When To See Your PCP?

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

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

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

There are kids who visit urgent cares often, yet never come in for routine care.  It may be years between visits with the primary care provider (PCP).  "PCP" is used broadly here, since the primary care isn't done.  I understand that sometimes it is because kids wake in the middle of the night and the parent wants a quick fix, parents don't want to take off work so go on weekends, or the drugstore with a clinic is on the way home, but this isn't good care on many levels.

I don't always trust an outsider's assessment of certain physical signs.  Studies show parents are much happier with a diagnosis of "ear infection" and a prescription than an accurate assessment of a viral respiratory infection and instructions on home remedies.  Many ear infections are over diagnosed, leading to inappropriate antibiotic use, despite better parental satisfaction.  It benefits a practitioner who will be evaluated with patient/parent surveys to provide a prescription rather than an accurate assessment and instructions.  It also takes less time to write a quick script than to discuss the diagnosis, when to follow up if worsening, what to do to help symptoms, etc. Less work and more satisfaction, sounds good, but...

I don't know if the provider has enough experience with infants/young children to recognize what is really going on. I'm sure some of the people working urgent cares are really good at what they do, but many have little experience when they start working without supervision. They have no one to ask for a second opinion, so even after years of working they haven't developed the same skills as a practitioner working with more experienced providers who are able to help when needed.  Bad habits can be reinforced because they simply have no way to learn better skills.

Quick treatment of some infections that really do need treatment leads to poor immune memory, increasing the reinfection rate.  Strep throat recurrences have been shown to happen more when kids start treatment with less than 2 days of symptoms. There is benefit to waiting!  Strep should be treated within a week to prevent complications, but allowing the body a couple days to fight it off first builds the immune system!  It is okay to wait until office hours for many (if not most) problems. 

Difficulty breathing, dehydration, altered mental status, many injuries, and other things do require emergent care. If your parent alert system is telling you your child needs to be seen, then an ER visit is appropriate.

Keeping a good timeline of infections helps the PCP know when it is time for more intervention, such as ear tubes or prevention medications. If quick fixes are always at another location, we might not recognize the frequency. Even when parents bring kids in with a history of frequent infections we can't make appropriate recommendations because we might not trust the diagnoses.  Parents might not ever be told that their child has asthma that needs a prevention medication, so they simply keep using the quick relief inhaler, which puts the child at risk for serious complications.  Asthmatics who have regularly scheduled asthma visits when they feel well have fewer wheezing episodes requiring emergent visits and admissions.  Improve management of frequent or chronic illnesses by visiting with the primary care provider for illnesses and when your child feels well to optimize medication use, make appropriate referrals, improve safety, and spend overall less time and money.

Recommended routine maintenance is spelled out clearly in a book that comes with every car, yet a maintenance book doesn't come with kids. Yearly exams for those over 3 years (more for infants and toddlers) are recommended at a minimum.  Routine care also means regular visits to check on chronic conditions, such as asthma or obesity.

Preventative Care Guidelines are developed by people smarter than me by reviewing statistics including risk/benefit ratios, cost analysis, and more.  These aren't perfect and are regularly reviewed and often change. Some recommendations are simply not followed because insurance companies don't cover the cost. Pediatricians and many others are fighting for better coverage.  Examples of things recommended at various visits (depending on age):

• height/weight measurements

• blood pressure screenings

• lab screenings (anemia, lead, cholesterol)

• vision and hearing screenings

• development assessments

• mental health screens

• more...    

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

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

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

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

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

Excessive milk can cause anemia? How?

A recent facebook posting recommending limiting milk intake prompted questions from followers about iron deficiency anemia from milk.  Nutrition and iron balance is actually a relatively lengthy discussion, so I will try to explain it here.

Short answer:  Cow's milk has little iron.  When kids drink a lot of milk, they don't eat iron-containing foods in sufficient volumes.  Cow's milk also has big proteins that can cause microscopic bleeding in the gut. The more milk consumed, the more bleeding (though usually still not seen in the stools).

More milk = more blood loss from the gut

                              but less blood produced because less iron in the diet

                                                 = anemia

Iron is used to build healthy red blood cells that carry oxygen throughout our bodies.  Too few red blood cells in the body is called anemia.  Red blood cells are made in our bone marrow and they live for about 3 months.  It is important for the body to continually make new red blood cells as it breaks down and removes old ones.

In general anemia can be caused from several factors:

• too little blood produced (iron deficiency being a major risk for this)
• increased blood loss (ie excessive bleeding)
• increased destruction of blood cells in the body (typically from abnormal blood cells or infection)

Iron deficiency can be due to several factors:

• poor iron absorption due to disease (some studies show milk inhibits iron absorption)
• poor iron in the diet (the most common cause)
• long term slow blood losses (such as heavy monthly periods or GI bleeding)
• increased iron need (such as a growth spurt or pregnancy)

Why does preventing iron deficiency anemia matter? Because the most common symptom of anemia is no symptoms.  It can go unnoticed for quite a while in some kids, yet cause long term problems with growth and development.  Symptoms develop when the anemia becomes more severe and include tiredness, looking pale, irritability, decreased appetite, slowed development, weakness, immune dysfunction, and pica (eating non food substances- such as dirt).

Newborns are designed to drink their mother's milk.  Humans have learned to make formulas that can nourish babies if they aren't able to drink their mother's milk for whatever reason.  Cow's milk, soy milk, and goat's milk are not acceptable for infants due to the nutritional voids they have (not just iron).  After about 1 year of age babies tend to wean from mother's milk and/or formula onto whole milk.  (Newer recommendations allow weaning onto low fat milk--another topic entirely.)  Unfortified non-human milks contain very little iron.  The iron in human milk is better absorbed and iron is supplemented into formula.  If toddlers and children drink too much milk, they fill up on it and don't eat a variety of other food groups that include iron and other important nutrients missing in their milk.

Foods that are good sources of iron:

• meats and poultry (especially organ meats, such as liver)
• lentils, peas, and dried beans
• eggs
• oysters, clams, and fish
• molasses
• peanut butter
• soy
• pumpkin or sesame seeds
• fruits such as prunes, apricots, and raisins
• vegetables such as spinach, kale, broccoli, and other greens
• whole grain fortified breads and cereals

Vitamin C increases iron absorption, so eat foods with iron and Vitamin C at the same meal!