hour like you would a school aged child.  Set age appropriate goals and work on a few new behaviors at a time.  Praise when they do a good job with patience or make a good choice to use a quiet voice.  Find the good in things they do throughout the day.  Sometimes it's hard, but you have to find good things to praise!  This does not mean that all is rosy. You must still be firm when they are not being good. Let them know what they did wrong with a short phrase. Set a consequence as appropriate. 
Many parents worry that their child is out of control.  I disagree.  Kids always want control.  Parents simply (ha ha) have to remain in control of the important things and give kids the control they can own.  This enables the parent to be in charge of the important things but allows the child to make decisions about things that won't affect his health or safety, which helps him develop a sense of well being, confidence and decision making capabilities.  

When a parent wants to change a behavior of a child, do NOT show anger.  Raising your voice shows the child that you are losing control and a child feeds on that to elevate the situation to a battle. 

Try to repeat the SAME short phrase of what you want the child to do.  It is very important that you don't say what you DON'T want...give the child clear directions of what you DO want.  If the child argues or ignores, simply repeat the SAME instructions of what you want them to do.  
An example of a clear statement of what you want: 
  • I want you to pick up the bear and put him in the toy box.  
Examples of unclear statements or negative statements include:

  • You made such a mess! Can't this place ever be clean?
  •  Don't leave a mess on the floor.

If your instructions aren't followed the child will get a consequence.  Consequences depend on age.  Toddlers may have to sit on a step, towel or special chair for time out.  Sometimes putting the toys in time out helps... simply put them away for a time if the toy is causing problems, such as kids fighting over it or if it is not put away.

When choosing consequences remember not to take away things that in general HELP behavior (such as outdoor play, which overall releases energy so the child will act better indoors).  The consequences have to mean something to the child or else he won't care if they are taken away. (I've never heard a parent say, "No broccoli for dinner if you don't clean your room!")

The way we tend to phrase consequences is just like that unfortunately:
 no *special treat* if you don't *do desired behavior*
This sounds like a threat and many children (and adults) take it as such.  Rephrasing the sentence to a more positive expression usually gets better results:
you can have *special treat* if you *do desired behavior*

The intention is the same, but the feel of the sentence is much more positive, and people tend to react better to positive statements.

This would sound like, "We will go to the park if you clean your room," instead of "we won't go to the park unless you clean your room."  

The second sentence sounds like a challenge to the child.  Hmmm... how can I get to the park without cleaning my room?  Throw a fit?  Run out the door?  Throw around all my toys?

What if you lose your temper and you see the situation is elevating?  You are yelling, the child is screaming, nothing good is coming from the situation.  How do you get back in control?

Time outs work well.  It gives the toddler a consequence.  The most important part of time out in this situation is not being a consequence, it is the calming effect of time.  
Parents may need the time out as much as the child.  This gives you a chance to collect your thoughts and come up with a game plan of what to say and do.  For more on Time Out, click here.

Another way to turn this out of control situation around is humor.  Many parents think that when a child is in trouble, you shouldn't be "fun", but it can really help.

One night my daughter was throwing a fit about getting dressed.  I started yelling (yes, I'm human and make mistakes too!) but then realized it was (of course) feeding her anger.  She was unable to tell me what was wrong, she was so upset.  I picked up one of her dolls, made the doll "cry", and started talking to the doll to try to see what was wrong.  I said my thoughts out loud..."baby is too little to use words, maybe she is hurt"...moved all the arms and I had my daughter's attention..."no, no hurt spots"...."maybe she has a dirty diaper"... smelled the bottom..."pee yew, dirty diaper"... By now my daughter was laughing instead of crying. ..."I guess babies are too little to use words, that's why she had to cry, I'm so glad you're a big girl and can tell me what's wrong."  Once she was calmed down, things got much easier.  
The trick is thinking of something that helps the situation when you are frustrated.  The best plan is coming up with ideas for your most common arguments before the next argument starts.

  The arguments tend to be the same every day, whether it is brushing teeth, getting into the car seat, putting on sunscreen... whatever it is, you usually have an idea of what it will be.  Think of things ahead of time that you can use to help situations.

Always lead by example.  Children learn what they see, not what they are told.  If you say, "eat your veggies," but never eat your own, they won't like their veggies.  If you make them buckle up, but don't wear your seat belt, they will argue about wearing theirs.

Corporal punishment is not beneficial.  Studies show that kids who are spanked become more aggressive.  If a child bites, don't bite back.  If a child hits, don't hit back.  If you hit as a form of punishment, your child will learn to hit to get her way.

Keeping a routine helps children know what to expect next.  Be sure enough sleep is available because tired children (and adults) are testy.  Same with hungry and sick children.  If you think that a child's bad behavior stems from being tired or hungry, offer a nap or food.

If your child has major behavior problems, choose the few behaviors that bother you most and work on those.  You cannot expect a child to suddenly be perfect.  Reward the small steps toward good behavior.  When a child sees you noticing the good behavior, they often want to please more and give more good behaviors.

Children also like to be in control, so if you offer them choices (with either choice something that is ok with you), they feel in control and are more likely to do what you want.
A choice may be "do you want to get dressed or brush teeth first?"  The child then chooses one of the choices, so she is happy that she chose to brush teeth.  She doesn't realize that you have manipulated her.  If she says "watch TV", you say, "that wasn't a choice, the choices were getting dressed or brushing teeth first."  Give about 10 seconds for her to make a choice.  If she doesn't decide, then you decide for her.  
Kids will be upset if they don't get their un-offered choice, but try to limit discussion and let her think about it.  Most children are smart enough to figure out what to do.  They can learn from it.  If you try to rescue them by letting them chose their own option, they don't learn.  If you try to make sure they know what they did wrong and what they should have done, they get angry and don't learn.  Let them do the learning.  Don't keep harping on them... it will just make them angry and resentful!

Behavior is a challenge to most parents, but with love and guidance, consistency, and proper sleep and nutrition, you can improve the odds that kids will behave.

Sunday, March 11, 2012

Spring Forward... Lose sleep...

As we move our clocks forward to increase the number of daylight hours, we all lose one hour of sleep.  In the whole scheme of things, this isn't much. Most people (kids and adults) lose needed sleep every night.  Only 8% of teens get the recommended amount of sleep.  Eight percent!  No wonder they have increasing rates of so many problems.

Last night I watched "Race to Nowhere" a documentary of the pressures placed on our kids today.  Kids feel pressure to do well in school (many while taking an overload of AP classes), leading to many hours of homework each night.  They participate in sports, which takes up valuable time after school away from homework, but does help them exercise and do something they enjoy (until they burn out and don't like it anymore). They feel the need to do community service and join clubs to build their portfolio to get into a great college.

While I think the film was developed with an agenda and not every kid is suffering from overload, I certainly see enough teens (and preteens) who seem to suffer from sleep deprivation, depression, anxiety, stress, and more.  Are these kids simply not using time efficiently?  Even the documentary showed one of the troubled teens doing homework with her cell phone right there and texting interrupting her thought.
Maybe a quick break after school to play outside for 30 minutes will help release energy and allow the brain focus to study.  Then turn off the tv and put the phone in another room and get to work.  My question: Are these kids spending 6 hours doing 1 hour worth of work?  
Interesting point made in the film though: Studies show that as the amount of homework assigned decreases, test scores increase.

Are we setting our kids up for failure from the beginning? Research shows that kids under 3 years who watch tv have higher incidences of ADHD and aggression along with lower cognitive development.  Kids with ADHD take longer to do tasks because they do not focus and concentrate until the task is complete.  They often need to re-read or re-do work because they miss concepts.  They can suffer from poor self esteem and increased rates of depression because they feel like failures.  In the short video below Dr. Dimitri Christakis explains how researchers are learning about the influences of stimulations (too little and too much) on learning and development.  Take 16 minutes to watch it!

Past growth and development cannot be changed, but we can improve current growth and development.  Maximizing nutrition, healthy exercise, and sleep can help the body and brain be its best.

Kids and teens are staying up too late (sometimes all night) to finish homework.  They are tired during class so take caffeine or other stimulants (such as those used to treat ADHD without a prescription) to stay awake.  They are too tired to focus in class, so they perform below their knowledge on tests.  Between 7-12 years old, kids need 10-11 hours of sleep every night.  Teens need 8-9 hours, sometimes more during rapid growth spurts.

Kids who once enjoyed a favorite sport feel the pressure from coach to train more, but the demands of school put the kids in a quandry: they need to make grades to play, but they don't have time after practice to do the homework.  Often practice and game times are late in the evening, making it hard for kids to fall to sleep at a normal bedtime, since the body needs about 2 hours after exercise to fall to sleep.  I have blogged on this before here.

I see many kids and teens who have chronic headaches or other symptoms that are likely due to sleep deprivation, but they insist it is something else and they want the million dollar workup to find a cause and expensive medications to treat the symptoms.  Once symptoms have started, they might need more treatments, but beginning with healthy nutrition, exercise, and sleep might prevent many of these problems!

The fear of failure and pressure to succeed is leading to kids trying anything to succeed, not just staying up late and drinking too much caffeine.  Cheating in schools, such as copying homework, plagiarizing, or cheating on a test is becoming commonplace. The large majority of high school students admit to cheating.  What does this mean for our future society if kids learn to cheat the system to succeed?

Kids who are chronically sleep deprived are at risk of physically hurting themselves due to slowed reaction times, concentration and focus failures, and difficulty processing information (much like being under the influence of drugs or alcohol).  They are more likely to be injured while playing their sport. Drivers are more likely to be in a car accident.  Drivers 16-24 years of age are the most likely to report falling to sleep at the wheel in the past year according to a study by the AAA Foundation for Traffic Safety.  Also in this study, people who sleep 6-7 hours a night are twice as likely to be in an accident as those sleeping 8 hours or more.  People sleeping less than 5 hours increase their risk 4-5 times!

How can we all wake up rested and still get everything done each day?  What can we cut back on with our families?  There are initiatives to get schools to enforce less homework and to start later, but until then, what can YOU do to help your kids get the sleep they need?

Friday, March 9, 2012


Ski trip from 2011
It's the start of Spring Break, and I'm starting to see pictures from all over on Facebook.  Friends in Colorado.  Friends at the beach.  Friends not home...

Which gets me thinking.

It isn't too hard to conceive that some unscrupulous contact would love to have a new computer, tv, personal safe...

Is it safe to post pictures or updates announcing your home is open for the week?  I know our co-workers and friends know we are going on vacation, but the cyber world is different.  A lot of people see that information.  A lot of people you don't know well.

What if...

Is it safe?

Can your postings wait until you get home?  I'd still love to live vicariously through your photos, but I want you to have a safe trip and a return to an intact home.

Wow!  My shortest blog ever.  EVER!  :-)

Friday, March 2, 2012

Why all the paperwork?

Every doctor's visit involves so many things-- many of which are behind the scenes.  All patients want is good, timely care, but there are other things that are important too.  Much of what our front office and billing staff do is never really noticed by patients.  Yes, they check you in and collect your co pay.  They schedule your follow up appointment.  They make small talk.

You might not realize that between checking in patients they have many other tasks to keep them busy.  One such task is to look ahead to the following week's schedule to check for incomplete information in charts to flag them for the upcoming visit.

We have always required that patients have a current patient information form filled out at least once a year.  (Please complete one sooner if your information has changed.)  This is actually required to comply with many insurance company contracts.  In my opinion it is irresponsible of us to provide care without correct up to date contact information.  We typically ask all new patients to fill out a form and for a new form with each well visit after 1 year of age.  Those who have not had a well visit in the previous 12 months are at the highest risk for having an out of date form due to the complexity of checking patients in and checking their chart for up to date paperwork.  Please keep up with your child's well checks!

While the information doesn't change often and it seems you shouldn't need to fill out another form, it is very important that everyone has an updated form yearly.  It is not uncommon for us to try to reach a patient's family and we have the wrong information.  In recent years many families have dropped their land line,  yet the main contact number we have on file is that number.  This means you miss your appointment reminder call.  We have a hard time calling with lab results.  We cannot reach you in case of an important question or result.  We give referral practices the wrong contact information and they cannot call to schedule your appointment.

I know when you are checking in your baby's crying, your toddler's trying to eat the books, and your oldest kids are fighting, but it is still important that we have your updated patient information.  Too often parents omit parts of the form and we are left with incomplete forms, or they simply never turn them back into the front staff.

This has become such an issue that we are now enforcing that you will not be checked in unless we have a form that has been completely filled in within the past 12 months.  So even if you arrive on time, if it takes you 15 minutes to fill out your form, you will be checked in 15 minutes late.  This might mean you are put behind the person who checks in with a completed form for the next appointment.

This was not an easy decision for us to make because we know that it will cause some backlog in our waiting room, which will make the providers wait to be able to see patients.  That means patients will wait longer to be seen.  The way we have done it for years (allowing parents to finish the forms after the nurse brings the patient to the room) simply isn't working and we need to do something different.

This new policy does not mean you must wait to be checked in.  All you need to do is fill out a form in advance.  They are available on our website.  If you cannot print it at home, come in a few minutes before your appointment and fill yours out if it is due.  We send this link to all patients prior to their well visit if they are registered on our website. (Note: each child must be registered. We do not send Johnny an email if Jenny is the one registered.)  You can easily register by clicking on "Create An Account" on our Home page.  Tips to create an account and add family members (additional children) are available here.

We hope that once everyone becomes accustomed to this procedure the forms will be filled out prior to appointment times so check in can proceed on time and your child will be seen in a timely fashion. Thank you for your patience and understanding and your help completing forms before your visit.