Hair loss in children

Spring is a time I often hear complaints of hair loss. It only took a couple seasons to notice the pattern, both in the office and with my own hairbrush. I have long suspected that it is similar to our pets shedding unneeded hair this time of year, but have never been able to find supporting evidence, at least on a reputable site.

Notice the hair loss pattern.
Photo source: Shutterstock

What I do see reproduced on many sites (mostly hair clinic sites, nothing I would rely on for information) is that both Fall and Spring are a time of normal hair thinning. Studies link hair growth to sun exposure and melatonin levels. I am definitely not a hair expert, but wanted you to know some warning signs of abnormal hair loss and when it is safe to wait it out.

Most of us lose 50-100 head hairs a day. Long hair is obviously more noticeable when lost, since it plugs shower drains, accumulates on brushes, and is seen on our clothing. Simply seeing hair being lost is not a concern.

Hair loss causes

Some causes of hair loss are easily identified. Others are harder to identify because associated symptoms are vague and not always noted to be associated with hair loss. If you are concerned, make an appointment to discuss it with your child's doctor. Since this can be a chronic issue, it is not ideally handled at an urgent care or walk in clinic. If indicated by the findings of their exam, your child's doctor may refer to a dermatologist, endocrinologist, or other specialist, but many of these can be managed by the pediatrician.

• Traction: Braids or other hair styles that pull the hair shafts (as in picture above) can cause hair loss in a pattern easily identified by the hair style. Treatment is simple: stop styling the hair with traction. If continued, damage to the hair follicles might make regrowth impossible.
• Babies often have hair breakage from friction on the back of their head. It usually develops the first few months of life. When they start sitting up most of the day and sleeping on their tummies it regrows. (Note: Do NOT put your baby to sleep on his tummy to prevent this. Tummy sleeping is associated with SIDS.)
• Trichotillomania (or hair pulling disorder) is the compulsive urge to pull out (even sometimes eat) hair. It can be seen in infants and toddlers, but peaks in young school aged kids. Treatment can be difficult and involves behavioral therapy. There is some encouraging research into N-acetylcysteine (NAC) treating trichotillomania and other behaviors. 
• Ringworm of the scalp is a fungal infection that can cause hair to break, leaving the base of the hair in the scalp. The skin can appear red and/or scaly. It can be secondarily infected with bacteria, causing swelling, pain, and drainage. After the diagnosis is confirmed, an oral medication is needed. 
• Malnutrition can cause thinning of the hair, growth problems, behavior problems, muscle wasting, and abdominal swelling. Too little iron and/or protein in the diet can lead to hair loss. Biotin, zinc, and B12 deficiency are specific associations. In this country malnutrition is very uncommon. Treatment involves improving nutrition and addressing any underlying condition causing the malnutrition.
• Too much Vitamin A has been linked to hair loss. If your child takes supplements, be sure to let your doctor know when you are discussing hair loss.
• Hypothyroidism (low thyroid levels) has many symptoms, including thinning of hair. Not all need to be present, and some symptoms can be there without hypothyroidism because they are vague and common issues. Hair may become brittle and break off more easily. Hypothyroidism can cause kids to feel tired and not have much energy. Constipation is a frequent complaint. Heartbeats might slow and kids may feel cold when others are comfortable. Skin is often dry. Kids can slow their growth and may become overweight. Blood tests can help identify hypothyroidism and thyroid hormone replacement can treat it.
• Uncontrolled diabetes can affect hair growth and loss. Working with an endocrine specialist is important to get diabetes under control.
• Polycystic ovarian syndrome (PCOS) can affect hair thickness. Girls with PCOS can have excessive hair growth on their body but male pattern hair loss on the head, acne, obesity, diabetes, heart disease, high blood pressure, and abnormal menstrual cycles. Blood tests along with a history and physical can help identify PCOS. 
• Medications can cause hair loss. The most commonly known type are chemotherapy drugs, but also some acne medicines, anabolic steroids and lithium can cause hair loss. If hair loss is a concern, be sure your doctor knows all the medicines and supplements you give your child.
• Alopecia areata causes patches of hair loss. It is an autoimmune disease --the body's immune system attacks the hair follicles. The patches can be small or cover the entire head (or even body). Skin in the area is normal. See the link above for more information.
• Hair treatments: chemical treatments, such as coloring, straightening, bleaching and curling can lead to hair loss. Heat from a hair dryer, curler, or flat iron can break hairs. Even combing wet hair leads to more breakage because wet hair is more elastic. Limiting these treatments can allow hair to re-grow.
• Severe stress, including that from infection or surgery, can lead to sudden hair loss. Because hair grows slowly, this is seen many weeks to months after the event. It will re-grow, usually within 6 -12 months.

Screen time for under 2 years might be okay? What!!!???

I was initially confused by recent headlines such as this reporting that Dr. Dimitri Christakis now says some interactive time on tablets or computers might be okay at young ages. He is one of the authors of the 2011 American Academy of Pediatrics Guidelines that recommended no screen time under 2 years of age, so this seemed at first contradictory. He has previously been on record affirming that television for children under 3 years is very detrimental for their attention span, stating that it permanently damaged their brains. So naturally my first impression was the news must have the angle wrong.

photo source: Shutterstock

Then I was reminded that when those guidelines were written, the scope of screen time availability was much different. The guidelines relied on research done well before iPads or other tablets were readily available. It was a time of flip phones, not smart phones. We have little information on what interactive screen time does for development since it is such a new concept.

Toddlers in my office are often on their parent's smart phone or other device. They scroll through family pictures. They try to match puzzle pieces. They find the letter or count the objects. They watch a movie. Each of these is very different in what the child is exposed to and what they can potentially gain. There are lists of educational games for 2-4 year olds to teach various skills. I suspect if the under 2 year crowd playing e-games is sanctioned officially by the AAP, lists for that age group will develop too.

We really are in infancy stages of learning what kids of all ages can learn from these devices or all the negatives that could be attributed to them. Of course the types of interactions make a big difference in addition to the total amount of time spent on these activities. As Dr. Christakis explains in this TED talk, some screen time is too action packed and fast moving for healthy brain development, encouraging short attention spans and hyperactivity. Children under 3 years have an especially rapidly developing brain, so they are more sensitive to the interactions they have in real life or on a screen. (He starts talking about television at about 5 minutes into the video but I encourage watching all of it, it is that good.) It is still unclear if television actually causes increased risk of ADHD or if children with ADHD are simply more drawn to action-packed television. Interestingly, educational television programs aren't linked to increased risk of ADHD but action packed and violent shows are. In short, any experience we have during our developmental years changes us, we just don't know exactly how influential television and video games are.

Toddlers who interact with a screen are learning hand-eye coordination and cause and effect. Yes, that can be learned the old fashioned way with exploring their world around them, and I encourage that most of it should be learned from playing with real objects. They need human interaction to learn social skills. Screen time can over-stimulate them if the action is too fast-paced, too loud, done in excess, or done at the wrong time (such as bedtime). Most of us know how addictive screen time can be. We can lose track of time as adults and so can toddlers and kids. If kids get frustrated playing (or refuse to turn it off when asked) they might be getting inappropriate or too much screen time. If this happens, stop all screen time for awhile and slowly re-introduce it after screening the games/ shows to evaluate if they are appropriate for your child's stage of development. Just because an older sibling or friend enjoys a show or game doesn't mean your child is developmentally ready for it.

For most families children using screen time is a given, it's not something parents avoid until at least 2 years of age. Regardless of recommendations to have no screen time under 2 years and only up to 10 hours per week for older children, most kids have much more screen time than that. Parents know that screen time is a great behavior motivator. Parents use screen time as a token to get chores done or to behave well. It can afford a parent time to get a few things done while kids are not running around the house. It is an easy way to keep kids occupied when they must sit quietly for a long period.

We still should use screen time wisely and responsibly. It should be age appropriate. Especially for younger children, it should have a learning goal and should not be too fast paced. A great video from CommonSenseMedia.org, Not All Screens Are Created Equal, discusses quality as well as quantity of screen time. I regularly use that site to pre-screen media my children want to watch or play to be sure it is appropriate for my child. I encourage you to do the same.

Playing learning games on a computer or tablet has the potential to be beneficial for children, as long as it is balanced with active play to allow for plenty of exercise. Remember as parents we must put down our devices too! Kids need our attention. If we are hiding behind our smart phone or tablet, we are not focusing on them like we need to. Set aside time just for family and turn off all the electronics. Model the behaviors you want your kids to do. Help toddlers and kids use screen time wisely and appropriately.

Allergy testing: When to Use It and When to Not

As food allergies have gotten more common, more parents than ever want testing. There are definitely reasons to test, but testing can be expensive, and not all tests are equal. There are also differences between food allergies and food insensitivities. A true allergy occurs when the immune system reacts to something that really is not a threat, but causes measurable symptoms.

Created at http://www.wordle.net

Food allergies are reaction to food proteins because the body's immune system is reacting to something that really shouldn't be a threat. They are different from food insensitivities or intolerances, such as diarrhea and gas from lactose intolerance or red cheeks after eating tomato sauce.

There are three main types of food allergies: immunoglobulin E (IgE)–mediated (immediate) reactions, non–IgE-mediated (delayed) hypersensitivity reactions, and mixed reactions. IgE-mediated reactions are the type we often think about when we hear about a food allergy-- hives, itchy skin, wheezing, vomiting, throat swelling, and anaphylaxis. These reactions can occur immediately following exposure. Non-IgE-mediated allergic reactions can cause localized or generalized reactions, such as a skin rash or stomach upset, or even Celiac disease. Some allergic disorders have components of both IgE and non-IgE mediated types, such as eczema.

Determining if there is a food allergy requires both a history of symptoms with exposure and confirmation testing. In general, there are two different types of allergy testing. Children and adults can be tested by either method, depending on symptoms and other considerations. Both types of testing can lead to false positive results, meaning there is a reaction that makes a person look allergic to that trigger, but they really aren't. That means we have to look at symptoms along with the tests. No one should undergo testing "just to know" if there really aren't specific symptoms to evaluate. This can lead to overestimation of allergies, which can result in patients being on a severely restricted diet and lead to nutritional deficiencies. It also uses healthcare resources inappropriately and drives up healthcare costs.

Available testing:

• The first step is a careful history of exposures and symptoms. This may include a food elimination diet to help diagnose allergies.  
• Skin testing involves scratching a small amount of suspected allergens onto the skin or injecting a small amount of allergen into the skin. It is typically done in an allergist office, though some primary care doctors will offer it. (If you do this type, be sure the doctor has adequate training and does it routinely-- it requires a lot of expertise!) Results are generally known within minutes, based on local reactions to the various allergen areas. It can be uncomfortable for children, but many tolerate it just fine. This type of testing is often less expensive than blood panels. Patients must be off of their allergy medicines for this type of testing, which can be difficult for some severely allergic people. It can also be difficult in people with extensive eczema or other skin conditions. 
• Blood testing involves drawing a sample of blood and running many tests on a single sample. This may be preferred in children who cannot tolerate being off their allergy medicines (they can stay on medicines before testing blood) or in those who will not tolerate multiple skin scratches for the skin testing. It is generally more expensive than the skin testing and results can take a week or so to learn results. Blood tests that are recommended for allergy testing involve testing IgE, one of our immunoglobins that triggers allergy symptoms. There are health care providers who recommend IgG testing for food allergies. These are NOT proven to be of benefit. More on that below.   
• Oral challenges (giving the suspected food to the person and watching for a reaction) is often the best test for food allergies, but obviously can be very risky and should only be done in an experienced doctor's office.

Our website has information on the testing we offer from our office on the Allergy Test Results page. I don't want to duplicate all of that information here.

The driving force to write this post is the number of patients who come to me requesting that I order tests that were recommended by another healthcare provider. I always refuse to order tests that I do not think are indicated or worth while. It is difficult in the space of an office visit to go into all the details of why we don't want to order the labs, but a simple "they aren't recommended" doesn't sit well with families when they have their hopes set on finding answers. Insurance rarely covers non-proven tests, so if you're warned that insurance might not cover testing, that is a red flag that you should investigate further.

What are some of the tests that are not recommended?

There are medical providers who will order IgG panels for food allergies. This is simply not an appropriate test. Both allergic and non-allergic people will have IgG antibodies. They are the normal antibodies used to fight off infections and it is thought that when a food is eaten, the body makes IgG antibodies as a normal response. When food allergic people have been in clinical trials to desensitize their food allergies with immunotherapy, the IgG levels actually go up, despite lessening of clinical symptoms. IgG antibodies show exposure to foods—not allergy. For this reason most people who are tested react to MANY foods and are erroneously told they are allergic to those foods. This severely restricts the foods they are told are safe to eat. I worry that kids will suffer from nutritional deficiencies with such restricted diets. Of course, many of the providers who offer this testing also sell nutritional supplements, so they make money from the "allergies"... Think about it awhile. Do they really care if the test is valid or not? They know the numbers look convincing. They also know the more a person reacts to, the more money is to be made. Maybe they really believe in the tests and their procedures. Maybe they feel it helps. I don't agree and neither do the studies.

Hair analysis is another test that some people will recommend to look for allergies. It simply isn't helpful. At all.

I've had a few patients who have been tested by holding the food while the "specialist" measures arm strength. Supposedly if they are weakened by holding the food they are allergic to it. This is called applied kinesiology and has not been shown to help at all in identifying allergies.

People will take your money. They are usually good sales people. They will claim that labs can't lie and it is based on science. Ask to see the research. Learn to evaluate research first, because sometimes they will show fancy graphs that don't really support anything. But they look impressive. Beware! For some information on how to help learn to be a good judge of whether information is scientifically valid or not, see some of the links below.

Want to learn more? There is a lot of information available!

• More about how blood tests work and why they have false positives: Foodallergy.org 
• More on how skin prick testing works and why they have false positives: Foodallergy.org
• More on IgE testing: ScienceBasedMedicine.org
• More on other unproven diagnostic tests: FoodAllergy.org
• Guidelines for the Diagnosis and Management of Food Allergy in the United States is a comprehensive summary for patients and parents of the guidelines outlining testing for as well as management of allergies. It is important to note that it was published in 2011. (I can't find an update.) The recommendations for influenza vaccine for those with egg allergy has changed since then. It is now recommended to give the influenza vaccine despite an egg allergy. For more information on egg allergy and influenza vaccine, see this update.
• Want to know if what you're reading on the internet is reliable? Take this quick tutorial from the National Library of Medicine. It's free and only takes about 15 minutes!
• Still want to learn more about how to evaluate science? Take a look a the many resources on www.ScienceOrNot.net.

Are you following your doctor's instructions?

Every day doctors assess and treat patients. Most doctors follow standard guideline practices or have good reason to not follow them for any individual patient. Insurance companies are taking it upon themselves to "help" doctors follow these guidelines. They review their records for certain diagnoses to see if proper testing and treatments are used by those patients.

While this can be helpful to nudge doctors who might not follow standard guidelines, it is annoying for those of us who try to. 

It is not uncommon for me to get a letter from an insurance company telling me that my patient is not being cared for properly. Usually it is because a child with a diagnosis of obesity has not had a lipid panel (cholesterol) drawn despite my ordering it months ago (or even multiple times with many reminders). Or a patient with asthma is not on a controller medicine or hasn't had an asthma check in 6 months.

The letter includes something like this (sorry for the poor focus):

picture from actual letter

These letters frustrate me because what am I supposed to do with them? I note it in the chart to discuss at the next visit and often have a nurse call for a parent to schedule a visit or go to the lab or pharmacy to get the tests or medications previously ordered, but typically it doesn't make a difference. Parents still do not follow through with recommendations.

Doctors are graded by insurance companies. We are supposed to follow guidelines to provide appropriate care in a cost -saving manner to the clients of the insurance company. Insurance companies can use the information they have about patient compliance (through coding and billing submitted by the doctor, the lab, the radiology facility, and the pharmacy) with standard guidelines to pay physicians various amounts (i.e. higher payments for "top notch" docs and lower payments for those who don't meet compliance standards) or they might simply stop allowing a doctor to be one of their providers. Remember it doesn't matter if a doctor orders a test or medication, only if those orders are completed. The insurance company only knows about the order if the code is submitted at the time the test is done or the medication is filled. They have no idea if the patient got samples in the office (therefore doesn't need to fill a script) or if the doctor gave a prescription, but the patient can't afford to pick it up or doesn't fill it for any number of other reasons.

Unless you were under a rock or never watch the news, you probably heard about the thousands of doctors recently removed from certain insurance panels. Some of this is probably unrelated to following the guidelines, but it is very possible that your favorite doctor might not be invited to participate in an insurance plan because enough of their patients do not get the recommended tests and treatments. Whether this is due to the physician not following guidelines or patients not following the doctor's recommendations does not matter. If a prescription is unfilled, the insurance company never knows it was written. If you fail complete the autism screen, do the lung function test, or go to the lab to have the labs drawn, the insurance company does not know they were recommended and ordered. If you do not follow up as requested by your doctor, the doctor gets dinged by the insurance company.

Part of the new healthcare laws includes that physicians must show follow up of referrals, completion of labs, and in general follow up on all orders.

Insurance is in a general state of uncertainty at this time. Pediatricians and other physicians around the country are nervous with all of the recent and upcoming changes. No one is certain how we will be paid. I know everyone thinks doctors are rich, but that is often not true and another discussion entirely. The truth is that any business needs an influx of cash to survive.

New high deductible plans mean that we will need to collect payment from patient families instead of the insurance company, which will likely decrease collections and increase the time to collect. This affects the bottom line. In October, a new coding and billing system is due to be implemented. Many experts expect that payments will be delayed by insurance companies for 3-6 months. What business can survive without any income for 3-6 months? New healthcare laws make it possible for patients to appear that they have active insurance, but if they haven't' paid their premium, the insurance company can refuse to pay. If insurance companies grade us on a "lower" quality scale or cut us from their panels, an office will bring in less income. All of these variables will make it more difficult for physician's offices to pay their bills (rent, insurance, staff salaries, purchase supplies, etc). Many private physicians are already selling out to big hospital or other medical systems. With this they lose control over their practice and become employees. I do not want to go that route.

What can you do to help insure that your favorite doctor's office stays in business?

• Schedule and keep appointments as recommended. This includes all routine well visits, follow up visits for chronic illnesses, and rechecks of acute illnesses as recommended. If you don't intend to do the recommended follow up, talk to your doctor about why.
• Know your insurance plan to estimate your medical costs. I know this is very difficult because there is little transparency in medical billing. What a doctor charges, what an insurance company has the doctor's office write off, what insurance pays, and what insurance requires the patient to pay is usually not clear. Believe me, I wish the system was different too, but we must work within the system until it changes. Take the time to ask the doctor's office about charges and call your insurance company ahead of time if there is question about your percentage of that charge.
• Pay bills on time. If you question a bill, call your doctor's billing office for an explanation. If you are unable to pay the full amount, call the billing office to set up a payment plan. Don't simply ignore a bill! It won't go away if you don't address it.
• If you disagree with a recommended lab, test, prescription, referral, or follow up: tell the doctor at that visit! Either we can change the recommendation and document in the chart why we are changing it, or we can discuss with you further why it is important. 
• If you cannot pay for the recommended lab, X-ray, or prescription, tell your doctor. We might have ideas of how to get help.

Bumps, ridges, and soft spots on baby's head

Parents often worry about lumps and bumps on a baby's head unnecessarily. Babies normally have ridges and soft spots on their head for a while after birth. Many have a type of swollen gland that parents can feel when rubbing the head.

All of this is normal.

Let's begin with a brief overview of a baby's head. We are born with many bones in our skull. This allows the head to be squeezed out of the birth canal as the boney plates move together or even overlap one another.

photo source: Shutterstock

Sometimes you don't really notice much with these bones, but other times they still overlap one another noticeably after birth. A baby might have a cone shaped head after birth, but this usually quickly reshapes into a round head over a couple days.

There are 1-2 "soft spots" at birth. Usually the one on top to the head (the anterior fontanelle) remains open enough to feel for the first 18-24 months of life. The one towards the back of the head (the posterior fontanelle) is unable to be felt by about 2 months of age. Many parents fear that touching the soft spot will somehow damage the baby's brain. Normal touching won't hurt, even from a 2 year old sibling. There are several layers of skin and other tissues protecting the brain. Doctors will feel the soft spots during routine check ups to be sure they are the right size for the growth of the baby's head. (There's a lot of variation here, so if you question the size of your baby's soft spot, discuss it at a visit with the doctor. He or she will need to not only feel the soft spot, but also will look at overall head growth, baby's development, and the shape of the head.)

Coming out of the birth canal can be traumatic for both mother and baby (and often for fathers too). Sometimes babies have a big soft or squishy bump on one side of the head, which usually is essentially a large bruise. The two most common causes for this are cephalohematoma and caput saccedaneum. A cephalohematoma develops when there is bleeding between the skull and the bone lining called periosteum. Since it is outside the skull, it doesn't affect the baby's brain. It covers only one of the bones, and never crosses one of the suture lines. A caput is from bleeding one layer above the periosteum in the skin. It can cross the bone areas since it's not limited by the lining of the bone (periosteum).  Both of these conditions can lead to increased risk of yellow jaundice due to breakdown of the blood collections, but usually self resolve without complications. If baby seems uncomfortable due to this area, discuss with your hospital nurse or doctor.

This picture attempts to show the layers of bleeding described here and includes more uncommon (and more concerning) types of bleeding.

photo source: http://en.wikipedia.org/wiki/File:Scalp_hematomas.jpg

Flat spots are common, especially if babies prefer to always look to one side. This can cause the forehead to seem to bulge on one side or an ear to appear closer to the face than the other ear. This is usually due to baby laying one direction most of the time, allowing the brain to grow all directions but spot baby is laying on. It is important to get baby to lay looking right sometimes, left other times. Supervised tummy time is helpful too. (I recommend starting tummy time day one. The earlier you start tummy time the less they seem to hate it!) When you hold and feed baby, alternate arms because they will look toward you and by simply holding in the right arm sometimes, left arm other times, they will turn their head. If your baby resists turning his head, check out this Torticollis information.

One of the most common head worries that brings parents to the office is a pea-sized (or bigger) movable bump on the back of baby's (or even an older child's) head. This is usually an occipital lymph node. When I say it's just a lymph node, some parents automatically worry about lymphoma. Don't go there. Most of us remember having a swollen lymph node (AKA swollen gland) under our jaw or in our neck when we are sick. When they develop on the back of the head, it is usually from something irritating the scalp, like a scalp probe during labor, cradle cap, or bug bites in older kids. They can remain large for quite a while (often seeming to come and go when kids have scalp irritations), but unless they hurt to touch, enlarge rapidly, are red and hot, or a child looks sick otherwise, I don't worry about them.

photo source: Shutterstock

In short, most lumps and bumps on your baby's head are normal. If you're worried, bring your baby in to have your pediatrician look and feel.

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Challenges to remain a financially stable medical practice

I recently posted Top 10 challenges facing physicians in 2014 and was pleasantly surprised to see that it was one of the more clicked-on posts that day. Business Facebook pages allow administrators to see  total reach (yellow), post clicks (blue), likes/shares (pink). (The post with the overall largest was of course a cartoon of the hazards of shopping at Target... cartoons and memes are always popular.)

Why was I pleasantly surprised? Because I want people to know more about insurance issues and our office financial concerns. I don't know if people made it through the entire 10 concerns, so thought I'd summarize them.

Why do I want to spend time blogging about this?

I fear that people presume we will always be there for them, but historically bills often aren't paid by families for various reasons. In the past we at least collected from the insurance company and a smaller percentage was patient responsibility. With the higher number of high deductible plans this year, we are at serious risk of not collecting payments or having delayed collection of payments at a time that our practice is forced to spend significant money on government mandated things. We will be implementing new billing policies soon to help protect the financial stability of our office. I know we will hear complaints because no one wants to think about money when they are worried about the health of their child, but the reality is we need to implement these changes so that we can continue to be around to take care of your children. If I could have a wish granted, I would ask that all money is paid to insurance companies, from the policy charge for the insurance itself (like we pay now, often with the help of our employer) to the money owed to the physician or hospital for services rendered. This would allow doctors and other medical professionals to stay out of the money game. I hate having the money conversations when parents think they shouldn't have to pay something. We submit a bill for services rendered to the insurance company and the insurance company ultimately decides what the patient family owes, based on your contract with them. If we don't then bill you that amount, it is a contract violation on our part. If you don't pay that full amount (that may have already been discounted by your insurance company) you are violating your contract with them. The system is not good because we bill something that is due based on your contract with a third party. It would make sense if they had to collect all the money and they paid all the bills. That is my dream...

But I'm getting off track. I want to summarize the very long article referenced above and point out how it affects our office. You will find that many of their points interlink with each other, which seems redundant, but they are so intertwined, it is hard to separate them out.

1. Payment for medical services. Payment structures are moving more toward an outcome based system. If our patients get quality care and we can prove it with metrics, we will be payed at a higher scale. While in theory this is good, it is really hard for physicians to prove that they do good care. It takes staff time and money to run reports. And we have no ability to make patients follow recommended care. A popular metric to measure is asthma, since it is a common pediatric condition. I get insurance warnings routinely that a patient isn't filling preventative medications on schedule. Sometimes that is because they are using it as told because of overall good control and my desire to use as little medicine as needed for good control, but that is less than the twice/day general recommendation. Unfortunately, sometimes it is because the co pay for the medicine is too much and the family uses it less than needed because they can't afford it.  With new plans that have higher deductibles, I see that more often. I can direct patient families to programs that help with drug costs, but I can't buy their medicine for them. When they end up suffering with more asthma symptoms, they use ER and office visits for sick visits, and then I'm dinged by that same insurance company that set their rates too high for families to afford the best medicine.
2. Government mandates. This year the coding and billing system that has been around for years is completely changing. This means that the computer systems on our end need to be updated and the computer systems on the insurance company end need to be updated. We will be required to use the new system, ICD 10, starting October 1st, but surveys are showing that it is very likely that insurance companies won't be able to accept those codes yet. This will delay processing of all bills submitted. Various experts say that payments may be delayed 3-6 months. How can any business survive if they make no money for that time? Not to mention the conversion costs to our practice. Estimates range from $83,000 to $2.7 million. Our practice is mid-sized, so will probably be somewhere in the middle of that. Where will this money come from? We are fortunate that we started using electronic health records (EHR) many years ago. That was a huge financial cost at the time, but I am glad we don't have to have that added expense now. (I'm not sure if EHRs will directly be required, but they certainly make it easier to meet all the other requirements now mandated.)
3. Payer headaches, and the fine print. Physicians are being dropped from insurance panels at a time when there are more insured patients. This will make access even more difficult. Insurance companies are requiring more prior authorizations than ever for tests and treatments. This takes staff and physician time. That time is not reimbursed by the insurance company. 
4. Time. I love to spend time with my patients, but with all these numbers adding up, I might have to schedule more visits per hour so that I can pay our office bills at the end of the month. This means less time with each patient. I don't know how that can be done and still provide good care, so altering my schedule will be one of the last changes I want to implement. 
5. Technology costs. Many practices starting a new EHR will not be able to see the same patient volume due to the added time documenting in a new charting system. As I mentioned before, I am thankful that we took that plunge and ate those costs years ago. But we still have IT costs on a regular basis and are looking forward to more this year with all the changes, both described elsewhere here and things like Microsoft is no longer supporting the version of Office that we were on, so we have to upgrade. This upgrade is not as simple as it sounds because it alters the way our EHR interacts with it and some of our computers are older and must be replaced to support the new software.
6. Staffing and training. We have been moving up the ladder in Patient-Centered-Medical-Home certification. Several staff members have put in significant time over the last few years building and implementing new practice policies and generating and reviewing reports. Our EHR has not always been able to generate the needed reports, so we had to find a company that could use data from our EHR to build them. Several times that we almost meet a metric, they update the rules, meaning new reports need to be generated. It has been a frustrating process, to say the least. I find that most of the things they want us to prove we were doing already, it's just that proving those things can be difficult. We are fortunate that we have a very low staff turnover rate. I hope all of our employees know how much we appreciate them!!!
7. Putting control back in the hands of physicians. Physicians generally go into healthcare to help others, but with all the stresses described here, many are dissatisfied on the job. Some are leaving patient care and finding other employment. Some still practice, but their dissatisfaction probably impacts the care they give. Many are fearful of all these stressors and leave private practice to be an employed physician. I have friends who used to love their doctor, but now can't get the access they used to have because of the bureaucracy of the new office management. Our local children's hospital has wonderful physicians, but I hear complaints often about the problems with access and other business themes. If these same physicians were self employed, they would be able to control these problems more easily on a smaller scale. As more physicians become employed, I think these problems will magnify.
8. Changing patient populations. More patients are opting for high deductible plans, meaning payment must first come from patients. This means the regular income physicians get from insurance companies won't happen until patients meet their deductibles. Most patients hope to never reach their deductibles. Now we will be relying on patients to pay their bills in a timely fashion. I personally hate talking money with patients. I want to provide the care that is recommended. While I think that having patients invested in their healthcare can make them more informed consumers and has the potential to help them make better healthcare decisions, it can also be a roadblock to good care. There is also the problem that I can't easily tell a parent how much it will cost. We can tell them what we bill, but their insurance will probably discount it. It might be covered in full by the insurance company and not cost the patient a dime. I don't know the patient's insurance payment requirements, and finding out information from the insurance company is difficult. We can provide the code so the parent can call the insurance company and ask, but at the time of service there simply isn't time to spend on hold with the insurance company to find out before the visit is over. Some parents have smartly called us ahead of time to ask what will be billed, but our staff can't know exactly what the physician will order at any visit. They can make best guesses based on the type of visit, such as an 18 month old well visit will have standard physical, vaccines, and autism screening. But if the child is tugging at an ear and there is wax obstructing the ear drum, we will remove the wax and diagnose either ear pain or ear infection plus impacted ear wax. None of that could have been anticipated based on the well visit scheduled. (Adding separate visits to a well visit is another topic entirely, since the well visit is often covered entirely by insurance, but the ear issue would be separate and fall to patient responsibility.) Using asthma again as an example (but it also goes for autism screenings, cholesterol screenings and more): I don't want to skip the spirometry for my asthmatic patient because the parent doesn't want to pay for it. That means I won't meet the metrics for asthma care, which puts me at a lower pay scale because I'm not a "quality" doctor. And more importantly, I'm not doing what I know is best for the patient's asthma management. How can I ethically treat patients with the standard of care I believe in only if they can afford to pay it? Should I lower the standards if they want to cut corners? That is a slippery slope I don't want to travel!
9. Primary care's changing role. Primary care physicians are going to be more accountable for being the central member of the health care team. As part of the Patient Centered Medical Home, we will continue to offer full scale preventative healthcare as well as management of most illnesses. We are also required to follow up to be sure patients got into the specialist we referred them to, or that they did the labs as ordered. We must have easy access for same day visits and extended hours. We must show that we follow practice guidelines. Although my practice already does these things, we must prove that we do, which takes even more uncompensated staff time.
10. Work life balance. This has always been a tricky thing for physicians. We cannot expect to work a 40 hour work week unless we are employed and there are shifts without any call requirements and all charting, follow up phone calls, review of labs, etc can be done while on the clock. Those of us who also own a practice must do business things when we aren't seeing patients. Either we cut our productivity and do business during business hours, or we see patients during business hours and do other business things after hours. This cuts into our family time. But we must be able to pay the bills... This explains the high rate of physician dissatisfaction and burnout. Physicians have a higher suicide rate than the general population-- up to 4 times the general population for male physicians by some estimates. This rate cannot support a healthy healthcare system, and with all the added issues with the 2014 changes, more burnout or sell out is to be expected.

In summary, there are many things that worry me and other physicians about our current healthcare climate. I still love my job, at least the parts where I get to take care of patients to improve their health and well being. I just wish we didn't have to worry about how to keep our office financially viable. Any time money comes into the equation, it can impact healthcare. I hope that all these changes help people take charge of their own health in new ways and that they can find ways to pay for all their healthcare needs. I also hope that all the regulations really do improve healthcare outcomes and help physicians provide better care, not just more documentation of care.

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What should I do after hours when my child is sick?

Parents often fret about whether or not to go to the ER (or urgent care center or walk in clinic) for a child's illness or injury. This week the American Academy of Pediatrics released a position statement against walk in clinics. Many parents don't realize the difference between a pharmacy walk in clinic and an urgent care or ER staffed with pediatric - trained physicians, nurse practitioners, and physician assistants. I believe that urgent needs do arise after office hours, and we are fortunate in our area to have pediatric urgent cares and ERs that can fit that need.

This post is written with my own practice patients in mind. There are variances in what is available in any community and what  a pediatrician is comfortable seeing in the office and what they refer out. Please speak with your own physician about what to do after hours in your situation.

photo source: Shutterstock

I also know that many parents take their kids to walk in clinics for convenience. Sometimes even when our office is open. I think that really fragments the healthcare of the child and I cannot support going outside the medical home when unnecessary. I've blogged about this before. Please visit Urgent Cares for Routine Illnesses... Yes or No for more on that topic.

When to call for after hours advice

Over the years I have found most of my patient families to be very respectful of after hours phone calls. They recognize that I am trying to spend time with my family or that they woke me from sleep. They often apologize for bothering me (which isn't necessary, it is my job). Only on rare occasions do they call for things that should have been called during office hours or in true emergencies where they should call 911. It is a reasonable call if you need help managing the symptoms your child has, especially if you can't find your answer on our searchable website. If you want a diagnosis or prescription, your child will need to be seen and evaluated.

Things to avoid calling the on call provider about:

• To schedule an appointment. We don't do that. Leave a message at the office or request an appointment on our portal.
• To cancel an appointment. Leave a message at the office for the office staff.
• Any billing question. 
• To ask when we open. That information is on our website and our office outgoing voicemail message.
• To discuss a chronic issue that you have been working on with your primary provider -- unless symptoms have worsened and you need treatment advice.
• To discuss treatment from another office, such as a walk in clinic not in our office or a specialist that is managing a chronic illness. If you question something done by another provider, talk first with that provider. If you want to discuss it with your primary physician, call during office hours or send a message through our portal. 
• Prescription refills. It is a very unusual circumstance that we would call out a refill for you.
• A diagnosis and prescription. We cannot make a diagnosis over the phone and cannot prescribe a new medication for something that hasn't been seen.
• Rashes. See below.
• Symptoms that have been ongoing for days but not worsening. If symptoms have been stable for days, it can wait until we are open for your child to be seen.
• Routine growth, development, or behavior questions.
• Routine lab results. Sometimes our nurses call with lab results, but must leave a cryptic message. (Due to HIPAA laws they do not leave specific information on voicemail-- another reason to be sure each of your children are registered on our password protected portal-- we can leave specific details there!). If it is a result that requires notification of the parent urgently, they will tell the on call provider to call you or they will give you instructions to call back (with the knowledge of the on call person). If they say to call back during business hours, the on call person does not have your results on hand.
• To "document" suspected abuse. These kids should always be taken to a place that can see your child directly and has staff specifically trained for that purpose. We usually recommend an emergency room, such as the ones at Children's Mercy campuses. A phone call is hearsay and would not help your case.
• Directions to an urgent care or ER. I don't give good directions, just ask my husband. Call them, look online, or set a GPS.
• Prior authorization before going to the ER or an urgent care. We cannot do PA's after hours and they are not needed for insurance companies.
• To learn if a particular location is covered by your insurance. Call that location or check with your insurance company. We won't know. 
• To ask if an urgent care or walk in clinic provides a particular service, such as possible urinary tract infection in a toddler or stitches. We won't know. Call them for information about what they do.
• Anything that needs to be treated urgently. Calling us delays care. We can be notified later. Just go. 
• And one last request. Please don't call from the ER or urgent care waiting room to ask if it's okay to leave because the wait's too long. If you thought symptoms needed to be seen in the first place, I would never feel comfortable telling you to leave. Ask someone there who can see your child.

How can you find answers if you don't want to call after hours? 

• For our patients, using our online portal allows parents to ask routine questions at any time of day/night, as long as they can wait up to 5 business days for a reply. 
• Our website has a ton of information to treat many symptoms and parents can search there before calling. (Parents will often say, "I looked on the website but didn't find..." so I know they try! Thank you for trying!!! It not only helps the on call provider not be bombarded with another call, but you will often get more thourough advice, especially in the middle of the night.) 
• Online searches can be helpful ONLY if you know the site you are using. Besides our own website, you can use HealthyChildren, KidsHealth, or recognized hospital websites, such as CHOP.

• Remember: We are open 6 days a week and we offer walk in hours all open business hours. This allows you to come in to our office for most illnesses and minor injuries.

For more on how to get the best phone advice when you call our office or after hours on call provider, please read Help Us Help You.

Times to go to the ER or Urgent Care: 

The big question in a parent's mind is when does a child need to be brought to a walk in clinic or emergency room. If in doubt after reading this, call the on call provider for specific advice. Some generalizations to help make the decision:

• Any temperature over 100.5 in a baby under 2-3months of age. (I usually say at least 2 weeks after the 2 month vaccines.) A pediatric specific ER is best for this unless our office is open. (We can do the initial evaluation if we are open.)
• Any temperature over 100.5 in an under-immunized or immune deficient child. Be sure to tell the providers of the medical history that makes your child high risk. We can see these kids when we are open. An ER, ideally pediatric specific, is best for this when we are closed.
• Signs of dehydration. This includes no tears, dry mouth (not just lips), no urine in 6-8 hours. Dehydration can be managed in some urgent cares and all ERs. (Call the urgent care to see if it is within their scope of practice.) Walk in centers are NOT generally equipped to manage dehydration. Our office can see these kids if we are open. 
• A child who is urinating a lot but still seems dehydrated based on dry mouth, weight loss, sunken eyes, etc needs to be seen immediately. This is a sign of diabetes and needs to be seen in an ER if we are closed.
• Signs of respiratory distress. This includes breathing faster than 60 times / minute in children under 1 year, 50 times / minute in older children. This can be treated in our office when we are open, or in a pediatric urgent care or ER. Walk in centers should be avoided due to provider variations in competence with respiratory distress.
• Excessive pain. If you can't control the pain with simple measures, such as acetaminophen or immobilizing a hurt limb, it should be evaluated. ERs are more suitable if it is a possible surgical issue or if imaging will be required.
• Gaping skin. If an injury causes the skin to open enough that it looks better if you pinch it together, it probably needs to be repaired. Stitches, glue, or staples need to be put in as soon as possible because the longer the wound is open the more likely it will become infected and after several hours we can no longer close it up. ERs will always do wound repair. Some urgent cares will. Walk in clinics generally do not. During office hours we can do laceration repair, so you can save the trip to the ER if we're open!
• Altered mental status. If your child is so lethargic he can't lift an arm to drink, or doesn't seem to recognize you, or doesn't make sense when talking he needs to be seen immediately in an ER.
• Parental comfort. This is a vague one, but I am a big believer in the gut feelings of a parent. If you are worried and can't sleep, there might be something going on. Of course, you can't second guess every illness or injury, but if you are so worried you can't sleep: go.
• Call 911 and go to the ER if there is a severe illness or injury that may be life threatening.
• Go to the ER if you suspect your illness or injury might require surgery. 
• If you suspect an x-ray will be needed after an injury, use an ER or urgent care with the ability to do X-rays. During office hours our office can handle minor injuries. If you suspect a broken bone but the child is not in extreme pain, there is no obvious angling of the bone, and the skin is not broken over the area, it may be okay to wait until our office opens.
• A child who loses consciousness after injury or with illness generally should be seen. Call 911 if consciousness does not resolve quickly. (Note: many kids will "pass out" when standing in a hot room or singing, when toddlers cry hard, when kids see blood, or if they hyperventilate due to excitement or pain. They usually awaken quickly from these episodes. If they act normal after this brief passing out time, they can generally be seen in our office. Call for advice.)
• Eye injuries that involve a puncture to the eye, a possible fracture of the bone around the eye, unequal pupil size, bleeding from the eye, vision changes, or other serious concerns should be seen in an ER. (Minor eye injuries, such as a possible scratch to the eye, can be seen in our office or a pediatric urgent care.)
• Seizures should generally be seen in an ER (unless there is a history of seizures and home treatment is available). If your child is running a fever when the seizure starts, call for instructions. It might be appropriate to be seen in our office or a pediatric urgent care.
• Allergic reactions involving hives or facial swelling can be seen in our office when open, an ER or pediatric urgent cares unless difficulty breathing (in which case, call 911 and go to the ER). Even if your child has epinephrine available, they need to be seen after epinephrine is used.
• Severe difficulty breathing should be called to 911 to be taken to the ER.
• Severe headache should be seen in the ER.
• Severe abdominal pain that does not allow the child to move normally should be seen in the ER. This could be a surgical issue.
• If you are unable to drive your child safely for any reason but they need to be seen, call 911.

Typical things seen at urgent cares or walk in clinics are things that usually would be seen in our office when we're open. Many can wait until we're open if you can manage pain, hydration, and breathing at home.

• mild wheezing or difficulty breathing that isn't worsening
• minor burns and injuries
• abdominal pain that is minor without dehydration
• constipation
• pink eye
• ear aches
• sore throat
• vomiting and diarrhea without dehydration (as discussed above)
• fever in children over 3 months of age who are immunized and immune competent
• objects in ears or noses 
• insect bites
• mild allergic reactions
• cough and colds
• skin rashes
• urinary tract infections 
• sports physicals should ideally be done at your primary care office so that growth, development, safety, and other issues can be addressed
• vaccines should ideally be done at your primary care office to keep all records in one place. If your child gets a vaccine elsewhere, be sure to call the PCP office during office hours to update their chart.

A few common concerns that parents call about:

Fever

Parents typically spend a lot of time giving me a play by play of all the temperatures of the past week.  I really don't need to know every up and down of the temperature. What does it really tell me if a child has a fever? They are sick. That's about it. There is no magic temperature that I worry about for most kids over 3 months of age. If your child is younger than 3 months, is not up to date on recommended vaccines, or has an immune deficiency, they need to be seen for any fever over 100.5F. For other kids, I care more how a child looks and acts than the temperature itself. The goal of fever management is to keep a child comfortable and hydrated. The American Academy of Pediatrics recommends treating temperatures over 102F and for comfort. The goal is not to bring the temperature to normal, but to allow your child to feel more comfortable. For more on fevers, see my Fever blog as well as our website's Fever page.

Rashes

Rashes are notoriously difficult to describe. I have a hard time documenting them in the medical record and will sometimes simply take a picture to put it in the child's chart. Even a picture doesn't completely tell the story because it does not show the texture, temperature of the skin, or the evolution over time of the rash. After seeing the rash we need to look for other findings that could be associated with that type of rash (such as enlarged lymph nodes, swollen spleen, swollen tonsils, mouth ulcers, etc). In general a rash needs to be seen to be addressed. Phone calls for rashes (even during office hours) are not helpful. It only needs to be seen emergently if there are significant other concerns. If the rash bothers the parent more than the child, schedule an appointment.

Ear Pain

Earaches generally are not emergencies. If you can control the pain at home with an over the counter fever reducer, you can usually wait until office hours. The exceptions: other symptoms, such as dehydration, difficulty breathing, or Mastoiditis -- If the ear physically sticks out from the head more than normal, it is an emergency. For more on earaches, see our Ear Pain web page.

Vomiting and/or Diarrhea

Stomach bugs are very difficult to manage, but usually can be managed at home. Follow the instructions on our Vomiting and Diarrhea page. Signs of dehydration include: dry inside the mouth, extreme weakness, no tears, and decreased urine (except with vomiting from diabetic ketoacidosis - those kids make a lot of urine but they otherwise look dehydrated). If you think your child is dehydrated, he should be seen. Diarrhea that is bloody, severe abdominal pain, and painful urination with vomiting are other times that being seen as early as possible is warranted.

Sore Throat

Sore throats can be painful, but with good hydration and no signs of difficulty breathing, they can wait until office hours.

Medication dosing

Unfortunately many over the counter medicines don't have dosing listed for infants and young children. We have common medications on our Medication Dosing page. You can also ask the pharmacist when you purchase the medicine. I personally don't like to give dosing amounts over the phone, especially if you wake me from sleep. It would be too easy to give the wrong amount, which could be dangerous for your child. It is safer for you to always learn your child's dose when you buy the medication.

Continued illness despite treatment 

Sometimes parents call because they're frustrated that their child is still sick after a few days. Typically these are Sunday evening calls because the parent wants to get back to work Monday. I can't fix this over the phone. See Evolution of Illness for more on how illnesses evolve over time.