Insurance Confusion. Please read and submit your comments!

I love my job. There are so many things to love, including helping kids get well and watching families grow together. Pediatricians get few instant gratifications, but many overall satisfactions of knowing we make a difference in the lives of children. (Warm heart!)

I knew there would be stresses to my job. All jobs have stress, and I expect things like

• time away from family working on weekends and holidays.
• sleep loss when there are urgencies or emergencies when I'm on call.
• sleep loss when there is a call about a non-urgency. (I do dislike those quite a bit, and yes, they do happen. Please respect our sleep and call during business hours for routine questions.)
• having to give bad news to a family of a very ill child.
• hearing stories of bad social situations and not being able to help immediately.

But one of the biggest stressors for me has nothing to do with the above. It has to do with billing and insurance. I keep thinking that if we educate our parents it will get better, but it doesn't. People who don't know their policy are upset about the charges left to them after the insurance company adjusts the bill and pays their portion.

Source: Shutterstock

During the summer we do a lot more physicals than other times of the year, so the end of the summer through the fall is when the phone call volume really picks up.

• If I knew there would be a charge for the autism screen I wouldn't have done it. Two autistic children recently diagnosed had a delayed diagnosis because parents refused the screen due to cost. Both families said they had no worries so didn't want the screening... so not screening isn't the answer.
• If I knew there would be a charge for the depression screen I wouldn't have let my teen take it. One of these complaints was a parent of a teen with a positive screen. The child was depressed and the parent hadn't suspected it. It is sad that even a positive screening is not worth the cost to a family due to financial circumstances, but every dollar is important for people paying bills. Yes, our health insurance system is broken!
• You should have told me there would be a charge for the ear infection treatment. They usually still want treatment for any sick symptoms. And I did warn them by email and the note posted in the exam room, but they usually say they were too busy to read it.
• I didn't know the lung function test wouldn't be covered by insurance. Neither did I. I don't have your insurance contract.
• I didn't know there would be a charge for ear wax removal. I couldn't see your toddler's eardrum. With that runny nose and poor sleep, it was important to remove the wax to see the eardrum.
• The list goes on...

I think the business of medicine stresses me more than the medicine because it is not what I'm trained to do. We have a business office that handles our billing and collections. I really don't want to get involved in that too much. It is a slippery slope. A big concern of mine is that I don't want to get involved in the billing because I don't want it to alter the way I practice in a negative way. Yes, I need to know the issues so our office can develop procedures to limit costs to families. I do believe that is important. But I don't want to follow medical practice guidelines on a subset of patients who can afford it and not do the recommended care for those who can't. If I do these services only for people who can pay for them (or those who know insurance covers the cost), I am not practicing good medicine for everyone. 

Guidelines are made by committees of well educated people who review all of the data and come up with the best ways to manage various issues. They recommend when we should do things, such as depression screenings, lead screenings, asthma follow up, get an X-ray, use a prescription medicine, and more. If I don't follow those guidelines simply because of cost, I am not providing great care. I only want to provide the best care. 

And if you bring up a concern at a well visit and I remind you that to discuss it might incur a charge to you, am I medically liable for not addressing it when you decide you no longer want to talk about it? It certainly won't get documented in the medical record, which means when you ask about it at a future visit I won't remember you mentioning it before. This can compromise good care because there isn't a good record of symptoms that could have been available if it was properly addressed at the visit. 

Our office really does try to help people with medical insurance issues.

On one hand, we try to limit costs to people. 

• If one drug is usually expensive, we try to order a cheaper option. (But we never know your formulary, they are all different and change often!)
• If I know a referral to a specialist probably won't result in any treatment that I can't offer, I will recommend against it. (If I think the specialist can offer more than me, then I am happy to refer so your child will get the best care. But don't call me when they charged more than you thought they should. Call them.)
• Our office offers extended hours so people don't have to go to the emergency department or urgent care (usually insurance charges you more for those services). 
• I try to talk parents out of vision screening in my office because if their insurance only pays for one per year I want it done by an eye specialist, not me! (See the 2nd scenario for more on this one.)

On the other hand, we try to anticipate and tell people in advance that insurance plans vary, and it is their responsibility to know their plan.

• We have a page dedicated to insurance on our website.
• Each of our well visit pages on our website reminds parents to check insurance.
• Before every well visit all patients registered on our web portal get an email with many important things regarding the upcoming well visit, including insurance issues.
• We have signs posted in each exam room reminding parents that separate issues discussed might incur a separate charge based on insurance.
• I post about insurance issues frequently on our Facebook page.
• I blog about this issue at times. Here. And here. And here. And here. And here. And of course this blog.

Yet the phone calls continue. Parents are upset about the way we charge them for things. This is misleading. Yes, the bill comes from us, but it we are only billing them what their insurance company tells us to.

Health care billing is complicated. We provide a service and apply the standard codes for each thing we do. Each code has a charge attached, based on typical payment for that code. We submit those codes to the insurance company. The insurance company adjusts the payment amounts to what our contract with them states they think are reasonable charges. Some companies allow more payment for one code, less for another. But it's not our choice how much they think is reasonable. We must write off the amount over their reasonable charge cost. The insurance company contracts with its clients to determine how much of each of those reasonable charge costs will be paid by them, and how much is the client's responsibility. We never see those contracts, so we don't know how much you will be billed at the time of service. We send the bill to the family based on what their insurance company tells us. We cannot adjust that amount -- to do so is insurance fraud. Simple as that. I'm not willing to commit fraud to decrease your bill, no matter how much I like you and understand your financial hardship.

Everyone in my office wants to provide good care, so we discuss guidelines and insurance issues in addition to other office policies and procedures on a routine basis. We review our practice for quality. We often hear complaints from staff that they want us to stop doing a recommended screening because they are tired of hearing complaints. But we continue to offer those that continue to be recommended because we care about the health of your child. We want to do what's right, not what's cheap. And I suspect that insurance will become more costly to people as the new plans roll out. Either you will pay a large premium to have more services covered, or you will pay less monthly but be expected to carry more of the load when you use services. 

Request: Please share how you think we can do it better. What are we missing? How can we better educate all of our families without spending the entire visit talking about possible charges instead of your child's health? We can't change the system (though that's the ultimate fix) but I want to know how we can make the system work better for all. 

First Period Q&A with a Tween

Over the years I've talked with many girls about what to expect during puberty. Some of the biggest questions we all have involve the mysterious first period. I have dug into the recesses of my brain to come up with all the questions asked over the years to put all the information down in one place, though I'm sure I've missed a few. (Note: I'm not going to cover the hormones and technicalities of the menstrual cycle. See the links below if you want to review those.)

If you have a daughter starting puberty, please share. Are there any other questions she has? Put them in the comments section and we'll tackle them!

Is there a good way to know when I'll start my period the first time?

You will never know exactly when your period will start, but good clues that it is getting close to time: 

• It's been about 2 years since your breasts started growing. (Remember those first bumps?)

• There's clear, white, or yellow stuff in your underwear sometimes. It can look like dried boogers or just a little crusty stuff in your underwear, but it's not from being unclean or peeing in your pants. Your body is just getting ready for the full cycle of ovulation (when the egg is released) and the period. Your vagina is moistened with a clear fluid that can drain onto your underwear. Another thing you might notice is mucus is released once a month, about half way between your periods when the egg is released from your ovary once you're on a regular monthly cycle. It often begins before the period starts. As long as there is no pain or funny odor, this discharge is normal. Talk to your doctor if it does smell bad or if you hurt or itch in that area.

• Pimples. Pimples are common with puberty (and for years following).  Many girls will notice that the pimples tend to worsen right before their period starts.

I'm too young for a period. None of my friends even have boobs! Can I stop it?

Puberty has such a wide range of normal ages so it is common for one girl to go things much sooner than her friends. Puberty is most common between 9 and 16 years of age (though some girls notice breast buds as early as 7 or 8 years old). The common age for a period to start is between 10-15 years old. If you are outside of this normal age range, talk to your doctor about it because there are many reasons. Some can be as simple as your family tree (when did your mom or sisters start?) but some can be a medical issue that can and should be treated.

And the opposite issue:  All my friends have had their periods for a long time, but I barely have boobs. When will I start?

Again, there is a wide range of normal (see the question above). Some families have a later puberty than others, so it might just be in your genes. There are other reasons that deserve talking with your doctor about, such as being underweight-- which delays puberty, and other medical issues that need an investigation to uncover a cause that might need to be treated. (That sounds like a mystery book, but your doctor will know what to do!)

Bottom line for early or late puberty: 

If you are outside the normal age range, please talk with your doctor. Don't be embarrassed to bring it up! They might either reassure you that things are still okay, or they might help find the reason and get your body the treatment it needs. Some of these can be serious problems, so don't be shy about going to the doctor. This is one reason that a yearly physical exam is especially important until growth is complete -- your doctor can help keep track of a normal growth progression.

How much blood will there be, and what does it feel like?

The amount of bleeding varies from day to day, month to month, and person to person.  It is common for the first 2 years to have irregular cycles, but many girls can begin to predict their blood flow volume pattern after a few cycles. 

Many girls have some pain during their period. The blood flow does not hurt, but as the uterus contracts it can cramp. Like other muscle cramps, there can be pain from period cramps, but the amount of pain varies in different people. Some girls have cramping with every period while others never feel anything. It is easy to take over-the-counter pain relievers (like ibuprofen or naproxen) to relieve pain. Some girls find it helpful to take ibuprofen or naproxen 2-3 times/day (per package directions) starting 3 days before the period is supposed to start to prevent the cramps. Eating healthy foods, getting regular exercise, and sleeping well every night also seem to help. For severe period cramps that keep you from doing what you want (or need) to do, talk to your doctor.

What do I do if I start my first period and I don't have any pads around or I'm not at home?

First, don't panic! Remember that ALL women have periods, so it is nothing weird to adult women (or men, for that matter, since they live in a world with women). Ask a teacher, school nurse, friend's mom, aunt, or whoever is around for help. She will not judge you or get freaked out. Really. 

How long should I wear a pad or tampon?

Pads should be changed if they are visibly full or after 4 hours, whichever is first. (Except overnight.) If left on longer, they start to have a foul odor, and you don't want that!

Tampons should be changed every 2-6 hours, depending on the amount of blood flow you have that day. Tampons come in different sizes for light days, regular days, and heavy days. Don't ever wear a tampon longer than 6 hours because it can allow germs to grow and cause a serious infection. For that reason I don't recommend wearing them overnight.

Once your cycle becomes more regular, you should be able to predict the flow by the day of the period (and time of day, since that often varies too). Use a calendar to track the amount of flow as well as the days of your period until you get it all straight. Either an old fashioned paper calendar or an app designed to track periods can help. (Search for "period calendar" or "menstrual calendar" in your app store if you have a smart phone or tablet.)

What do I do with the pad or tampon after it's been used?

Most pads are disposable. You can roll it up, wrap it in a little toilet paper (or the wrap it originally came in) and throw it in the trash can. (Use a single layer, ladies! Don't be wasteful with a wad of TP!)

If you use re-usable pads, they will have to be washed before the next use. Talk to your parent about where to keep them between uses. 

Many people flush tampons down the toilet, but that can lead to clogged toilets in many sewage systems. Never flush into a toilet that uses a septic tank. Tampons do not break up like toilet paper does and they will clog a septic tank system. If you aren't sure, you can wrap it in toilet paper and throw it in the trashcan.

Never flush a plastic applicator. You can either put it back in the wrapper or wrap in toilet paper and throw it in the trash.

I leaked! Not only am I totally embarrassed that everyone will know, what do I do to clean up my underwear?

When a period first starts, it often comes without warning and underwear can get soiled. Heavy flow days can also cause leakage onto your underwear. If you expect a heavy flow day, you can wear old underwear, prepare with a product designed for heavier flow, and go to the bathroom more often to change the pad or tampon. 

Despite the best techniques, all women sometimes soil their underwear and even their outer clothes. If you can change right away, fresh blood is easier to clean than dried blood. (This goes for just about any spill in the kitchen too, so clean up as soon as you spill!)

If you're at school, go to the nurse's office. She can help and it probably won't be the first time a girl has come to her for help-- really! If you're at a friend's house, see if she has something you can borrow if you don't have an emergency change of clothes. 

In general, cold water to rinse out blood is better than hot. Because blood is made of proteins that change in heat, the heat can "cook" the blood into the clothing and make the stain permanent.  If you have laundry detergent you can put a few drops on the stain and rub it in. If you have a spray or stick stain remover, you can use that. Allow that to soak overnight in some cold water before putting in the regular laundry. 

Basic tips:

• Carry a clean set of underwear (and pants if needed) in a plastic bag to use in case of emergency.

• Carry a stain stick (they sell these near the laundry detergent) if desired. 

• Rinse in cold water as soon as you can.

• Rub stain remover or laundry detergent into the stain and let it soak. Put it in the plastic bag you carry if you aren't home.  

• As soon as you get home put the soiled clothes in cold water (rub in more stain remover or laundry detergent as needed). Allow clothing to soak overnight. 

• After soaking overnight, rinse in cold water. Repeat a scrub and soak in detergent if needed.

• Once you don't see the stain any more, you can wash with the rest of your clothes like normal. 

What about when a pad won't work, like swimming or ballet? Am I too young for a tampon?

Tampons frighten a lot of girls, but they are safe to use as soon as you are comfortable using them. They do not affect your virginity. They simply are a product that will collect the blood inside you so you don't need to wear a pad on the outside. Many girls use one with their first period. Others don't use them at all. It is up to you! 

How exactly do you get the tampon in? 

First, some general anatomy. You need to know what things look like down there. You can use a hand held mirror to look at yourself and compare to this picture. This is a drawing, so you will look a little different, but you should be able to see the basic parts.

Photo source: Shutterstock

Tampons are inserted directly into the vagina. Much like an absorbent sponge, a tampon will gently swell as it becomes soaked with blood. A string allows for easy removal from the body. Tampons are convenient for swimming or exercising and can be paired with a panty liner - a type of thin pad or a regular pad for extra protection on heavy flow days. When using tampons, women should change them every 4-6 hours.  

It's time to change the tampon, but I can't find the string. Did it get lost up there somewhere? 

First: Don't panic! Your tampon is not lost forever! Sometimes the string can stick to the skin between your labia (labeled labium magus and minus above). You might need to feel around a bit. If there's a mirror nearby, you can use it to look. Sometimes going pee can help the string fall down if it is stuck around the skin somewhere. 

If the string really is up in the vagina, you can put your finger into the vagina to see if you can slip the string back out.

If you can't get the tampon out, tell an adult as soon as possible. If they can't help you get it out (or if you don't want them to try) you might have to go to the doctor to have it removed.  

NEVER forget about a tampon that has been put in... you could get a serious infection if you leave one in too long. 

I seem to always get spotting on my underwear when I wear a tampon, but the tampon isn't full of blood yet. Why is that?

There are several reasons I can think of that blood can get on your underwear. The first, of course is the tampon overflows because it was left in too long for the amount of flow you have at that time. But you can tell that when there is no more white showing on the tampon. If it isn't full, there are other reasons to consider.

First, was the blood on your skin when you put the tampon in? If you wipe after putting the tampon in, that can help this issue. Actually, more than wiping, pushing the toilet paper  (TP) up towards where the tampon is (with the string out of the way) can show if there's blood in the area. Repeat until the TP is clean. You can also wipe the folds of skin with a flushable wet wipe (sold near the other feminine hygiene products or near the diaper wipes -- same concept: wiping with a wet cloth works better than dry TP for many issues).

Another cause would be if the tampon is not inserted properly. Be sure it is completely in. Signs that it isn't in also include being able to feel it when you walk or sit. If it is in all the way, you should never feel it.

Did you pee or poop with the tampon in? This can move the tampon enough to let blood leak around it. Try changing the tampon (and wipe after placing it) each time you go to the bathroom.

Why do I need to pee so much when I'm on my period?

Many women gain water weight just before their period. (Have you heard women complaining of bloating? That's the water.) Your body's hormone changes cause this slow gain, and they also cause the release of the excess water back out of your body (called diruresis). This increases urine production. Look at it in a positive light: you have to go to the bathroom often, so it reminds you to change your pad or tampon frequently!

Can you pee or poop with a tampon in?

Short answer: Yes. But if you do, it is possible to have the tampon shift and cause leakage, especially if you have a bowel movement (poop). If it is too soon to change the tampon and you need to go, you can hold the string to the side so it doesn't get as soiled while you go. Wipe carefully so you don't pull on the string-- you can keep holding it to the side while you wipe too for "safe keeping."

My school uniform doesn't have pockets. How can I carry a pad or tampon to the bathroom?

If your uniform is a skirt, you can wear shorts with a pocket underneath. Some girls will be able to wear a tampon with a pad so that when they remove the pad mid-day, they leave the un-soiled pad on for the afternoon. If you're allowed to carry a purse, carry one every day for unexpected first period days and to get in the habit of always having it. You can also talk with your school nurse or a teacher about what other girls do.

I track my periods on a calendar, but there doesn't seem to be any pattern. Why aren't they once a month like they should be?

Once a month is more of a phrase than a reality. A typical cycle is about 21 - 35 days from start to start. Bleeding can be as little as 2 days and up to 7 days. The first 2 years after starting a period, many girls are irregular. After those 2 years, it becomes more predictable. You might be different than your friend, but your cycle should be about the same each month after the first 2 years. It does help if you track your cycles on a calendar or online app. 

My bleeding seems so heavy. I soak a pad within an hour and there are sometimes clumps in the blood. What is that?

If you are having very heavy bleeding, talk to your doctor because you can be at risk for anemia (too low of blood counts from blood loss). This can sometimes simply be your body adjusting to a period, but it can also be from a treatable condition. Your doctor can help you decide what needs to be done.

How long will the bleeding last?

The amount of bleeding and how long it lasts varies from person to person. Some days there will be barely any blood (called spotting because it looks like just a spot of blood). Other days are heavier. Bleeding can last between 2-7 days normally. Again, charting it on a calendar or app can help you figure out your pattern.

How do I keep from getting stinky?

First, be sure to regularly change your tampon or pad. If it goes without being changed, bacteria start to make a very foul odor. You should change pads or tampons at least every 6 hours (except overnight, when the pad can be left on as long as you sleep). This is important to avoid infections as well as bad smells!

You can use flushable wet wipes instead of toilet paper to help clean the area better. If you need them outside of your home you can carry some in a plastic zip lock bag and keep with your pads or tampons.

There are feminine hygiene products with deodorant available, but who wants to smell flowery? Seriously, I don't recommend these because too many girls have an allergic reaction to them and who wants to have an itchy rash in the place you can't publicly scratch?  

Another thing that's important: Wash! Once you go through puberty, your body in general smells more, so it is important to bathe regularly. Don't forget to do a daily wash of all the skin folds between your legs. You can use any soap (avoid fragrances if your skin is sensitive), but be sure to rinse well! Soap that remains between the folds can cause rashes. You can rinse the area by splashing a cup of clean water between your legs a few times. If you have a hand-held shower head available, that makes it easy to rinse the area well. You can also lift a leg so the shower water can rinse between your legs -- but hold on so you don't fall!

Do I need to wear protection between periods?

You might want to wear a panty liner when it is getting close to your next period, just in case you start, but it's not necessary.

How do I know when the next one will be?

Over time it becomes easier to predict. Keep track of the dates of bleeding as well as how heavy it is and any other symptoms. These can include pimples, cramping, mood swings, tiredness, constipation or diarrhea, back pain, sore breasts, bloating, food cravings, or headaches. All of these symptoms can help predict your cycle. There are several apps available on the computer, smart phones, or tablets, many of which are free. I suggest going to your app store and reading reviews to pick your favorite.

How much more will I grow since I started my period?

Growth speeds during the years before your period, then slows after your period. Some girls stop growing all together, but most still grow for the next 1-2 years. Ask adult family members how they grew (if they remember) because growth patterns tend to follow parents and other family members.

What is PMS?

Common effects of PMS include: bloating, cramps, fatigue, moodiness, headaches, or pimples. There are over-the-counter medications that can ease these symptoms. Ibuprofen or naproxen tend to work well. If you have severe cramping and you are expecting your period, you can start the ibuprofen or naproxen three days before your symptoms start. This decreases the pain better than starting the medicine when the cramps start. Some girls prefer wearing loose clothing or using warm compresses on their stomach. Mothers can share with their daughters their own tricks for coping.

My boobs hurt with my periods. Why is that?

Many girls notice breast tenderness during PMS (Pre Menstrual Syndrome). Your hormones are changing at this time and they can cause the breasts to swell. The swelling causes tenderness. You can help minimize this by eating right, exercising, and getting enough sleep (all month long). Caffeine can worsen it, so avoid things with caffeine.

Where can I get more information?

ThePeriodBlog has a lot of great information, including how to insert a tampon, information about your body,  counting your cycle, and more.

My favorite book for girls about puberty is now a series of books. The Care and Keeping of You and The Care and Keeping of You 2 are available from many retailers. I like that they go over everything from staying clean to eating right to the importance of sleep and more.

I rarely hear questions about the hormones or technicalities of puberty, but for more on the menstrual cycle check out All About Menstruation by TeensHealth. (They also include more related topics links at the bottom.)

A good review of puberty, including how it is staged is found on Young Women's Health (Boston's Children's Hospital).

P.S. I'd love to meet you on Twitter. Stop by and say "hi"!

P.P.S. If you've enjoyed this blog, go to the top of the page and enter your email address so you will get future posts direct to your In Box!

Flu Vaccine 2013: The story unfolds

photo source: Shutterstock

I wrote about this year's flu vaccine new twist last month (Flu Shot Information 2013-14 Season).

Since that time I've learned some frustrating things.

Although it is not new news that companies are making two types of injectable flu vaccine this season (trivalent and quadrivalent), there are signs that we won't be able to start using it. The quadrivalent vaccine was not approved by the FDA until after the CPT coding book was published for this year, so no currently recognized code exists for the quadrivalent vaccine. Since every service and procedure a physician's office does is reported to the insurance company with a CPT code, the quadrivalent vaccine can't be given and appropriately documented with appropriate notification to the insurance company. The codes (90685 for 6-35 months and 90686 for 36+ months) are now assigned for the quadrivalent vaccine in CPT 2014, but insurance companies have until January to recognize them (with a retroactive time of 90 days possible- so possibly as early as October they can be used, but with a question of reimbursement for this very real cost, many businesses will be hesitant to use it).

There is only one type of FluMist, so there is only one code, allowing it to be used when in stock. (For more on CPT codes: What Are CPT Codes?)

You might wonder why this is important. First, CPT codes are used to document which vaccine is given and to send it to the insurance company. We must report the code accurately for inventory, billing, and proper documentation reasons. Insurance companies value each code differently, so the vaccine reimbursement will be different from code to code (and also varies among various insurance companies). The quadrivalent vaccine is of course more expensive than the trivalent vaccine, but it also covers another strain of virus, which makes it a better vaccine.

Our office received notice that our first shipment of quadrivalent injectable vaccine would soon be shipped. Since we won't be able to use it, we were forced to cancel that order. (It was only a small fraction of our overall order, so we hope to have more coming later when this mess is sorted out.)

My biggest frustration is that I want my most at risk patients vaccinated with the quadrivalent vaccine because it covers an additional strain of influenza. They can't wait until January. Many of these kids are not able to get the FluMist because they are under 2 years of age. I will be forced to give kids the less-preferred (though still good) vaccine, fully knowing that the only reason is tied to coding and billing. I've had parents mention that they would pay cash to avoid the delay, but that gets complicated with insurance contracts.

And what about the companies that have made all of their pre-ordered quadrivalent vaccines? If we all cancel our orders, they will have invested time, money, and resources into an entire line of product that will go unsold. Over the years many manufactures have gotten out of the vaccine market due to it being a money loser (despite what some anti-vaccine people state of us being in it only for the money). For a historical review of why companies stop making vaccines, leading to shortages over the years, please see this article: Why Are Pharmaceutical Companies Gradually Abandoning Vaccines? I worry that this type of craziness will lead to future flu vaccine shortages, resulting in more people getting sick and dying from influenza.

That all being said, the FluMist recommendations have become more relaxed as we gain experience in how it affects at risk groups of people. Because it is a live attenuated vaccine, initially higher risk people were not eligible to get the vaccine out of fear it would lead to wheezing. It is still not recommended for children under 2 years of age, but other groups for whom it used to be not recommended now may consider it. Children over 2 years who have a history of wheezing, a weakened immune system, diabetes, and other higher risk conditions MAY be eligible for this vaccine. Pregnant women also used to not be eligible, but many OB's are now recommending it because of its superior protection, which helps protect the newborn as well. You will need to talk with your provider if you feel your child should get the FluMist but has historically been unable due to higher risk status.

So, in a nutshell: this flu season follows suit with the fact that there is always something crazy that happens with flu vaccines. This is the most frustrated I've been though. In years past it usually has to do with shortages and trying to get mass numbers vaccinated within a relatively small window of time. Things that really are beyond what anyone can do. We can't anticipate the need, so ordering (and manufacturing) isn't always matched to demand. Proper codes for a new vaccine that had been announced is something that should have been anticipated. These coding problems are due to something people should have addressed, not unknown issues, which is why I am more frustrated than ever!

Stay tuned...

Common Sleep Myths - by guest blogger Kerrin Edmonds

made at www.quickmeme.com

Social Media really is shrinking the world. How else would I be able to keep up with my friends without leaving my living room? I've realized that people I know from different aspects of life somehow know each other because they are friends of friends. I can easily share great information with hundreds of people with one easy click.

Business networking through social media is a wonderful tool. I have recently been contacted by a number of sleep consultants who found me through Facebook. Since there are always so many questions about sleep, I'm excited that many of these certified sleep consultants have offered to share articles when they write them. Some have been published on other sites, and I have (or will) post those articles on my Social Media sites. For those who have great information to share but don't have a website to link, I will have them guest blog here.

I'm excited to introduce my first ever guest blogger, Kerrin Edmonds.

Kerrin grew up on California’s Central Coast and has lived there her whole life.

Growing up with a Mom who owned and ran her own preschool, as well as being the oldest of three kids, Kerrin has always been around children from the start. But her passion for babies and more particularly, for baby sleep issues, was born with her first baby. After weeks of crying and sleepless nights, she felt there had to be a better way……So she started her journey to a better sleep for her whole family. After graduating from the Family Sleep Institute, and becoming certified with the International Sleep Consultants Association, Kerrin founded “Meet You in Dreamland,’ where she helps families find and keep their restful nights sleep.

Kerrin also works with a local group called Pickles and Tickles, a organization that offers early intervention services to families with children under the age of three.

Kerrin lives in California's San Luis Obispo North County with her husband, daughter, son, funny looking little dog and sweet kitties.

Common Sleep Myths

By Kerrin Edmonds

As we parent our children in regards to sleep, there is a myriad of information, recommendations, myths, rules and even legends! It can be tough to sort through and make sense of it all. In this article I will respond to 5 of the most common Sleep Myths.

1. Putting Rice Cereal in a Babies Bottle will help them Sleep Longer-

This one has been around for decades! Many studies have  proven that babies who were given rice cereal in their bottle did not sleep any longer than those who did. Some parents have even found the opposite to be true….that babies who were given too much rice cereal or were given rice cereal at a young age suffered from indigestion and tummy upset.

2. Keeping a baby/child up later at night will make them sleep in.

This one couldn’t be further from the truth. While on the surface this makes sense, we must think biologically not logically when it comes to our child’s sleep. If we allow our children to become overtired they release a hormone called Cortisol, which is similar to adrenaline. This hormone makes it very hard for them to fall and stay asleep. Babies sleep better, longer, and cry less if they are put to bed early in the evening. Babies who go to sleep late in the evening are often "over tired", even though they seem to have energy. A typical and healthy bedtime, depending on how they napped during the day is between 6-8 pm.

3. A Baby should sleep through the night at 12 weeks-

While this would be nice, and does happen in some cases with some babies, it can be an unrealistic expectation and just cause stress if it doesn’t happen for you. It isn’t unreasonable for a baby to “need” a feeding during the night till around 9 months of age.

4. My child doesn’t need as much sleep as other children-

I hear this one a lot in my profession and while this might make a parent feel better about how little their child sleeps, it really isn’t true. It is true that some kids need/love sleep more than others but usually this varies by only an hour or two, not huge amounts that I tend to see. It is not uncommon for children to fight sleep but that doesn’t mean they don’t need it.  I am confident that all children can be taught to be good sleepers…..and isn’t that what we want?!

5. You can sleep train a newborn-

In all reality you can’t sleep train or schedule a newborn. Sometimes an infant might appear to be on a schedule until it suddenly changes. This is because our babies Circadian Rythmn or body clock is not biologically mature yet. This maturing starts around 4-5 months of age and this is when we can start scheduling naps, etc.

Most basic baby sleep myths can be busted by remembering to think biologically instead of logically in regards to our children’s sleep.  Respecting and encouraging our children’s need for sleep is something every baby deserves!

Flu Shot Information 2013-14 Season

Dr. Mellick getting FluMist

Dr. Stuppy getting a flu shot

Many parents are already asking about this year's flu vaccine, which means we've done a great job in the past making them aware that they need to think about getting the vaccine before they start seeing people get sick!

We feel so strongly that the vaccine is effective at protecting not only the person vaccinated but also the community around them that our office requires all staff to get a vaccine. We made the Honor Roll for Patient Safety from the Immunization Action Coalition for this requirement!

What's new this year?

Every year scientists predict which strains of Influenza A and Influenza B will likely be prevalent. The World Health Organization makes the recommendations for the vaccine based on these predictions. The strains chosen are the same for every company that makes the vaccine. The difference this year is that some will have three strains (trivalent) with two A and one B, others will have four strains (quadrivalent) with two A and two B.

Flu shot season causes headaches for doctor's offices. 

We must anticipate our need many months in advance and get our orders in. Each year the vaccine demand varies (a lot based on press reports on how badly people are getting sick, which we don't know when ordering). As more places offer vaccines (such as offices and pharmacies) the numbers of people getting vaccines at their doctor's office might go down. (I am biased, but of course believe getting them at your doctor's office is superior since we keep all your medical records in one place.)

From a business perspective, no one wants to be stuck with thousands of dollars of unused vaccine-- we can't stay in business if we lose money. We also don't want to have kids at risk of disease because they're unprotected and unable to find an appropriate vaccine when we run out. We certainly don't want parents yelling at our staff because we run out. Sometimes we've ordered enough overall, but our shipping allotments don't come fast enough for the demand. Shortages have happened over the years, something beyond anyone's control.

Scheduling mass flu vaccine clinics is often the best way to vaccinate large numbers of patients, but they are fraught with complications: how many people will show up, what flu vaccine (injectable vs nose spray) will they need? How many doses do we need on hand to hold a clinic? In times of shortages or low stock, how do you prioritize who gets the vaccine -- or do you want to just keep giving to anyone until it is gone so the office isn't stuck with unused vaccine at the end of the season? Do you give one dose to a 6 month old who you know won't be able to get the 2nd dose due to your supply running out?

This year there's a new spin to the variety of headaches: different vaccines will be available. Not just injectable vs nose spray. There will be some with 3 strains of virus, others with 4 strains. (For a review of how strains get into vaccine and how this year is different, see Quadrivalent Flu Vaccines: Four Means More Protection.)

So this year we have new questions: How are we supposed to order the different types, who gets which type, and are they interchangeable? How will the public perceive the difference and will they demand one or the other? Will insurance companies reimburse the cost appropriately, given that one is more expensive than the other? While in health care our goal is to keep everyone as healthy as can be, no office can afford to lose money on vaccines and stay in business.

What kinds of vaccine will be available this season?

There are many companies that make influenza vaccine, each with their own indications. For a complete list, see the chart on the CDC website. Our office has pre-ordered the FluMist and the Fluzone products (both forms) in part because we didn't know which would be available at the start of the season. We do not purchase the brands that are only available for older children or adults. Ask your doctor what they order.

All FluMist will be quadrivalent (4 strains) and is for children over 2 years without high risk conditions, such as asthma (presumed based on previous recommendations, this year's statement has not been released yet). It is expected to start shipping in July or August, though any individual office may not receive their order with the first shipping dates.

Fluzone Quadrivalent (4 strains) is an injectable vaccine for everyone over 6 months of age. It has already sold out  based on pre-season orders and will be available in limited quantities. Shipping dates will begin in August or September.

Fluzone Trivalent (3 strains) is an injectable vaccine for everyone over 6 months of age. It is expected to begin shipping in July and August. I have not heard of shortages.

Is adding a new strain dangerous?

Based on the chaos in the year of H1N1, I know that many parents fear "new" strains added to a flu shot. In actuality, every year the vaccine changes with very rare exception. That is because the flu strains predicted to cause disease change year to year. Adding a new strain does not make the vaccine less safe, just more effective.

Who needs the flu vaccines and how will they be given?

As of today, the finalized recommendations have not been approved. The preliminary recommendations  continue to recommend flu vaccine for all people over 6 months of age. (The link should update to the final recommendations as they become available.)

Last year it was recommended to start giving the vaccine as soon as it was received (previously it was suggested to wait until October so it remained effective throughout the season, but the vaccine is effective longer than previously thought so earlier vaccine is effective.) I presume this will remain the same.

If a child under 9 years of age has not had flu vaccine before, they need 2 doses in the same season to "prime" and "boost" immunity. If only one vaccine was given, the next season the child needs 2 doses unless they have gotten 2 of the same strain before. (This was easier last year because it was a rare year that the vaccine didn't change, so they could have gotten one the season prior, and the booster last year.) For children over 9 years, only one dose is needed, even if never received previously. After that first year of 2 doses, each year everyone just needs one dose unless it dramatically changes (as in the H1N1 year). I suspect since 3 of the 4 strains are the same this year, if a child needs 2 doses because they have not had 2 doses of the same strains, the vaccines are interchangeable. We will all find out when the final recommendation is given.

At this point I have not heard if high risk people should get preference for the quadrivalent vaccine. I don't think this will be possible in many cases, since many of the high risk are under 2 years old, and not eligible for FluMist. The injectable quadrivalent vaccine is in short supply, and many offices are likely to not get it at all. I personally feel it would be bad to wait for the quadrivalent vaccine if we have the trivalent vaccine in stock and an eligible patient is in the office. I'd rather vaccinate than potentially miss the opportunity all together. I'm sure others will differ in opinion since the quadrivalent vaccine is better protection. Talk to your pediatrician about their preference.

Although we cannot require all patients to get vaccinated, we certainly encourage it and try to make it as painless as possible (though the kids who get shots don't always agree). We will once again allow any patient in the office to get a flu vaccine (even if just there with a sibling for an appointment) and we will offer on line sign up for our clinics. On line sign up has proved very popular, both among our nurses and the families who come. It has really made the process run much more smoothly. There will not be a co pay collected at those clinics. (After we submit the claim to your insurance company if they tell us differently we will send a bill, but do not expect that in most cases.) Be sure you have registered for our e-Newsletter so you will be among the first to know when sign ups are ready for our patients. (No dates are set yet because we have not gotten verification on shipping dates. Please don't call the office to ask-- staff have no idea.) We will put information on our website as it becomes available in addition to posting on our Facebook page and sending the e-Newsletter.

We will all have to wait to see how this plays out! Every year something is new with the flu vaccine. What will be next?

Updated Sinusitis Guidelines

photo source: Shutterstock

This month the American Academy of Pediatrics updated the guidelines for management of sinus infections in children (1-18 years of age) in the June edition of Pediatrics, available online.

Many parents bring kids in to the doctor for green or yellow runny noses because they're worried about bacterial sinusitis. Sinuses can be infected with viruses or produce mucus from allergies, so not all sinus infections are bacterial. Most of these kids do not need antibiotics to get better, but the guidelines help determine who might benefit from them and when to change an antibiotic if not improving. The guidelines are based on duration of symptoms and severity, not the color of the drainage, how much drainage there is, or fancy testing. Only infections caused by bacteria need antibiotics. Overuse of antibiotics can lead to resistance (so when there is a severe infection it becomes more difficult to treat), side effects (such as diarrhea), or allergic responses.

Unfortunately, a physical exam is not helpful in distinguishing a simple viral cold and cough from a bacterial sinus infection, but is needed to identify other problems that might complicate the picture, such as pneumonia or an ear infection. The inside of the nose can be swollen and various shades of pink, red or blue in sinus infections from bacteria or other causes. How often have I palpated those sinuses to see if tender, yet I know from personal experience that mine hurt when my allergies flare-- certainly not a reason for antibiotics!

I wish there was a simple test, but nose swabs for culture have not been found to be accurate in predicting bacterial cause of the infection. Imaging studies are not needed to help diagnose sinusitis because the inflammation seen in pictures can be from other causes, not just bacterial.

Most cases of runny nose, fever, and/or cough are due to a viral illness. The nasal discharge usually starts clear, but can become thick and discolor over time for several days. It often goes back to a thinner, clear color before resolving without antibiotics. Fever in a typical viral illness tends to be the first several days, and may precede the other symptoms. Fever usually resolves by day 3, when the nasal discharge and cough tend to worsen.  Symptoms tend to peak between the 3rd and 6th day, then resolve after about 10 days. (Though some studies show longer.) Back to back infections are common in kids, especially during the winter months, which can be confused with one prolonged sinus infection.

Guidelines to diagnose and treat acute bacterial sinusitis in a nutshell:

• Symptoms in a child with upper respiratory infection suggest acute bacterial sinusitis if: 

• there is persistent illness (nasal discharge or daytime cough) of 10 days without improvement. This persistence can be difficult to distinguish from back to back viral illnesses, so a careful review of symptoms is important.

 or

• there are worsening symptoms (nasal discharge, cough, fever) after initial improvement. (New in the 2013 guidelines.)

or

• there is severe onset (fever over 102.2F and discolored nasal discharge for at least 3 consecutive days). Several viral infections, notably influenza, can cause severe onset of symptoms, but a clue to the bacterial nature is the combination of fever with mucus in the initial days, since the fever usually comes before the mucus in many viral illnesses. 

• Observation without antibiotic is acceptable with a persistent infection over 10 days for another 3 days if there was not a severe onset or worsening of symptoms. (This differs from the 2001 guidelines to use an antibiotic for symptoms of 10 days.)
• Imaging is not recommended to diagnose routine sinusitis. Plain x-rays, computed tomography (CT), magnetic imaging (MRI), and ultrasounds (US) cannot distinguish between viral, bacterial, or allergic nature of the inflammation. 
• If there is a suspicion of extension of the infection outside of the sinus cavities, such as into the eye orbit or central nervous system, a contrast-enhanced CT scan is indicated. These might be suspected if the eyelid is swollen and the mobility of the eye is decreased, sensitivity to light, severe headache, seizures, or other neurologic changes. 
• When antibiotics are indicated, amoxicillin or amoxicillin with clavulanate (Augmentin) is the first line choice unless there are documented allergies to penicillins. If there are allergies or failure to respond to the amoxicillin, a cephalosporin may be used. There are other good choices, but studies do not show that azithromycin (Zithromax) or trimethoprim sulfamethoxazole (Bactrim) are good choices because they aren't effective against the most common bacteria of bacterial sinus infections. The duration to take an antibiotic is not well identified. Recommendations vary from 10 to 28 days, or 7 days from the time symptoms go away. This will vary by prescriber's preference and experience.
• If there are worsening of symptoms or failure to improve within 72 hours of initial visit, a repeat evaluation is recommended. If no other source of symptoms is found on physical exam, adding an antibiotic (if not previously initiated during the observation period) or changing the antibiotic is recommended. 
• There was not enough evidence to support other treatments, such as decongestants, antihistamines, nasal corticosteroids, or saline rinses. More studies in children are needed to validate whether these are effective or not. There's always more to learn!

Bicycle Safety

I like the simplicity of picture blogs. They make it easy to share a lot of information in an easy to see format, so when I decided to do a blog on bicycle safety, it was an obvious choice.

Bicycle Safety Tips

Teach kids to use hand signals to alert others where they are going:

From: http://www.nhtsa.gov/Bicycles

Use a properly fitted helmet:

From: http://www.nhtsa.gov/Bicycles

Help your kids learn about bike safety with these fun activities from the National Highway Traffic  Safety Administration.