Top 10 Posts

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There are many Top 10 lists at the end of the year. Since I've been running low on blog ideas and short on time with the holidays, I thought I'd do my Top 10 blog posts.

What started as a quick project has sent me down memory lane, since most posts are triggered by an event (or series of events) that make me want to write about the topic. I'm adding a bonus #11 because it is one of my favorites and I am feeling nostalgic.

11. Potty Training is one of my most personal blogs, describing my own potty training parent moments. Sorry kids!

10. Walk In Clinic Etiquette was written in part because of my frustration of the many options of urgent cares, some with good treatment, others with less than ideal treatment. It also highlights some of the issues our walk in clinic providers deal with regularly.

9. Fever is... one of the biggest worries of parents. There are so many real fears but also a lot of exaggerated fear. My attempt to set the record straight.

8. Cut the cord... Give them the World! My thoughts on parenting to allow kids to grow to be independent and productive adults.

7. Parenting when you're angry: Keep Cool We've all been there.

6. Oh, what a (sick) season! This is one of my newest posts. Tips on what to do if your family gets what's going around are still pertinent.

5. Itchy Bottom? Is it Pinworms? What to do? We had a number of pinworm calls from worried parents and I wanted to help our phone nurses out since the treatment options are confusing to parents.

4. Got Milk? Cow, Coconut, Soy, or Almond? Questions on milk alternatives are common for kids with dairy allergy or family preference.

3. Ear Wax: Both Good and Bad Ear wax is another common frustration to parents. When to leave it and when (and how) it should be removed are discussed.

2. Car Seat Confusion and Booster Boo Boos I love that this has been so widely read. It is such an important topic. Please share this one!

1. New Guidelines for Treatment of Strep Throat This surprised me as the most read post. I'm glad people are interested in reading things like this. I hope it decreases the demand for unnecessary antibiotics and educates people about why we do some of what we do in medicine.

One final "bonus" blog update. Pediatric Partners joined Team Mighty Maxwell (March for Babies) in support of Dr. Ratliff's son. Max remains at Children's Mercy. He continues to require help breathing with a ventilator but his doctors are trying to slowly decrease the amount of help he needs. He has had surgeries to help reduce pressure in his eyes and is seeming to be happier overall. For more updates, check out his CaringBridge page.

Oh, what a (sick) season!

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This cold and flu season has started early and hit hard! The number of kids we are seeing with severe illness, such as prolonged fevers (over 5 days over 101.5F) and difficulty breathing, are not typical for this time of year. On more than one occasion we have tried to admit a sick child, only to be told there are no available beds. While we are familiar with this in January, this started in November and is more common this month. I feel the need to review a few helpful tips.

What are we seeing right now? A bit of everything. Fever. Vomiting. Diarrhea. Strep throat. Influenza (fever, cough, sore throat, body aches). Bronchiolitis (from RSV and other viruses). Pneumonias. Asthma flare ups. Sore throats from viruses. Whooping cough. Mild colds and coughs. Basically, if you ask if it's going around, chances are the answer right now is "yes".

Wash hands and surfaces! First and foremost is control of spreading infection. You never know when someone is shedding a virus before they feel sick. If you are taking care of sick kids, you are at risk of getting sick along with them. Wash hands and surfaces often. Don't share food and drinks, even with your family! Avoid touching the eyes, nose, and mouth. These are where germs enter to make you sick! When's the last time you cleaned your phones and keyboards?

Fever can be a good thing. We worry in infants under 3 months, those who are immune compromised, or those that are not up to date on vaccines ~ they should always have a medical exam with fevers. If a fever lasts longer than 3-5 days kids should also be seen. For everyone else, we treat symptoms, not the thermometer. If a child is playful at 101F, no need to treat other than pushing fluids and watching carefully. Usually by 102F kids start feeling body aches and feel better with treatment. Watch your child's symptoms, don't worry about the actual degree on the thermometer. Use either acetaminophen or ibuprofen, but most pediatricians don't recommend alternating. Follow dosing charts for weight, and if weight is not known, use age. For dosing charts, see our Medication Dosing page.

Stay home if sick. Again, this is paramount for controlling the spread of all the germs. Don't try to mask symptoms with a fever reducer so you can send kids to school or you can go to work. Stay home and rest!

Never underestimate the power of water. If there is vomiting, an electrolyte drink in small volumes frequently is best. For most colds and coughs, simply drink more water. If there is congestion, runny nose, or cough, add water to the air with a vaporizer or humidifier while you sleep. Even if you have a home humidifier, using an additional one in the bedroom helps. Use saline in the nose. Drops are okay for infants. Older children and adults can learn to flush the nose with saline. Check out Nasopure for tips on learning how to do this and videos to see that it's not as bad as it sounds. (I am not associated with or paid by Nasopure. I just like their product.)

Antibiotics don't make viruses go away any faster. Please don't ask for a prescription if cold and cough symptoms just started within the past 10 days. Unless there is an identified infection requiring antibiotics, they won't help. Even some things we often treat with antibiotics don't need them. Many ear infections and sinus infections are viral and will resolve without antibiotics. At your office visit ask about the need for antibiotics if your child has one of these infections.

We cannot make any diagnosis over the phone. As descriptive as you are on the phone, there is no substitute for examining a child. I encourage people to go to their medical home as often as possible and use other urgent care centers or emergency rooms for true urgent/emergent needs. Going to the same office for sick visits helps to track infection rates to identify kids who might need another treatment, such as ear tubes for frequent ear infections. Even if you get good care elsewhere, it is hard to keep track of dates they were sick and which medicines were used. With most pediatricians open extended hours these days, it is usually possible to be seen by someone you know and trust in a familiar setting.

Some illnesses need multiple visits. I know this is time consuming (and expensive with many insurance plans) but illnesses progress, symptoms change, and exams change. Just because your child was seen a day or two ago and it was "just a cold" doesn't mean it won't progress into an ear infection, pneumonia, or dehydration over time. Unless your child is really sick, you don't need to bring them in at the first sign of a runny nose or fever. Try home therapies first. Coming in early doesn't stop the progression of illness. Preventative antibiotics are not recommended, even if your child has a history of frequent ear infections.

We are in the middle of a whooping cough epidemic. Unfortunately whooping cough can mimic mild colds at the beginning, but the cough can last for several months if not treated in the first couple weeks. A small percentage of people who have been vaccinated still develop whooping cough, though it may be milder it is still contagious. If you child has been exposed to whooping cough and develops any cough, visit your doctor for evaluation and treatment. If your child develops a cough that is followed by a whoop or a cough followed by vomiting, he or she should be evaluated for whooping cough. Be sure kids and all care givers are up to date on vaccine. Typical pertussis vaccine is given at 2, 4, 6, and 12-18 months, 4-6 years, and 11 years. If not given at 11-12 years of age, the Tdap should be given to all teens/adults once. Get vaccinated!

Our influenza season has started earlier than usual and is predicted to be a bad season. Flu vaccines are the best prevention against influenza, so yearly vaccination for all over 6 months of age is recommended. We gave more influenza vaccine than ever in our office this season, but we are out of stock. If your family has not been vaccinated, check with your health department and other locations offering flu vaccines.

If you need information on treating specific illnesses, use our tips on Illnesses and Symptoms, but please see someone at your usual physician's office as well if you are concerned. 

Violence... I think parents can help prevent from home

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I, like most of you, am horrified by the event's of last week's shooting. I have read countless articles in the aftermath about talking with kids, safety in schools, gun control, and even mental health services needing to improve.

I keep wondering if there is something each parent can do at home to help the future.

Violence in the media is constant. It is becoming more graphic and violent. Children do not have the ability to separate fantasy and reality, which makes them more vulnerable to altering behaviors depending on what they are exposed to. Until the last part of our brain matures during adulthood, we have not fully developed self control, emotional regulation, and judgement. So for those of you who think your children or teens are mature, they are still developing important parts of their brain!

If we limit exposure to violence, would it help prevent violence? If children are exposed to less violence at home and in the media, can we cultivate a society of people who can work through conflict in a civil manner?  It's been shown in study after study that violence exposure leads to violent behaviors. What about the opposite? Model positive behaviors and limit negative exposures to encourage healthy development of behaviors.

Research shows that the more violent video games kids play, the more violent they become. Very young children exposed to aggressive acts on television will be more aggressive with their play. There is even long term effects from early exposures. A study showed that men who were high TV violence viewers as children were significantly more likely to be physically aggressive with their spouse and to be convicted of a crime at three times the risk of other men. Women with high TV violence exposures as children were four times as likely as other women to be physically violent.

Parents: you can't "take back" early exposures. Don't wait until you are worried about your child/teen's behavior. Prevent it!

Some limits to violence are more difficult to enforce than others.

If kids live in violent homes, they are vulnerable on many levels. Recognizing these at risk kids and helping their situation improve or remove them from the situation is very difficult. There are free online resources to help (use a safe computer if you are at risk!) Even if you are not in an abusive situation, learn to recognize signs that someone is. You could save a life! SafeHome provides education and assistance for those in need in the Kansas City area.  The Hotline is a nationwide hotline that also has educational information on its website. 

When our children are at other homes, we don't always know the parenting styles or supervision as we do at home. Get to know the parents of your children's friends. Let them know your expectations of what your child can/cannot watch or play. Talk to your children and teens about what they do elsewhere. 

Easier fixes involve the media. (Note: I didn't say easy. I said easier.)

Remove the televisions and other electronics from bedrooms. They cut down on sleep (sleep deprivation adds to poor decision making and behaviors) and allow private, unsupervised viewing. 

Parents should screen what their children watch and play for age appropriateness. I have heard many parents say something to the effect of "He's always been around shows like this, and is not scared. He loves to watch them." Why is he not scared, if his age would typically be scared? Is he already desensitized? That scares me. Check out free on-line reviews from a reputable site, such as Common Sense Media, before deciding if something is appropriate for your child. Choose appropriate times that do not allow younger children to be exposed.

Listen to the music your children and teens enjoy and check out their reviews on Common Sense Media. Many songs promote partner violence, fighting, and sexual violence. Songs have a way of getting into our head. Fill their brains with healthy lyrics, not brainwashing songs that promote any form of dangerous behaviors!

Set maximum times children and teens may have screen time. The American Academy of Pediatrics suggests no more than 10 hours per week for children over 2 years of age. No screen time is recommended for children under 2 years. Remember that screen time includes television, movies, video games, social media, and all other things on a screen. 

Learn the technologies your children are using. If your child or teen is playing online, you need to learn how to set parental controls and monitor what has happened on line.

I am not advocating that families should never enjoy an age- appropriate movie or video game. We actually went to see The Hobbit last night. Although it is PG-13, I read reviews and decided that it was appropriate for my 11 year old. She has a strong sense of reality vs fantasy and was able to sit through the show without being scared at all. (She felt it was "boring" and too long.) It wouldn't be good for all 11 year olds though, and I don't think I would have taken her much younger. Point: parents must know their child, have the facts, and make educated decisions. Don't just say "yes" because it's easy!

And finally, the best parent is an active parent. Participate in activities with your children. Build up their self confidence. Talk to them about what's on their mind. Show them you care. Set limits and stick to them. Give healthy physical contact (hugs, high five, back pat, tickles) often, no matter how old they are, unless it makes them uncomfortable. Tell them you love them. Be their rock.  



Sources:

"Impact of Media Violence Tips." Reviews and Ratings for Family Movies, TV Shows, Websites, Video Games, Books and Music. N.p., n.d. Web. 16 Dec. 2012.

"The Teenage Brain-- Why Do Teenagers Think Differently than Adults?" The Teenage Brain-- Why Do Teenagers Think Differently than Adults? N.p., n.d. Web. 16 Dec. 2012.

"Childhood Exposure To Media Violence Predicts Young Adult Aggressive Behavior, According To A New 15-Year Study." Childhood Exposure To Media Violence Predicts Young Adult Aggressive Behavior, According To A New 15-Year Study. N.p., n.d. Web. 16 Dec. 2012.

"The Impact of Media Violence on Children and Adolescents: Opportunities for Clinical Interventions | American Academy of Child & Adolescent Psychiatry." The Impact of Media Violence on Children and Adolescents: Opportunities for Clinical Interventions | American Academy of Child & Adolescent Psychiatry. N.p., n.d. Web. 16 Dec. 2012.

"Media Violence." Media Violence. N.p., n.d. Web. 16 Dec. 2012.

Stepping outside my comfort zone

Getting ready to start in our party scene!

This past week I was on vacation from my day job to be an active parent.

Sometimes we need that.

I really had to step outside of my comfort zone for this parenting act -- being in the cast of Clara's Dream (a version of The Nutcracker).  Parents often do things we never thought we would for our kids.  We intentionally put our nose to a probably dirty diaper to be sure it needs to be changed. We forego sleep to take care of kids. We take care of their needs before our own routinely.  They change us in many ways for the better.

For years my daughter has loved to perform on stage for theater and dance. She has asked on several occasions for me to audition for "family shows" where they allow parents of students to be in the cast. Each time she has asked, I answered with a firm "No".  I have never acted or danced. I prefer one-on-one conversations, not large groups - and definitely not the stage!

Several months ago she asked and I actually considered it. I had already requested vacation for that week due to show week always getting crazy with time constraints. Rehearsals were later in the evenings, so they wouldn't interfere with work. As I thought about it, I considered the joy of being an active part of her favorite activity and put away my fears of being on stage.  (Of course the fear returned each time we were called backstage to line up for the scene- but it was too late to turn back then!) It was an act of faith because I had never seen the show and knew little about what I was signing up to do.  I figured parents would mostly be "background" people and didn't realize we would learn dance steps and actually be a part of the scene. No, I didn't have to do ballet - just a Victorian ballroom style dance.

It was fun to be a part of my daughter's life in a way that will always have a special memory. Call it working mom guilt, but I want to make special memories in addition to daily quality time.  Quality time is not spent watching tv with kids, but doing things together.  Some things are small, like taking a walk or playing a game. Some things are more memorable because they are unique.

Not only did I get some great times with my daughter, I also met a number of fun people in the process.  Spending so much time with other parents of dancers was a great bonding experience in itself. And I got to know some of the students and teachers my daughter works with on a regular basis at dance classes.  It is always a good idea to know the people that hang out with the kids!

So when your kids ask you to do something and your first thought is "no way", take a moment to think about it. You might just change your mind and grow with your child!

Bow time... my "German son" is blocking me.

To be in your children’s memories tomorrow, you have to be in their lives today.  – Anonymous

Know Your Insurance Formulary

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When kids with a chronic illness (migraines, asthma, ADHD, acne) need a first-time prescription, I often ask the parents to look at their formulary first. This upsets some parents because they want to start something today, but I refuse to play the phone tag game for the next week.

What do I mean?

Most diseases have more than one medication that can be used to treat the condition. Many of these medicines are very expensive, and insurance companies put them in various tiers depending on how much they pay for the medicine.  The more they are contracted to pay, the higher the tier, resulting in a higher copay for the consumer. This varies from company to company, so what someone with a prescription plan from Company A has different costs than someone with a plan from Company B.  Even different plans within company A vary.  High deductible plans add in even more confusion because your cost depends on how much you've already spent.

I saw a formulary for one company recently that the medicine was generic tier for those under 18 years, but over 19 years it needs a prior authorization. Huh? The condition doesn't change with the birthday. The medicine is approved for both age groups. Why they have that prior authorization requirement is a puzzle to me.

I simply can't keep all the plans straight. Ideally electronic records would link to each insurance plan's formulary and let us know immediately how much a prescription will cost, but they don't.  Even pharmacies can't give the cost until they "run it through".  There are simply too many insurance plans.

So if you think you will need a long term prescription for a long term problem, I simply ask that you do your homework first. The insurance company won't tell me what your plan says. You must ask.  When we know the formulary, we can discuss the best option to begin treatment.  When 2 medicines have equal risks and benefits for a condition, we will choose the least expensive. If the lesser expensive options don't work, we may end up on a higher cost medicine. At that point other things have been tried and the cost is more acceptable.

Without the formulary, what tends to happen is I write for Drug A. When the parent goes to the pharmacy to pick it up, it is too much money, so they call use to change. Of course they don't know what to change to, so I change to Drug B.  Same story.  Turns out, it will be Drug E that is the lowest tier. Parents are frustrated with me for not giving the "right" one, but I am blind. Drug A was cheapest on the last plan I wrote a script for. Who knew yours is different?  This leads to too many trips to the pharmacy and phone calls back and forth. Everyone is frustrated and time is lost. It is faster to spend some time in advance finding out what to try first!  Please.

Believe me, this is frustrating for all of us. I wrote about my personal experience with formularies in Health Insurance Woes.  As an update to that, we are now using a mail order pharmacy. It is still much more than our last plan, but better than local pharmacies.

Is an apple a good bedtime treat?

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As parents we try to get as many fruits and vegetables in our kids as they will take, so when Junior asks for a bedtime snack, it is tempting to allow a piece of fruit. Sounds healthy, right?  Surely better than ice cream...

An apple is healthy and can be a great part of a healthy snack, but kids (and adults) shouldn't have a high carbohydrate snack before bed without some protein and / or fat.

Why?

When we eat, our body senses the increase in blood sugar and sends out insulin to store the sugar in cells for future energy. An apple (or other fruit) is high in carbohydrates (sugar) and low in fat and protein. Sugars and can be quickly stored, lowering the blood sugar pretty fast unless there is fat or protein to stabilize it.

Fats and proteins are more complex to digest.  They must first be converted into smaller molecules before insulin can store the food for energy.  This allows a more gradual fall of the blood sugar.

Why is this important at bedtime?

We always have some sugar in our blood, ideally 70-100 mg/dl, but rising after eating and falling when fasting (not eating).  Normal sugar levels give our cells energy for all they need to do. We go for many hours without eating again when we sleep all night. If the insulin level is still high after storing all the easy to store carbohydrates but there aren't more molecules from the breakdown of protein or fat around to start storing, the insulin lowers the normal blood sugar to unsafe levels.  This is especially dangerous at night because one early sign that the blood sugar is too low is tiredness, which is unnoticed when asleep.

Diabetics should be especially aware of this response because their body does not regulate insulin normally, and they can suffer from severe low sugar if too much insulin is given without the proper balance of nutrients.

It would be extremely uncommon for a person with normal sugar management to have serious consequences of low blood sugar (such as coma or seizures) from this apple before bed, but without a good sugar level, the body will not get the most benefits of sleep: restoration of the body and growth in children.

So what's my recommendation for that bedtime snack? Go ahead and give that apple-- with a glass of milk, yogurt, peanut butter, cheese, or other food with protein.

And ice cream isn't all that bad as far as a snack that won't lower blood sugar too much... it just has less nutritional value.  So as a fun treat when kids are eating enough fruits and veggies the rest of the day and have gotten exercise and not an overabundance of empty calories, it's okay to have an ice cream once in awhile.  After all, it's made from milk, so not all bad!

Which reminds me of this great Bill Cosby clip: Chocolate Cake  (Who says we can't have a little fun when talking nutrition?)

Taste a Bite Without a Fight

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Here's another blog inspired by a facebook question:

Megan Brower Lynberg My 2.5 year old son is super picky and I swear he looks at certain foods and decides not to eat them. I know most parents have the try it rule, or just one bite, but we can't even get him to do that most times. Any suggestions on how to implement that? Or should we just let it go and know that for the most part he gets a balanced diet and hopefully he'll branch out as he gets older?

Picky eating is synonymous with most toddlers and school aged kids. I smile inwardly when parents boast that their one year old will eat anything, unlike "other kids" who are picky, as if the other parents did something wrong.

It is between 15 months and 3 years that kids who used to eat anything go through phases of pickiness. I say phases, because sometimes it is a favorite food one week, only to be "yuck" the next week.  I knew this when my kids were young, so I took pictures of my toddlers devouring things like broccoli, so I could show them later that they did, in fact, love it.  (It didn't help.)

Overall the two biggest food groups kids dislike, vegetables and meats, are two of the most nutritious, so parents fret about how to get the nutrition in.  My general advice: parents decide what foods are offered, kids decide how much they eat.

My kids learned "Taste a bite without a fight" at daycare. Why silly rhymes work, I don't know, but sometimes they do.  I usually advise to enforce a bite after 3 years.  Before this age, they might just be too young to fight the battle yet. They simply don't know how to follow rules until about 3. I have heard of parents turning on the tv so the child mindlessly eats what the parent puts in his mouth. Don't do that! It sets up so many bad eating habits!!!

Until the taste a bite rule can be enforced (and even after that) I like to use hidden foods as nutrients. We are having pumpkin french toast this morning-- pumpkin puree added to the eggs/milk. This is not much vegetable, but more than they would get from a bowl of cereal or standard french toast. If this is done with many meals, it all adds up. Find foods your child likes, then "tweak" to fit in needed nutrients.

Vegetables and fruits can easily be pureed and put into sauces, casseroles, smoothies, and ground meats (meatballs, burgers, meatloaf).  Put a can of beets into the blender with your spaghetti sauce for a funky colored sauce. If your kids don't like sauce on noodles, try making pizza with a zucchini/carrot/beet jazzed up sauce. Some people just finely shred or chop. I find that puree works better because they don't see it and pick it out! There are many recipes for this online and in cookbooks for parents.  Check out my Pinterest Meal Ideas page for starters. (Not all ideas are healthy on this page... some are things I just want to try!)

Putting a cheese sauce over vegetables or offering a dunking sauce (yogurt, catsup, ranch dressing) makes it more acceptable to many kids. 

Add fruits and vegetables to breads or noodles. Most kids love the bread group. Banana bread, pumpkin bread, zucchini bread, spinach noodles, and more are all ways to add a little fruit or vegetable into something they will eat. Yes, they will get more sugar this way, but ...

Try a soup or stew. This is a great time of year to throw things in the crock pot in the morning and come home to the smell of dinner already ready!  

If it's meat he doesn't like (most don't at this age) use other forms of protein and iron (eggs, nuts, legumes, etc). Dairy helps with the protein, but has no iron, so don't only use cheese - a common food they love! You can also try meat hidden in casseroles or in fun forms, but remember there are entire countries of people who don't eat meat. Just make sure your kids are getting the nutrition they need.

Play with the food: make the food fun to eat by arranging into shapes. Use a cookie cutter for fun shapes. Arrange food into a face on the plate. There are many ideas of this online! 

Let kids help prepare the meals in an age/ability safe way, starting with washing vegetables, or arranging them on a plate. Start a garden next season so kids can see the food grow! 

A tip from my mother-in-law: kids will eat anything on a stick or fun appetizer sized! Make roll ups with a tortilla, cream cheese, lunch meats, spinach, or whatever sandwich fillings you use and cut into circles. Put a toothpick in small pieces of fruit or jazzed up meatballs (or load up fruit or vegetables on a skewer for a fun kabob).  

Read books that involve foods. I have put some ideas on my Pinterest Books page. Two of my favorites: "I Will Never Not Ever Eat a Tomato" by Lauren Child and "Green Eggs and Ham" by Dr Seuss. Use the books to stimulate ideas-- like making green eggs!

Above all, try to keep meal time pleasant. It should be a time the family gathers to talk, laugh, and enjoy one another. If the focus is a fight about eating, it is not serving one of the big benefits of eating together.  Work the nutrition in, but keep the meal itself fun!

Post suggestions of what has worked for your family. I always love to hear new tricks!  And if your child is really restricted in foods, talk with your doctor.  Sometimes it's more than just picky!