Allergy Tips

photo source: Shutterstock

It's allergy season! Prevention and treatment is important if you have seasonal allergies so you can enjoy the great outdoors.

Symptoms of Allergies: 

Allergies can impair sleep (leading to all the problems associated with not enough sleep) and can lead to the annoying symptoms of itching, coughing, sneezing, runny nose, and watery eyes. Some kids get a crease across their nose from wiping. Others get purple circles under their eyes called allergic shiners. These symptoms last longer than the typical cold, which usually resolves after 1-3 weeks. Fever is a sign of infection, not allergies. Other than fever, it is very difficult sometimes to decide if it is a virus or allergies until a seasonal pattern really develops. Even then it is possible to get colds during allergy season some years!

Treatments: 

It is best to treat before the symptoms get bad. I registered on (and recommend) Pollen.com for free alerts at the beginning of the season to anticipate the need to treat before symptoms begin. Treatments include medicines and limiting exposure.

Medications:

I don't want kids with outdoor allergies to be afraid to go outside, so taking medicines to keep the symptoms at bay while out can help. Types of medicines:

• Antihistamines work to block histamine in the body. Histamine causes the symptoms of allergies, so an antihistamine can help stop the symptoms. Some people respond well to one antihistamine but not others. In general I prefer the 24 hour antihistamines simply because it is impossible to cover the full day with a medicine that only lasts 4-6 hours. Different antihistamines work better for some than others. Personally loratadine does nothing for me, fexofenadine is okay, but cetirizine is best. I have seen many patients with opposite benefits. You will have to do a trial period of a medicine to see which works best. If they make your child sleepy, giving at bedtime instead of the morning might help. Prescription antihistamines are available, but usually an over the counter type works just as well and is less expensive. 

• Antihistamine and decongestant combinations are available but are not usually recommended by me. Once control of the mucus is achieved, a decongestant isn't needed. 

• Nasal spray antihistamines are available over the counter and as a prescription. An office visit to discuss the value of these for your child and proper use is recommended. 

• Eye drops can help alleviate eye symptoms. They are available both as over the counter allergy drops and prescription allergy eye drops. If over the counter drops fail, make an appointment to discuss if a prescription might help better. Tips to administer eye drops include washing hands before using eye drops, put the drop on the corner of the closed eye (nose side) and then have the child open his eyes to allow the drop to enter the eye. 

• Singulair (Montelukast) works to stop histamine from being released into the body. It helps control both allergies and asthma and is best taken in the evening. It is available only by prescription, so make an appointment to discuss this if your child might benefit.

• Steroids decrease allergic inflammation well. These can include both oral steroids for severe reactions (such as poison ivy on the face or an asthma attack) and inhaled corticosteroids for the nose (or lungs in asthma). These require a prescription, so a visit to your provider is recommended to discuss proper use.

Limiting Exposure:  The longer your airway is exposed to the allergen (pollen, grass, mold, etc) the more inflammation you will have.

• Wash hair, eyelashes, and nose after exposures -- especially before sleep. They all trap allergens and increase the time your body reacts to them. I have found the information and videos on Nasopure.com very helpful to teach kids as young as 2 years to wash their noses. (Note: I have no financial ties to Nasopure... I just love the product and website!)

• Remove clothing and shoes that have pollen on them when entering the house to keep pollen off the couch, beds, and carpet.

• Wash towels and sheets weekly in hot water.  

• Vacuum and dust weekly. Consider cleaning home vents. Consider hard flooring in bedrooms instead of carpeting. 

• Wash stuffed animals and other toys regularly and discourage allergic children from sleeping with them. 

• There are many types of air filters that have varying benefits and costs. For information on air filters see this pdf from the Environmental Protection Agency: Aircleaners. 

• Keep the windows closed. Sorry to those who love the "fresh air" in the house. For those who suffer from allergies, this is just too much exposure!  

• Keep pets out of bedrooms. If you know a family member is allergic to an animal, don't get a new pet of this type! If you already have a loved pet someone in the home is allergic to, consider allergy shots against this type of animal. 

• If itchy eyes are a problem for contact lens wearers, a break from the contacts may help. Talk with your eye doctor if eye symptoms cause problems with your contacts. 

What if all of the above isn't helping?

• Maybe it's really not allergies. 

• Allergies to things other than foods are rare before 2 years of age.

• Viruses can cause very similar symptoms to allergies. 

• Allergy testing is possible by blood or skin prick testing, but can be costly. In most cases I don't find it very helpful for environmental allergens because you can't avoid them entirely and you can always limit exposures as above. I think that tracking seasonal patterns over a few years can identify many of the allergens. You can still treat as needed during this time. Reports of pollen and mold counts are found on Pollen.com. Note also animal exposures and household conditions. Write symptoms and exposures weekly (or daily). It often doesn't take long to see patterns. Testing is important if allergy shots are being considered.   

• Need help tracking allergy symptoms? There's an app for that! Here's one review I found of allergy apps. I don't have any personal experience of any, so please put your favorite in the comments below to help others!

• Wrong medicine or wrong dose. 

• Some people have more severe allergies and need more than one treatment. Allergies tend to worsen as kids get older. Switching types of medication or adding another type of medicine might help. If you need help deciding which medicine(s) are best for your child, an office visit for an exam and discussion of symptoms is advised.

• Some kids outgrow a dose and simply need a higher dose of medicine as they grow. 

• Consider allergy shots (immunotherapy) to desensitize against allergens if symptoms persist despite your best efforts as above. Schedule an appointment to discuss if this is an option for your allergy sufferer.

Generic Concerta Not Working Like the Brand Used To?

Note: there is an update of this post here. It is much easier to follow, since the original post has so many updates.

I used to be a huge fan of generics. They save money, right? They are equivalent to the brand name, right?

That's what I've always been taught and what I teach taught.

I've been jaded by many problems and now disagree with the above.

Generics aren't always cheaper than the brand name.

Some generics are not equivalent to the name brand.

A recent discussion on a psychology/pharmaceutical listserv I follow brought up the issue of generic Methylphenidate HCl not working as well as the brand name Concerta. Several members had some great insight into why this is. The discussion peaked my interest in the issue and I started looking online for information earlier this week.

Ironically today I went to pick up a family member's medicine. We have filled at the same pharmacy previously for generic "Concerta" and have always gotten the equivalent generic. When I looked at the pills in the bottle today, I told the pharmacy tech they weren't OROS (see below). She looked confused. She had no clue what I was talking about.  (Lesson to all: if you have any questions, ask to talk to the pharmacist. Hopefully they will understand the pharmacology better than the tech.)

Generics for Concerta (Methlyphenidate HCl) might have the same active ingredient, but have a completely different time release system, resulting in varying drug peaks in the bloodstream. The original generic for Concerta (from Watson pharmaceuticals) uses a special technology to time-release the active drug. This time release technology is called OROS (osmotic controlled release oral delivery system). There are several other time release methods. The active ingredient may be imbedded in various substances from which the medicine must exit slowly or a gel cap is filled with beads that dissolve at different rates. With the technology used by Concerta, the capsule IS the time release. It doesn't dissolve. The medicine is slowly released through a small hole in one end of the capsule. The pill works like a pump, pulling in water from the intestines, pushing the medicine out of the tube slowly throughout the day. See this photo from Medscape.

from http://www.medscape.org/viewarticle/547415_10

I have recently learned that not all generic formulations of Methylphenidate HCl are using this technology. This alters the time-release nature of the active medicine.  For some people this substitute might be just fine, or even preferable. But if it seems like your medicine isn't lasting long enough, has times that it works well followed by times it doesn't until the next peak, or any other problems -- check your pills!

You can tell the difference by closely looking at the capsules. The OROS capsules are a unique shape, a little more blunted than a standard capsule. If you look really closely at the ends, you will find that one has a "dimple" where there is a small hole covered by a thin layer matching the rest of the capsule. I just happen to have at least one of three dosages:

Photos of the Mallinckrodt brand are now listed under "Updates."

So if any medicine doesn't work like it used to, look closely at the pill itself to see if it is the same as previously. If you don't have any left, ask the pharmacy for the company / maker of the medicines you've filled over the past several months. Let your doctor know if you can't use a substitution so they can specify "Watson brand only."  If the new "brand" works better, be sure to ask for that manufacturer.

Better yet, call ahead and see who the manufacturer is of the generic for Concerta sold at your pharmacy. Watson Pharmaceuticals is the one that makes the OROS system. If they don't use that generic and you plan to shop elsewhere, be sure to let them know why!

Let me know your experiences with generics... See the Updates below if you want to report your experience to the FDA.

Update 4/29/13:

Reporting Adverse Events: A pharmacologist from the listserv I mentioned above suggests that if you have an issue with the duration of action of a different brand of Methylphenidate HCl you should report it to the FDA. This will allow them to review cases and possibly stop the substitution of these non-equivocal products. Click on this link for the MedWatch Report. Thank you SS!

Manufacturer Clarification: Watson Pharmaceuticals is authorized to market Concerta in the US for Ortho McNeill Janssen Pharmaceuticals, the original manufacturer.

Teva markets another type (not OROS) in Canada and Mallinckrodt markets another type (not OROS) in the US.

Update 5/27/13:

Photos of the Mallinckrodt pills (from www.mallinckrodt.com):

As a comparison, the pill shape of the OROS pills (Janssen Pharmaceuticals, McNeil, and Watson all look identical -- from www.goodrx.com):

Update 10/5/13:

I just learned another company is making a generic for Concerta. A patient suddenly found the medicine to be not effective. It looked entirely different, so suspected it was the wrong medication. The pharmacist confirmed that it is another generic for Methylphenidate HCl ER from Kremers Urban Pharmaceuticals. The parent sent me this picture of the 18mg pill and I found the 27mg on the Kremers website:

From http://www.kremersurban.com/products/Product_Details.aspx?ProdName=MetaT&ProdID=62175-311-37

If your pharmacist says he can't order a drug because of a shortage, you can check to see predictions of how long the shortage will last at ASHP.org. Be sure to look closely for the generic name and if it is an extended or immediate release form because it can be confusing.

Update 12/12/13:

Watson Pharmaceuticals will now be called Actavis, so ask for the OROS pill instead of a brand. I think I will do a whole new blog on this topic since there are so many updates since April. Watch for it!

This is a great resource on the difference in authorized vs true generics: An Update on Generic Concerta.

Update 5/1/14:

I'm excited to hear that the FDA has this issue on their watch list. Please read Gina Pera's We Did It! Concerta Generics on FDA Watch List.

Update 11/16/14:

Generics that are non-OROS will no longer be automatically substituted. They will still be available. See ADHD Roller Coaster's blog on the topic for details.

Resources:

The Pre-MMA 180-Day Exclusivity Punt? What Gives? A legal blog explaining how medicines lose their exclusivity and can become generically available, specifically the Concerta dispute.

How To Tell The Difference Between Concerta and Generic Concerta A Canadian ADHD blog provided the picture of how to recognize the difference. Generic formulations have been available in Canada years prior to in the US.

Special thanks to the members of the Child-Pharm listserv!

Screen Free Week April 29-May 5, 2013

For several years now I've been a supporter of Screen Free Week, a time to turn off all screens (television, computers, video games, social media, smart phones) unnecessary for school or work.

As you know, I am a Facebook junkie. I post often and follow many. How can I support Screen Free Week?

Because it is a good reminder. I don't think we should never use screens, but we should learn to limit. Sometimes the best way to cut back is to go cold turkey.

Screens (television, smart phones, computers, movie screens) dominate our lives. I recently saw this picture show up on PreventDisease.com's Facebook page:

I wish I thought it was an exaggeration, but it seems so true.

I have seen a group of teens all dolled up for prom sitting across each other at a restaurant table, all texting instead of talking.

I often see preschool aged kids watch another kid play a handheld video game. I've tried watching someone else play, and I can't even see the screen, so I have no idea why they like to watch each other so much. It is like a drug... they have to watch.

I ask kids what their favorite activities are at their well visits, and a large percentage of the time "play video games" is the top answer. 

Screen Free Week gives us time to reconnect. Turn off all screens not required for work or school. Limit the off-hours work-related screen time. Stop answering texts and emails during family time. Turn it off!

Not sure what to do with all your free time? Check out this list of 101 Screen Free Activities.

Want your kids to get on board? Talk to them about the fun things you can do with them. Have them sign a Pledge Card. Share the cards with their friends or teacher.

Do I realize how hard this is? Yes. See my Screen Free Week Reflections blog for some of the issues I encountered while going screen free in 2011. Despite the logistics of going Screen Free, it is overall a great experience!

Why is this needed?

• Screen time is associated with obesity, loss of sleep, aggression, and attention problems.
• Children are exposed to marketing, negative events, and age-inappropriate themes.
• Preschoolers spend an average of 32 hours a week on a screen. That's almost a full time job! Where's the free play time?
• School aged children average 7.5 hours of screen time a day-- that's over 50 hours a week!
• Screen time cuts into sleep time for many kids and adults. Sleep is one of my big three needs: proper nutrition, daily exercise, and adequate sleep. These should be among the top priorities of every day.
• For more facts and research on screen time, see this pdf from Campaign for a Commercial-Free Childhood.

I challenge you and your family to a Screen Free Week April 29th - May 5th.

Reflect on the changes you made at the end of the week. What new habits can you initiate long term? Hopefully you can keep family time more protected from the screen interruptions. Instead of watching tv with your kids, play a game. Resist answering that text during your child's replay of his school day. Stay off the computer until the kids go to bed. Turn the tv off during meals and keep the television set to age appropriate programming if your kids are in the area. (For ideas on age appropriate television, movies, books and games, check out CommonSenseMedia.)

In the long run the real answer is balance, not complete avoidance. Screen time offers a lot of benefit: relaxation, entertainment, knowledge sharing. But it becomes a problem when it overshadows other things. Small doses are acceptable. Too much of anything isn't good. Find the balance!

Share what changes you made during your week and which ones you think your family can do long term. I'd love to hear from you!


Previous Screen Free blogs:
Why Screen Free
Screen Free Week Reflections

Help! My child has ___ up his nose!

Help! My child has ___ up his nose!

If you've ever said these words, you know how awful it can be to know your little one has something stuck up there but cannot blow it out. The longer it has been there, the more chance there will be secondary complications, such as irritation to the nasal mucosa ("skin" in the nose) or infection.

Sometimes the first sign of  something in the nose is a foul smell to their breath and thick yellow or green discharge from only one side of the nose. This is due to infection from the body's rejection of the object. (Usually a cold or allergies affects both nostrils, right?) These kids should be seen by their doctor (or midlevel provider) for further evaluation and treatment.

Sometimes you are lucky enough to find out about the foreign object soon after it is placed up the nose, before complications arise. But even then, how do you get it out?

Some parents feel most comfortable with a medical professional removing it. That is fine. Come in to our office and we'd be happy to help.

But if you want to try to get it out at home, there is a really good trick I learned from an ER doc friend long ago: blow it out for them. This is something you can try at home or in our office if you're nervous or unsure how to do it. (Never try to reach up there with something to pull it out... you might push it in higher and get it stuck in a turbinate-- see picture below.)

The basic problem is kids who put things up their nose don't usually have the ability to blow hard enough to get it out. If you blow into their mouth you can often force the object out. (Think of CPR, only you don't block the nose to force the air into the lungs- that would be bad!) 

It is important to not block the exit from the other nostril and not to do this if something is up both nostrils. There are those kids... We don't want to force the air into the lungs and cause problems there!

We often put Neo-Synephrine in the nose to shrink the nasal passageways to make it easier for the object to be blown out, especially important if the object has been there awhile and there is mucosal swelling. Be sure to keep your child calm because if they are crying they can suck the object in further. Blow into the mouth with a quick puff of air. This forces air up the back of the throat into the nose. This can be repeated several times if not successful at first. The parent usually ends up with a cheek full of mucus along with the object!

Of course, if this fails, you will need to bring your kiddo in to be evaluated. Sometimes with fancy tools we can remove the object. If it is deep into the nose or into the turbinates, an Ear Nose and Throat specialist might be required.

As always, prevention is the best cure. Keep small things away from kids and when they are working with craft beads, eating corn, playing on a gravel road, or otherwise in the vicinity of small objects, keep an eye on them!

Photos from Shutterstock.

Group Teaching With Physicals

Around the country the idea of group physicals has been gaining momentum. A recent article in Everyday Health "Group Appointments With Doctors: When Three Isn't a Crowd" explains it well. Before you get creeped out thinking of the doctor examining everyone in a big room, everyone still gets a private exam. The benefit is getting more detailed information and sharing questions with others in a similar interest group.

There are so many teaching points to discuss at annual well visits that it is impossible to fit them into a typical 15-20 minute appointment. If you're really interested in the recommendations (and I will admit I fall short on addressing every one of these sundry things at standard visits and still won't be able to fit them all into the group visit) they are found on Bright Futures.

A solution many doctors are finding helpful to cover more topics is to do a group teaching session to review all the nutrition, safety, development, and vaccine information, then break into individual rooms for history taking, vitals, vaccines, and exams. This eliminates the repeated advice and instruction for separate patients, allowing more to be discussed with a group of patients and still allow time for individual exams.

The benefits to patients are many:

• More information shared in a comprehensive manner
• Start on time!
• Individual time with the nurse and physician 
• Potential to learn from others in the same age group (from discussion/questions raised)

Since summer walk in clinic tends to be slow and many teens need physicals before school starts, I think the opportunity is presenting itself to have a Saturday morning session. Although it is hard to know exactly how it would pan out, I expect that the entire time will be about an hour (which is about the same time for a standard well visit, but less time waiting). Some kids would check in before the discussion to have their vitals and exam, others would arrive for the session and have the exam afterwards. This would allow everyone to be there less overall time, with more information shared. This venue does NOT allow time to be devoted to other health issues, such as chronic illnesses and prescription refills. People who wish to discuss a laundry list of things will be asked to return for a separate visit to be able to devote appropriate time to issues. (This applies to standard well visits as well since each topic can be given its own importance at a separate visit.)

If your teen(s) (13-18 years) would like to participate in this pilot project, please call the office to get on a list of interested people. Be sure to let staff know any blackout dates you can't attend. I will assess how many people are interested, available dates, and ages of the interested teens to offer a few dates for appropriate ages. If your teen already has an appointment scheduled, my staff can move them to the group visit easily.  At the end of the session you will be asked to complete a survey about the concept and the work flow of the visit.

If this idea works out, I will add other age groups.  I think newborns would especially benefit, because they could follow with the same group as the kids age, allowing them to form bonds with other families and get support for all the concerns of their age group.

Call the office soon if you're interested!

Waiting times...

No one likes to wait at the doctor's office.

We don't want patients to have to wait.

We want to get home to our families at a decent hour each day.

Thankfully our waiting room doesn't usually fill up as above. (This is a screen shot from our Harlem Shake video.) Since our move to our new location, we have fewer people showing up late ~ amazing what a convenient and open parking lot can do ~ and this has contributed to our being on time more often.

Unfortunately there are always things that can come up unexpectedly in our schedules. We can be running right on time, but one patient is all it takes to fall behind. Please be patient! Remember that if it is your child that needs the extra time, we will take that time. We do respect your time and know that it is important, so our office will also accommodate patients as needed. If one provider is running behind, another will offer to see your child if that will help everyone be seen more quickly.

If it is important to you to have less of a wait time, avoid late morning or late afternoon appointments (more time for us to get caught up in something), and avoid busy Mondays and Fridays, as well as the day before and after holidays.

What makes the wait so long in the first place and what do we do to prevent long waits?

• Sick kids. Most of our “sick” appointments are fairly quick visits, and are scheduled as such. Children who are truly sick and require more time (breathing treatments, stitches, admission to the hospital, sending for x-ray, or watching as they sip fluids over a few hours) back us up. They take extra provider and nursing time and may tie up a room for several hours, limiting the available rooms for other patients. Please understand that this may happen any time, and even an otherwise low patient volume day can be consumed by one sick child. Most importantly, if it is your child, we will spend the required time to adequately treat him/her. If one provider is backed up, we will attempt to have another provider help out.

• “Oh, by the way…” This is a common phrase in any doctor’s office. When you have an appointment for one thing, but bring several concerns, the visit runs long. Scheduling experts recommend putting off all non-urgent and non-related things for future appointments, but we realize that families have limited days off to bring in their children. We try to help by addressing many of the concerns so you do not have to return. Sometimes it is not appropriate to tackle too many issues (none will be covered adequately if too many are attempted) and we will ask that you schedule another appointment. Things that go together, such as cold, cough and earache are easily addressed at one visit. It is not possible to discuss chronic headaches, warts, asthma, and other complaints when a simple "sore throat" appointment was scheduled. This also applies to the list of questions and concerns parents bring to well visits. A well visit is designed to address safety, growth, nutrition, development, and other specific topics. Saving up a year's worth of concerns to discuss at that one appointment is not wise. It does not allow time to devote to each issue appropriately. We ask that you come in for separate visits as needed and not wait to discuss everything at one visit.

• Siblings. Many times each day our providers are asked to “just take a look” at brother or sister. This innocent question seems to only take a few minutes, but these minutes add up by the end of the day. Since we will see all sick children on a same-day basis, please check in each child you want checked or discussed. If you just want to discuss another child without an appointment, call the nurse line or e-mail your provider through our web portal.

• Sometimes we joke that the bus just stopped by. There’s no one in the waiting room, then suddenly the waiting room is full of people. If someone's late to an appointment, someone else right on time, and someone early, then it gets backed up. Please be on time for appointments whenever possible and call if you will be more than a few minutes late. We understand that sometimes there is unexpected traffic or a child pukes during the drive, so we will always attempt to fit people in who missed their appointment time, but realize that it makes others wait. Do not schedule an appointment if you know you will be late. It’s amazing how often we hear, “It always takes so long to get from work to daycare and then to your office.” If it always happens, why not adjust your travel time to be at the office on time?

• We will see your sick child the same day during business hours. It is easy to pre-schedule well visits and follow up appointments, but it is difficult to anticipate how many kids will be sick on any given day. We track visit numbers by time of year, but there is variability. Our providers have more well visit openings in their schedules and fewer sick slots during the summer, but more sick visit openings and fewer well visit appointments during the winter. Call early in the day if you want to schedule with a particular provider. If a schedule is full, we do not "overbook" a provider. 

• Inappropriately scheduled appointments. It is difficult for our schedulers to know exactly how long an appointment will run, but they do attempt to schedule based on the concerns of the caller scheduling. For instance, a sick visit with ear ache, cough, or sore throat is typically well covered in 10-15 minutes, and is scheduled as such. If the child is actually wheezing and in need of breathing treatments, this becomes a long appointment where the provider will need to assess the child several times. Understandably the child needs this attention, but was not scheduled for a long visit, so other patients will end up waiting longer. Please attempt to be clear with your concerns when scheduling to allow proper time allotment for your appointment. 

• Insurance information and other “bookkeeping” issues. Please be ready with all current insurance information as you check in. If you have not filled in a Patient Information Sheet in the past 12 months, you will be asked to provide a new form. Filling this out at home is easier for most parents. You can print out and fill in our Patient Information Form ahead of time if you prefer. For all new patients and existing patients with insurance changes, our receptionists may need to call the insurance company to verify information, so please arrive 10-15 minutes early. Have your co pay ready. Again, it is amazing how many people have to run back to the car because they leave their wallet there. (Never a good idea, by the way... thieves love wallets in cars!)

• Physical forms. Often high school age kids come in for sport and camp physicals without the required form filled in. The form MUST be completed before the provider can sign it. Many of these forms are detailed and take time to fill out. Please fill out your forms before coming to the office. If you do not have a form, click here.

• Behavior. Some parents spend an extraordinary amount of time disciplining their children in our office. Often it is the sibling of the child with the appointment, not even the child being seen. We know that all children are rowdy sometimes, but it makes the visit long if we have to repeat what is said multiple times because the parent was distracted by the child, or if we have to wait for the parent to calm the child down. Bringing only the child(ren) with appointments helps this situation. If a child resists being weighed and measured, it takes the nurse longer to get him ready and the next patient might be ready before you, meaning you might end up waiting longer for the provider. If the child fights an exam (very common between 12 and 36 months) it takes longer to adequately evaluate the child and extends the provider time in the room, making the next patient wait longer. We expect and understand this, but it still adds time to our day, and if we have several of these children in a row, it slows us down. 

• Walk-ins. We offer an urgent care walk-in clinic daily. We staff this based on time of year and expected volume of patients. Obviously without scheduled appointments, this is at best an educated guess. Try arriving before the last 30 minutes of walk-in, as this is the busiest time. It usually has fairly short waiting times and you don't need to spend time calling to schedule then waiting for your appointment. (A benefit to our walk in clinic versus another clinic around town is that we have your child's records and the visit will be added to your child's permanent health record. We know you and your family. By seeing us, you help us keep current in your child's health.)

What can you do to help?

• Try to be on time. If you will be late, please call. Your appointment might only be set for 15 minutes, so arriving just 10 minutes late nearly misses it altogether. It is not possible to shorten the actual visit, so we will now run late for everyone else. We may ask people who are late to see another provider to lessen the disruption to others. 

• Arrive no more than 5 minutes early or warn the staff that you are early. People who arrive early are just as disruptive to a schedule as those who show late. Although you might luck out and show up early when someone else has called that they are running late, but it rarely works that way. Early patients take front office staff and nursing time away from people checking in on time, and may put people scheduled ahead of them back in line. Kids learn early in school "no cuts" and this is the same concept. We attempt to keep track of who is being seen and order them in order of appointments, but some patients show up early and then are upset at the "long" wait time and their kids are out of control in the room from boredom of the extra wait time. 

• Schedule your appointment appropriately. Scheduling for an earache when you really want to discuss the implications of your divorce on your child's behavior is not appropriate. An earache is a short appointment. Chronic conditions, behavior concerns, and well visits are long visits on the schedule.

• Be flexible. If the provider you scheduled with is very busy due to unexpected issues and you are offered to see another provider, please consider this option. If you want to see only the person you scheduled with, remember you will wait longer. If another provider has an opening, you will get more prompt (but still great!) care.

• Avoid scheduling during nap or meal times. Being tired, sick, and hungry makes kids more irritable, can prolong visits due to behavior problems, and makes the visit less valuable due to difficulty holding a conversation, answering questions, and staying on task. (Please avoid giving children snacks in the office. It can be a real problem for others with food allergies.)

• If you must leave by a specific time, let your nurse know. She might suggest seeing another provider if the one you are seeing is delayed.

• Bring only the child scheduled for an appointment if possible. This allows the focus to be on your child that is being seen, and not on the fighting and running around that happens with siblings. Also, there is less exposure to the germs in our office, so you don't make a trip back a few days later with a sick sibling!

• Schedule all children you wish to have seen or discuss.

• Have your insurance card and co payment ready at check in.

• Pre-fill out any forms needed: Camp and Sports forms and our Patient Information Sheet.

• Schedule early in the morning or afternoon - less time for us to get hung up with another patient.

• Bring books or toys (this is a great time for hand held electronics) for your child to stay occupied with during the wait to make it seem shorter for all! 

Feeding Your Newborn

I wrote today's blog as a new web page for our office website, but it works well for here too...

Determining what to feed your baby is a big decision when you become a parent. Regardless of whether babies get breastmilk, formula, or a combination of both, the most important thing to remember is that they need to be hydrated and get the nutrition needed to grow. Many parents are guilted into choosing one feeding over another based on friend's or family's opinions. Some parents have a feeding plan that simply doesn't work. You must choose what works best for you and your baby! Remain flexible if needs change.

Breastfeeding is the ideal way for many babies to be fed. Just a few reasons breast is best: it protects against illness, helps prevent allergies, is inexpensive, and even helps the mother in many ways! The American Academy of Pediatrics recommends breastfeeding for as long as mother and baby mutually desire. We think it is ideal to use exclusive breastmilk for 4-6 months, then add foods with breastmilk until at least 1 year of age.

Ideal does not mean this is the only option. Despite being natural, it is not always easy (or even possible) for mothers to breastfeed. We recognize this and support all parents in feeding their infants a nutritionally sound milk - whether it is formula or breastmilk.

Problems breastfeeding? We have several pages of breastfeeding topics on this link.

Some babies are born with a short frenulum under the tongue. Many people refer to this condition as "tongue-tied" (medically called ankyloglossia). Sometimes affected children may have trouble feeding or later talking. If it is a problem feeding in the newborn period, one of our physicians can clip the frenulum (the part that "ties" the tongue down) and release the tongue so it can move better. We will be happy to discuss and evaluate if you feel your child will benefit from this procedure.

We also have a Nurse Practitioner and nurse available in our office who have additional breastfeeding education (not IBLCE certified) and can coordinate a lactation consultant (IBLCE certified) to visit with you in our office or at your home. Just ask!

Formula has come a long way over the years to becoming more tolerable and nutritious. There are as many reasons parents use formua as there are brands available. There are even several varieties within each brand, making which formula to use a difficult choice for some. We support partially hydrolyzed formula as an initial formula for most babies who will take formula to reduce risks of milk protein sensitization. Soy formulas and lactose free formulas are not generally recommended unless there are specific medical needs. Discussion of why we have these recommendations is found on How to Choose What to Feed. There may also be benefit to whey formulas over casein products. Discuss any formula changes with your provider. We don't want babies to be on a new formula every other day... they don't tend to tolerate that well and it is difficult to determine their response to changes if they are made too frequently.

How much to feed? This common question varies by age and size of your baby. In general the first few feedings are measured in milliliters, regardless if breast or bottle feeding. Too much too soon tends to come back up!

Breastfed babies usually do well on colostrum alone until milk comes in (around day 3-4). They typically feed immediately after birth, but then are sleepy until about 24 hours of age, so might need encouragement to eat. We expect them to lose up to 10% of their birth weight during the first week. We want them to feed at least 8 times per 24 hours, which averages to about every 3 hours. They should wet at least 1 diaper the first day, 2 wet diapers the 2nd day, and 3 diapers the 3rd day. By day 4, milk should be in and they should have wet diapers about every time they eat. Some urine might hide in stool, so if they are feeding well, stooling, and not losing excessive weight, don't worry if they don't seem to be making urine. Most mothers will work with a lactation consultant and their nursery nurse while in the hospital. We watch their weight carefully until weight gain is established. Term babies should be back to birth weight by 2 weeks of age.  

Formula fed infants typically take 10-15 ml with the initial feed. They eat about every 3 hours (range 2-4 hours), and slowly increase the amount of formula to about 30ml (one ounce) per feed over the first days. When they show hunger sooner than their schedule, it means they are ready to increase the volume per feed. Like breastfed babies, we expect them to lose weight the first week, although typically less is lost compared to a breastfed baby. By the end of the first week they take about 60ml (2 ounces) every 3 hours. They should be back to birth weight by their 2nd week birthday. By the end of the first month they take about 24 ounces per 24 hours (average 3 oz every 3 hours).

For more on feeding volumes, see Feeding Your 0-2 Month Old.