Sudden Barky Cough? Think Croup

The barky cough of croup is distinctive. It’s not a typical wet or congested cough. It’s like a seal bark. The good news is we can often treat it at home.

Many parents get scared when they hear the barky cough of croup. I’ve even been scared when my own children have it. I know what it is, but their breathing gets so labored that it’s scary.

Sounds of coughing

Parents describe many coughs as “croupy” but most of the time they’re mistaking a wet, mucous-filled cough for croup.

It can be difficult to sort out all the various sounds of coughing, which is why I previously gathered a number of videos into one blog.

The barky cough of croup is distinctive. It’s not a typical wet or congested cough. It’s like a seal bark. The good news is we can often treat it at home.

What is croup?

Croup is a distinctive set of symptoms that occur due to inflammation around a young child’s voicebox in the larynx and trachea.

Many people describe a croupy cough as a seal bark sound. They often make a hoarse or squeaky sound called stridor when they inhale.

Croup often starts suddenly in the middle of the night. 

What causes croup?

Croup is usually caused by viruses and tends to be most common in the Fall. The viruses that cause croup are common and usually cause runny nose or congestion and sometimes cause a fever. 

One child may get full-blown croup, but another will get a simple cold with the same virus. Some kids seem to get croup often, while others may never get it.

Can older kids get croup?

Croup is most common in kids less than 5 years of age, but older kids can occasionally get it. 

Older children and adults tend to get laryngitis with the same viruses that cause croup. Their airways are bigger, so the swelling that occurs near the voicebox isn’t as severe.

Croup is tricky

Croup often looks like a simple upper respiratory tract infection or cold during the day. Nothing to worry about…

In the middle of the night you will hear a sudden barking sound, much like a seal barking. A child with croup looks distressed and very sick at night, but seems much better the next day. 

For many kids, it’s just one night of this scary cough, but it can last several nights in others.

Some kids continue to have what is called stridor or trouble talking during the day. Stridor is a hoarse sound that you can replicate by breathing in while tightening your vocal cords. It sounds like a squeak or wheeze as kids breath in. Stridor is due to the swelling near the vocal cords that’s found in croup.

This is a simple yet very helpful video to hear the sound of croup and for management tips. 

How is croup diagnosed?

Croup is what we call a clinical diagnosis. No lab or x-ray is needed.

A doctor or nurse will ask questions about various symptoms, and if we hear the classic cough or stridor, it supports the diagnosis.

How is croup treated?

If you recognize croup, there are many at home treatments you can try. 

Cool air

Taking kids outside into the cool night air often helps soothe the airway. 

If the weather isn’t appropriate, you can open your freezer door and let them breathe in that air. (This has never been my favorite advice because it means a sick kid will be breathing on the frozen food and then there’s the wasted energy…)

Steam

The airway can also be soothed by taking kids into a bathroom, closing the door, and turning the shower to the hottest setting. Just sit in the bathroom – not in the shower. 

Usually after 10-15 minutes breathing normalizes. 

One thing I learned when my son first had croup: don’t leave the bathroom as soon as breathing calms down. Turn off the shower and just sit there for awhile. We had a rebound croup that was less scary, but unnecessary, when we tried to get him back to bed quickly. Letting the room get closer to the home’s normal air quality before going back into the hall and bedroom is time well spent.

Humidifiers and vaporizers

When we’re sick in the dry weather months, I always recommend adding a vaporizer or humidifier to the bedrooms. This is especially helpful if a child is at risk for croup due to age.

What about medicine?

Fever/pain relievers

If kids are uncomfortable, you can use acetaminophen or ibuprofen as a pain reliever. These do not help the cough, but they can help with comfort.

Steroids

Since steroids decrease inflammation, they are often used when kids get croup. These can only be used with a prescription and your doctor’s instructions. See your doctor if you’re interested in any prescription medicine.

Breathing treatments

Croup is often mistaken for wheezing, but it is not treated with a bronchodilator like asthma.

The swelling near the voicebox is much different than the smaller airway narrowing that occurs with wheezing, and the bronchodilators (albuterol or levalbuterol) work on the smaller airways. 

If kids have asthma, they can wheeze from the same virus that leads to croup, and in that case their asthma medicine helps.

In the hospital or ER setting some kids will get a breathing treatment of epinepherine. This should only be done in a supervised setting so they can be properly monitored.

Antibiotics

Croup is usually caused by a virus, so antibiotics don’t help.

There is also something called spasmotic croup, but that also is not treated with antibiotics. 

When should kids go to the ER or their doctor?

Since croup is worst at night, most of the kids who need to be seen end up in the ER. If your child has stridor during the day, they can be seen at their usual doctor’s office. 

If the above home treatments don’t work after about 15-20 minutes, you should take your child to be seen.

Kids who seem very anxious due to breathing difficulties will also benefit from a proper medical exam and treatment.

Trouble swallowing along with difficulty breathing should be evaluated by a physician.

If you notice that your child seems better leaning slightly forward while sitting, he should be seen.

Any child who is not up to date on vaccines, especially the Hib vaccine, should be seen with labored breathing. Epiglottitis is now rare, thanks to vaccines, but if a child isn’t vaccinated, it is still possible to get this. It can cause stridor, fever, difficulty breathing, and other similar symptoms to croup. Be sure the physician knows your child isn’t vaccinated!

Teal Pumpkin Project

Teal pumpkins have been popping up during the Halloween season in recent years, yet many people don’t know what they really mean. Displaying a teal pumpkin means that your home has non-food items available for the little goblins and superheroes as they come looking for treats.

Why is this important?

Because what child likes to be left out of the fun of Trick or Treating?

When a child has severe food allergies, diabetes, or another condition that limits the types of foods he or she can eat, they are often left out of class parties and trick or treating.

What can you do to support these kids?

Show parents that you are giving kids the option of a safe treat by displaying a teal pumpkin.

There are many non-food treats that kids would love ~ stickers, pencils, glow sticks, bubbles, plastic jewelry, vampire teeth, pencil toppers, hair pieces, magic trick cards, and many more. Be sure you have some that are safe for toddlers.

Why non-food things? Can’t we just avoid nuts?

Non-food items are better than nut-free because kids have allergies to all kinds of things, and it is impossible to know in advance what all those allergies are.

When kids must limit their overall sugar intake, non-food treats rule.

What about the kids who want candy?

Just because you offer non-food items, it doesn’t mean that you can’t also give candy.

Simply let kids know you have both options and ask which they prefer. Keep two containers: one of candy and one of non-food items.

How do you get a teal pumpkin?

We put together some reusable teal pumpkins at my office several years ago. My initial plan was to spray paint some plastic pumpkins, but decided to use Duct tape to cover plastic pumpkins instead. Duct tape has less smell. We didn’t have to wait for them to dry, and if we ever want to use them outside, they will be fairly weather-proof. They’ve held up well over the years.

Pretty cute, huh?

Let people know you’re participating!

Share this idea with your neighbors and friends. Use social media. Put a note in your neighborhood bulletin. Share with your school nurse. Ask stores to display a flyer.

Kids have to know what the pumpkin means. Display signs as well as your pumpkin letting them know you have non-food options as well as candy.

Register as a site that will offer non-food items on FoodAllergy.org.

For more information and a free printable flyer (like the one pictured in our office above), ideas on what to provide, and more information in general, see The Teal Pumpkin Project.

Use a teal pumpkin to show kids with medical conditions that you have non-food items this Halloween!

My child has Neutropenia. Should I worry?

One abnormal lab we see in otherwise healthy kids is a low absolute neutrophil count (ANC). This is also called neutropenia. Know when you should worry.

It is recommended to screen for anemia (low red blood cell or hemoglobin levels) around one year of age. Our office orders a complete blood count (CBC), which checks for red blood cells, white blood cells, and platelets – the main components of our blood. Sometimes we find things that we weren’t looking for. In the winter months, neutropenia is one of those things.

What is neutropenia?

One relatively frequent abnormal lab we see is a low absolute neutrophil count (ANC). A low ANC is also called neutropenia.

What are neutrophils?

Neutrophils are a type of white blood cell that fights bacterial infections. When their numbers get too low, it can increase the risk of serious bacterial infections.

While some people have low ANCs that cause significant immune deficiencies and can lead to infection, the most commonly seen low ANC we see are brief dips after a viral infection. 

Blausen 0676 Neutrophil
By BruceBlaus. Blausen.com staff (2014). “Medical gallery of Blausen Medical 2014”. WikiJournal of Medicine 1 (2). DOI:10.15347/wjm/2014.010. ISSN 2002-4436. [CC BY 3.0 (https://creativecommons.org/licenses/by/3.0)], from Wikimedia Commons

What causes neutropenia?

Most causes of neutropenia are due to infection, drugs, severe malnutrition or immune disorders.

The most common cause of neutropenia we see in otherwise healthy kids is due to a recent infection. In most cases this type of neutropenia quickly resolves without any treatment.

Some viruses, such as hepatitis B, Epstein-Barr, and HIV, are associated with prolonged neutropenias.

The drugs that can cause neutropenia are not commonly used medications.  Routine testing for neutropenia would be done when those medications are used because the risk is known. That’s one reason why people with cancer treatments often have regular blood counts checked.

Vitamin B12, folate, and copper deficiencies are very uncommon in children, but can lead to abnormal blood counts.

Three levels of neutropenia:

The large majority of kids with neutropenia have only mild drops in their ANC and are not at significant risk of illness. In general the more severe the drop, the more significant the infection risk.

  • Mild neutropenia: The ANC ranges between 1000-1500/μL
  • Moderate neutropenia: The ANC ranges between 500-1000/μL
  • Severe neutropenia: The ANC is less than 500/μL

What do you do if there’s neutropenia?

Since most mild cases of neutropenia self-resolve, it is not usually anything for parents to worry about.

I used to recheck all of these, but found that many kids needed several rechecks because they always had a mild viral infection so the levels stayed suppressed (low). Despite the low ANC, they never got significantly sick.

Of course if there is another clinical reason, such as a significant illness or growth problems, following up even a mild lab abnormality is recommended. If kids start getting sick, their blood counts should be rechecked because of the clinical concern.

When kids are otherwise healthy, I find that we end up chasing abnormal levels if we try to recheck, so I’ve stopped rechecking automatically.

  • When a child is overall healthy and growing well, the level is only mildly low (above 1000) I do not recheck the level unless there is a clinical concern. If your doctor wants to recheck it (or if you want it rechecked), that is appropriate to do.
  • When the level is in the mid-range (500-1000) or if the child has had problems with recurrent infections or growth, a confirmation (repeat test) and possible further evaluation is more likely to be recommended.
  • If the level is in the severe range (less than 500), it should be rechecked and the child should be closely monitored due to high risk of severe bacterial infections.
  • Some physicians recommend repeating a blood count with any fever for a year in kids who have had any degree of neutropenia, so you’ll have to talk to your child’s doctor for a plan.

What symptoms might happen if the ANC is low?

Most children with a temporarily and mildly low ANC will have no symptoms and need no treatment.

Children with chronically low ANCs may have more infections that require antibiotics, such as pneumonia, skin infections (abscesses, cellulitis) and lymph node infections. They might also have chronic gum disease, mouth sores, or vaginal or rectal ulcers.

Common colds often contribute to the temporary dip in the ANC, but are not caused by the low ANC. A different type of white blood cell fights off viral infections, so the low neutrophil count is specific to bacterial infection risk. 

Common symptoms seen with neutropenia:

  • Frequent significant infections (not just the chronic runny nose of a daycare kid)
  • Serious respiratory infections, including pneumonia or sinus infections
  • Skin infections (e.g. cellulitis, abscesses)
  • Multiple serious infections (e.g. meningitis, bone infections)
  • Lymph node infections
  • Gum disease
  • Mouth sores/ulcers
  • Vaginal, urethral, or rectal ulcers

When should you worry?

The level of ANC as well as the cause both determine the risk level.

Lower levels of neutrophils increase the risk of an overwhelming infection. An example would be when people are immune suppressed from chemotherapy they are at very high risk of bacterial infections.

On the other hand, an otherwise healthy person with a mildly low ANC is not more likely to get a bacterial infection than another person with a normal ANC.

If the child has any of the symptoms noted above or a very low ANC level, we start to worry more. Each case must be evaluated by the person who ordered the test and who has recently seen your child.

What treatment is done for a low ANC?

Most children do not need any specific treatment. They are monitored for recurrent infections, especially infections that require antibiotics. They are also monitored for growth, since if a body is chronically sick, it often doesn’t grow well.

Each infection that requires antibiotics is treated and blood counts might be checked to see how low they are at the time.

In children who have a chronically low ANC or a significant illness with a low ANC, a hematologist (blood specialist) is often consulted. They help evaluate why the ANC is low and if it requires a special treatment that stimulates the bone marrow to make more neutrophils.

For more information:

Benign familial leukopenia and neutropenia in different ethnic groups.

Pediatric Autoimmune and Chronic Benign Neutropenia

Developing Responsibility and Resiliency in Our Children

Our goal as parents is to have our kids grow up with responsibility and resiliency so they can leave our home. How can we accomplish that?

As the years go by, I have seen very bright kids struggle with life and average intelligence kids thrive. I often think about how parents could help their kids grow into independent adults or hinder that growth by trying to be a good parent. Good intentions aren’t always the best way to do things, and sometimes the best parents sit back and let kids figure it out themselves. In the end, our goal as parents is to have our kids grow up with responsibility and resiliency so they can leave our home. Our desire to keep kids safe can seem to conflict with the need to let them grow up.

Is it safe?

So often parents attempt to keep their kids safe in the moment, but don’t consider what long the term implications are.

Parents want to keep their kids safe under their wings, at home or in a supervised activity. If their child is not directly in sight, they are at least within reach of a cell phone for immediate access.

Cell phone for “safety”

I often hear that parents buy a phone for their kids “for safety” purposes, but studies are showing the opposite. Cell phones lead to many dangerous situations for young kids and tweens. Smartphone use is associated with anxiety, depression, poor sleep, and more.

Bullying has always been a problem, but now it is more widespread. Kids can’t even escape in their own home due to social media.

Screen time takes away from playing outside, which contributes to obesity.

Smartphones also decrease the time spent interacting with people in real life and getting tasks accomplished. When kids spend excessive time communicating with their friends through apps, they miss out on real interactions that can help develop important social skills. Although it’s not a diagnosis yet, screen behaviors seem to be very addictive. Limiting time can become difficult when kids always carry a device.

Screens interfere with sleep. Sleep is critical to a growing brain and body, so sleep deprivation leads to many problems.

Inappropriate material is easily accessible online. Kids learn how to starve themselves and get encouragement for unhealthy behaviors. They share challenges that are very dangerous. Pornography and sex trafficking are huge issues.

Look into the Wait Until 8th movement for reasons to wait until 8th grade to give your child a smartphone. Gain support from other parents when your child says they’re the “only one” without one. Even teens recognize the problem.

Being out and about

If you never let your child visit a friend’s home or play outside, they will learn to be afraid outside their own home.

Many parents are afraid to let their kids walk to school. Realistically it’s a low risk that their child will become abducted, but a very real risk that the loss of exercise will impact their long-term health.

It’s rare in many neighborhoods to see kids outside playing. Some may be inside unable to go out because parents aren’t home. Others prefer to play video games. There are many at structured after school activities, which don’t allow for child-driven play and problem solving. If other kids aren’t out playing, the incentive for your kids isn’t there to go outside. It isn’t as fun to play alone. Talk to your neighbors to find times that their kids will be home and encourage outdoor fun at that time. This helps to build your neighborhood into a community!

Dr. Peter Gray shows how the decline of free play is directly correlated with dramatically increasing rates of anxiety, depression, suicide, and narcissism in children and adolescents. He discusses why free play is essential for children’s healthy social and emotional development. He also offers suggestions of how we can make this happen while keeping our kids safe. Take 15 minutes to watch it.

Playing sports

As Dr. Gray mentions, it’s the free play that seems to be important to help our kids develop resiliency.

Our kids consider sports their “play” time, but sports are directed by adults. Kids don’t learn what they need to learn about creativity, self motivation, problem solving, and all the other skills learned by kid-directed and kid-initiated play.

Overprotected kids

An article that I read years ago still resonates with me. The Overprotected Kid shows how parents try so hard to keep their kids safe that we sometimes prevent them from learning about real life.

The article is based on allowing kids to roam and play with things that haven’t been engineered to keep them safe. In our litigious society, that seems excessively dangerous to some. There are even stories of parents being turned into authorities for allowing their kids unsupervised time outside or even taking public transportation to school.

In my opinion, too many parents worry that kids aren’t safe when unsupervised. They forget what dangers lurk in too much supervision.

Where’s the right balance?

Building Snowmen from Snowflakes

Dr. Tim Elmore is a recognized speaker and author who focuses on building the next generation. Here’s an excerpt from his post, How to Build Snowmen from a Snowflake Generation:

Too often, our young give up due to “learned helplessness.” This happens, however, in both a surprising and sinister fashion. It’s all about control. Studies reveal that when the activities in their day are controlled by adults (and hence, not in their control), both their angst and hopelessness rise. The more we govern and prescribe the agenda, the less they feel hopeful and the more they feel helpless.

Further, learned helplessness promotes irresponsibility. Kids feel little responsibility to work because it’s “not up to them.” I believe most middle class students assume that if they make a mistake, some adult will swoop in and rescue them. While this may feel good, it hinders development. Feeling that outcomes are in their control gives them a greater sense of hope and ownership.

Established generations must slowly encourage and even insist on giving them control of the “agenda.” This is the only way to build ownership, engagement and responsibility. It requires trust and flexibility, since young people may not perform to our standards. We must decide what we want most: perfection or growth.

He goes on to say:
What message do you suppose it sends a student when the adults in his life continue to swoop in and save him whenever something goes wrong? While it may feel good at first, it communicates: “We don’t think you have it in you to solve this problem. You need an adult to help you.” Consequently, these young people don’t feel like adults themselves until somewhere between ages 26-29. They can remain on their parents’ insurance policy until age 26. In one survey, young adults reported they believe adult-life begins with “having their first child.” Today, this doesn’t happen until long after 18 years old. So while we give them the right to vote, they may have no concept of reality. Rights without responsibilities creates virtual adults and often, spoiled brats.
Teaching children responsibility is like teaching them to ride a bike. Offer less support and finally let go.

Growth Mindset

Did you know that success is not determined by intelligence? Our mindset, grit, and resilience are more predictive of success.

The good news is that we can all learn to have a growth mindset, which is a great start to becoming resilient. See my sister blog for more information on How to Get a Growth Mindset.

Success is correlated with a growth mindset more than intelligence. So how do you get it? It's not as difficult as you might think.
How to get a growth mindset.

Downsides of outside urgent cares

Do the downsides of using an outside urgent care outweigh the benefits? Is it worth it to wait for your usual doctor’s office?

I started writing a simple blog about using urgent cares appropriately to get the best care, but I quickly realized that it’s a bigger topic than it first seems. I’ve covered the visit experience itself and the benefits of using your medical home. Now it’s time to talk about the downsides of using an urgent care outside your medical home. Do the downsides of using an outside urgent care outweigh the benefits? Is it worth it to wait for your usual doctor’s office?

Who will you see?

There are many types of independent urgent cares. My community has some that are associated with hospital systems or pharmacies and some that are independent. They are staffed with many different types of providers. Some are even pediatric focused, but others are staffed with people who have little training or experience seeing kids. That means you need to know who you’re seeing and what their background is.

Limited pediatric experience

The provider at the clinic may or may not have adequate training in pediatrics. They often do not have others around who can help if a problem arises that is out of their comfort zone or level of experience and training.

This can lead to over treatment,  under recognition of a serious condition, and over testing with unnecessary labs or x-rays.

Training matters

Simply put, make sure your provider has extensive training in pediatrics.

This is not a “we’re better than you” point.

I do not think that every physician is a good clinician by default. Neither do I think nurse practitioners or physician assistants are not good at what they do. Both physicians as well as NPs and PAs can be great or not so great. We all have our strengths and weaknesses which are built on our interests, training, and experience.

I am getting the following numbers from What Kind of Doctor is Your Doctor? The link includes a nice chart of even more doctor types.

Pediatricians spend at least 3 years during residency learning how to take care of kids. This involves about 2400 hours per year for 3 years taking care of sick kids after medical school. Medical school is about 6000 hours of training. Total clinical training (excluding college years) is a minimum of 13,600 hours. Pediatricians know kids.

Family physicians also spend 3 years in residency after medical school, but that time is not focused on child health. The amount of training caring for children varies based on the program and their experiences.

Physician Assistants spend 2-3 years in a master’s program, with an estimated training time of 2000 hours total. This is not focused on child health at most programs. Much like family physicians, their time is divided between adults and children.

Nurse practitioners spend 1-2 years in a master’s or doctorate program. Clinical training requirements vary from 500-1000 hours. Again, these hours include both adult and pediatric patients. Traditionally most nurse practitioners went into graduate school after many years of nursing experience. That is becoming less common as many are going straight from nursing school into graduate programs, so they do not always have those working years of experience prior to getting their advanced degree.

Years of experience

Of course with all of the training hours, there is also experience after training. You are correct if you say that every person with experience is not better than someone without experience, but in general experience helps.

If a person spends 40+ hours a week for many years taking care of kids, they  continue to learn along the way. Sometimes they pick up bad habits, but I can only hope that with experience comes competence. This is best done when people work in a setting that has more experienced colleagues to offer advice along the way, not when they’re thrown into a clinic alone from day one and made to figure it out on their own.

Remember all those clinical hours medical residents spend learning? They are essentially working under those who are more experienced for several years, learning to manage complex (and minor) issues along the way. So even a brand new physician has more experience than some other providers with several years of work experience that may or may not have been supervised.

The risk of getting what you want vs what you need

Most people use walk in clinics for convenience. When their child is sick or injured, they want help ASAP. That’s understandable.

I’ve written before about why convenience isn’t always best and why sometimes it’s okay to wait. Here’s a very common example of not getting what you need:

If a baby is crying, the eardrum gets red, but isn’t necessarily infected.

Misdiagnosis

A provider without a lot of experience will often err on calling it an ear infection simply because it’s red. That makes parents happy because they think they’re doing something to make their child better.

They’re not if it’s not a bacterial infection. There’s risk to taking unnecessary medicine.

Quick medicine

It’s fastest to write a prescription and move on to the next patient rather than to explain what to do to treat a viral infection.

This is not good care, but it’s common.

Treatments don’t always need a prescription

Don’t feel like you leave empty-handed if you leave the clinic with the information that your child doesn’t need labs or prescription medicine.

Leave with the knowledge of what to do if symptoms change.

Learn how you can help ease symptoms and make them feel better.

You’re not empty-handed – you’re empowered with knowledge!

And then there’s the required surveys…

You have probably been asked to do a survey after shopping. Sometimes you do it for store credit or to help a nice sales person meet their quota.

Sadly, surveys have made their way into healthcare. We can’t offer a discount for your next visit, but many of us are required to collect a certain number of surveys each quarter.

Medical staff are being graded by patients to be sure they’re giving “quality care” ~ and I put that in quotes because I don’t believe that it measures quality at all. I discuss this in more detail in Don’t look for quick fixes for your cold!

Giving a prescription for an antibiotic makes parents happy, regardless if it is necessary. They feel like their trip was worth it because they “got something” to treat the symptoms. This means better satisfaction scores for the clinic because people like to leave with a treatment. It also brings in more money because faster turn around means more patients can be seen. The shorter wait time also drives up satisfaction despite the fact that it’s not good care.

It takes longer to explain how to treat a cold than it does to write a quick script. Parents are generally happy with the visit, but antibiotics are overused and the recommended treatments aren’t adequately discussed. And that’s not okay.

No follow-up

Independent urgent cares do not offer follow-up of issues to see if there is improvement.

Not following up not only prevents assurance that the patient gets appropriate follow-up, but it also keeps the provider from learning how diseases and conditions progress over time. This is one reason why some people with years of experience still tend to over treat or under recognize things.

Phone help

Stand alone urgent cares do not take phone calls to answer medical questions. They don’t even answer follow-up questions about your visit by phone.

If you have questions, you must call your PCP or return to the urgent care. If we haven’t seen the child for the issue, we are unable to give appropriate advice.

Prescription “refills”

I’ve been asked on many occasions to refill a medication from an urgent care because it was spilled or forgotten on a trip.

I can’t refill a prescription I didn’t write.

The parent can’t call the urgent care provider for a refill because they don’t accept calls.

That’s quite a predicament!

Referrals

If you require a referral to see a specialist for any reason, it is usually required for your PCP to do that paperwork. There are insurance plans that do not require referrals, and you may schedule on your own unless the specialist requires a referral.

If we haven’t seen your child for the issue at hand, especially if we have no documentation at all about the referral, we often cannot do it without seeing your child.

Why do we need to see your child first?

It is one of the requirements that we must abide by in some of our insurance contracts. Seeing the physician who knows a patient best can help to avoid unnecessary appointments with specialists.

Required documentation

Sometimes it’s as simple as we can’t refer for something we don’t know about. Many referrals require a copy of an office visit.

If we didn’t see your child for a visit, we have no visit supporting the need for the referral. We need documentation to send for the referral.

Sometimes a specialist is not needed

I have seen many situations where an urgent care physician, NP, or PA recommends follow-up with a specialist of some sort that isn’t needed. They often don’t realize that it is quite within the scope of practice of a primary care provider. They cannot know the skill set of every PCP in town. Call your PCP to see if they can handle the issue. It can save you money in lesser copays if you see your PCP first.

An example of this is a concussion. Every provider in my office is competent following most concussions and clearing for play when indicated. Other examples are rashes (including acne), simple fractures and constipation. I’ve seen patients who waited a very long time and paid a lot of money to see specialists for each of these indications based solely on the urgent care recommendation. Most of the time I’m completely unaware of the whole issue until I see them next and they mention seeing the specialist.

They get the same treatment plan at the specialist as we could provide in my office, but at a much higher cost and decreased convenience.

Incorrect diagnosis

I’ve also seen a number of kids with issues diagnosed at urgent care centers that I disagree with the assessment or plan. This brings us back to all the issues listed above.

One common example of this is a toddler with “recurrent ear infections” who has only had ear infections when seen by an urgent care provider. Every time they see me with the same symptoms, their ears are okay. I often wonder if these kids ever had a real ear infection. Maybe they did and it is simply coincidence, but if they didn’t, they don’t need the risk of anesthesia for tubes. I’d like to have the conversation face to face with the parent after I examine the ears myself.

Continuity of care

There are gaps in care even at urgent cares where there is a pediatrician, nurse practitioner, or physician assistant with extensive pediatric training.

They do not know your child’s full medical background and do not update your child’s health record in the medical home.

Following in one office allows us to see the chronicity or recurrence risk of an issue. If your child goes multiple places for every sore throat, no one recognizes that a tonsillectomy might be beneficial.

Related posts

Don’t look for quick fixes for your cold!

Convenience Care

Help Us Help You! Make the most out of phone calls

Improper Use of Antibiotics: Don’t take the risk

Top 10 Tips for Going to an Urgent Care

Evolution of Illness

Don’t withhold recess!!!

Play is an important part of every child’s day. Recess should never be held for behavior modification. Chris Dendy shares important facts in this post.

I’m amazed at the number of parents who tell me that their child misses recess to finish homework or as a consequence for inappropriate behavior. It seems counterintuitive to restrict play when kids are unfocused or behaving out of line. We now have a lot of research on how kids with ADHD don’t respond to typical behavioral modifications. It’s not really a choice for them to do the behaviors they’re doing, so trying to offer recess as a reward just doesn’t work. With all this accumulated research, it’s surprising that some schools and teachers continue to support restricting recess.

Today’s blog is from Chris Dendy, an expert on ADHD. She is an acclaimed author and speaker. Chris has worked as a classroom teacher, school psychologist and mental health counselor. She’s worked as local and state level mental health administrator, has been a lobbyist and has served as executive director of a statewide mental health advocacy organization and as a national mental health consultant on children’s issues. Her Facebook post below shows the importance of recess.

I have edited her original post to make headlines more visible, but I did not change the content at all. See her original post linked at the bottom of this page.

BOTH AAP & CDC STRESS THE IMPORTANCE OF PLAY

EVERYONE SUFFERS WHEN YOU WITHHOLD RECESS:

When recess is withheld as a punishment for misbehavior or incomplete academic work, both teachers and children suffer. Teachers who know their research never withhold recess and here’s one key reason why:
“misbehavior is higher on days when children with ADHD don’t have recess.”

CHILDREN’S BRAINS WORK BETTER AFTER EXERCISE:

After exercising, students show improved attention, retention of information, working memory, mood and social skills. School officials also report a reduction in school suspensions. Students with better fitness levels earn higher scores on academic achievement tests.

EXERCISE GROWS NEW BRAIN CELLS:

Interestingly, John Ratey, M.D. a well-known psychiatrist, describes exercise as “Miracle-gro” for the brain because it actually builds new neurotransmitters and increases blood flow to the brain. The author of How the Brain Learns, Dr. David Sousa, explains that “down time” is needed to allow the brain to recharge and process new information. Recess provides this much needed recharging time.

IF A STUDENT IS CONSTANTLY MISSING RECESS, LOOK FOR UNIDENTIFIED LEARNING PROBLEMS:

One of the most common reasons for keeping students in during recess is to complete unfinished work. Instead of withholding this important activity, educators must determine the underlying reason for the failure to finish the classwork and implement a preventive strategy: utilize positive interventions instead of punishment!

For example, the culprit may be deficits in executive skills including inattention, difficulty getting started, or slow processing speed. Secondly, many students with ADHD have trouble getting started on their work and must be given an external prompt to start working. Finally, twenty-eight percent of children with ADD inattentive have slow processing speed. Children who struggle with this slow processing should be provided shorter assignments and/or extended time.

Unfortunately, researchers report that many of our children are on doses of medication that are too low for peak academic performance. Even though they are on medication, students with low medication doses will have problems paying attention and working efficiently. Teacher rating scales of classroom performance are available that reflect how well medication is working.

INCREASE MOVEMENT THROUGH “IN-HOUSE FIELD TRIPS:

Veteran teacher Jackie Minniti, suggests giving “in-house field trips” to allow increased movement and subsequent increased blood flow to the brain: for instance, give out supplies, close the door, take a note to the teacher across the hall that simply says, “Hi”, and then the student returns to his class. Doing jumping jacks or dancing to music in the classroom can be very helpful. Minniti’s positive incentives include rewarding timely work completion with five minutes extra recess time or giving stars on a chart toward a class pizza party.

FIND VOICE OF REASON AT SCHOOL OR ASK YOUR DOCTOR OR PSYCHOLOGIST TO WRITE A STATEMENT SAYING RECESS SHOULD NOT BE WITHHELD.

If you have a reasonable teacher, talk with her about trying these positive intervention strategies first instead of punishment. If you think the teacher will not be receptive to your suggestions, then consider getting a note from your physician stating that your child must have recess each day. The next step will be to ask that deficits in executive skills and the need for recess be addressed in an IEP or Section 504 plan. If the teacher fails to comply with these requirements in the IEP, you will have to approach the guidance counselor, special education coordinator, or principal for assistance.

THE CENTER FOR DISEASE CONTROL (CDC) STATES THAT RECESS SHOULD NOT BE WITHHELD AS PUNISHMENT:

Because of growing concerns about obesity and other chronic diseases, Congress passed the “Healthy, Hunger-Free Kids Act” in 2010 that resulted in the Centers for Disease Control in Atlanta developing guidelines in several areas including recess.
Each local school system that has a National School Lunch Program must develop a school wellness policy to address Congressional concerns. The CDC expressly states, “Schools should not use physical activity as punishment or withhold opportunities for physical activity as a form of punishment.” Exclusion from recess for bad behavior in a classroom (including incomplete academic work) “deprives students of physical activity experiences that benefit health and can contribute toward improved behavior in the classroom.”

AMERICAN ACADEMY OF PEDIATRICS (AAP) STATES UNSTRUCTURED FREE PLAY IS CRITICAL:

Here are highlights adapted from their policy statement.

1. Eliminating recess may be counterproductive to academic achievement. Recess promotes not only physical health and social development but also cognitive performance.
2. Creative supporting free play as a fundamental component of a child’s
normal growth and development.
3. Recess is a necessary break in the day for optimizing a child’s social,
emotional, physical, and cognitive development.
4. Recess may help provide the recommended 60 minutes of moderate to vigorous activity per day to fight against obesity.
5. Recess offers the opportunity to build lifelong skills required for communication, negotiation, cooperation, sharing, problem solving.

Updated from Dr. Dendy’s original article published in ADDitude magazine.

For more information:

From the AAP: The Crucial Role of Recess in School

Why Wait to See Your Regular Doctor?

Why should you wait to see your regular doctor? The benefits of using your regular doctor’s office to see your PCP or another provider with access to your child’s medical record are many. I previously wrote several tips about how to use an urgent care wisely, but I wanted to spend more time on the benefits of going to your own doctor rather than an independent walk in clinic in more detail, so removed that portion of the post.

Almost as promised, here it is. The almost is that I promised to post this the next week, but a few other topics interrupted the posting schedule. Better late than never!

There is more to this than could be covered in one post, so this is Part 2. It covers the benefits of seeing someone in your regular doctor’s office. Part 3 will cover some of the problems with seeing someone in an independent urgent care.

Your primary care office knows you

Humans benefit from relationships in many ways. When you see the same people over and over, familiarity brings comfort. This can be the same face at the reception desk, the same nurses, or the same physician. Even if the faces change from time to time, the overall clinic’s familiarity can bring comfort in a time of significant illness or disease. When you have something difficult to talk about, it’s easier with someone you’ve built a trusting relationship.

Consider teens…

Think of tweens and teens who need an adult to ask for advice.

If they do not have a medical home where they feel welcome, they are less likely to talk about their problems.

As much as we’d all like to think that our kids will talk to us, they aren’t always comfortable with that. I’ve had kids ask parents to leave to talk about so many issues. Some of their “confidential questions” may seem silly to not talk about with a parent, such as how to use deodorant or how to shave, but it happens. Some are really troubling things, such as suicidal thoughts or abusive relationships.

These need to be discussed with a responsible adult, not another tween or teen, so I’m happy when they are comfortable talking to me.

If they’ve come to the same place year after year for illnesses, injuries, and yearly well visits, they will feel more comfortable.

Even different faces in the same practice offers some consistency

Even if you see different physicians, NPs, or PAs from time to time or go to a satellite office, there is still continuity within that practice.

The medical record has your child’s immunization history, previous drug reactions, any underlying illnesses or frequency of illnesses, as well as any other pertinent information. As long as you use that clinic for most medical care. The more often you use outside clinics, the less comprehensive the medical record becomes.

Primary Care Providers (PCPs) and their staff also know your family and that alone can help!

Business of medicine

Talking about the business of medicine might seem self-serving, and it is, but think about keeping your favorite physician in business. The reality is many private clinics are selling out (or just joining) larger health systems. This raises healthcare costs, increases administrative burdens, and diminishes the personal touch of healthcare.

I hate thinking about business and insurance issues, but as a business owner, I must.

I have two big regrets from my student days.

The first is that I wish I studied abroad because once work and family life start, it’s too hard to take long trips.

The second is that I wish I took business classes to prepare myself for a career in medicine. Most medical students are so eager to learn the massive information about medicine, they forget that one day they might be a business owner.

Unfortunately the number of physicians who own their own practice is falling. I suspect that has a lot to do with physician burnout and the increasing suicide rate of physicians, but that’s another topic!

I’ve learned a lot of business along the way, in large part to SOAPM. Unfortunately not all physicians have learned about business. Life is busy and it’s hard to balance everything. We tend to already work long hours, so it’s hard to fit one more thing in at the end of the day. I think medicine is in the state it’s in now because healthcare has been led by non-clinical business people who might understand business, but have no idea how it impacts the health of people.

Care outside your primary office (Medical Home)

Now that many routine visits are going to outside providers, family physicians and pediatricians are struggling to stay in business.

We still see our patients for illnesses, but they tend to be more chronic issues.

Daily headaches for the past 6 months takes a lot more time in the office than an earache that started this morning. We can’t see as many chronic issues as acute illnesses, so the amount of money we bring into the office is down due to less volume.

The costs of rent, insurance, staff salaries, and more doesn’t go down, so covering those costs becomes difficult.

Urgent care from a business perspective

Routine sick visits are quick and easy.

They’re the bread and butter of primary care offices.

That’s why urgent care centers are popping up in pharmacies and on every other corner. They are short visits, but insurance companies pay well for them. Because they’re short, many can be done in a standard shift. This brings in easy money to a clinic.

Chronic issues, mental and behavioral health, and other issues not typically seen in urgent cares take more time.

If a patient with symptoms more than what can be handled in an urgent care shows up, they are quickly assessed, offered a token treatment and told to follow up with their doctor. Or they’re simply told to go to the ER. Urgent cares don’t waste time on big issues.

The impact urgent care use has on a PCP schedule

You wouldn’t think at first of all the trickle down effects that going elsewhere for care has on your primary doctor’s life.

Remember that if we’re not seeing patients, we aren’t brining money into the practice. The money doesn’t directly line our pockets – it’s needed to pay essential bills. We have to fill our day with patients one way or another.

Well visits and short vs long sick visits

Many doctor’s offices differentiate sick and well slots in their appointment schedule. This allows us to see a balance of well visits for routine care as well as to save time for sick kids and those with chronic issues. Many of us have short and long visit slots to account for the amount of time typically needed for each visit concern.

The more patients go to urgent cares for quick visits, the fewer same day short sick visit slots are needed in PCP schedules. This means we must adjust our schedules to have more well visit and longer chronic issue slots so we’re not sitting around doing nothing.

Schedules of today look and feel different

Since we have less need for short acute visits, we fill those with longer chronic issue visits and well visits. Both of these tend to fill in advance, unlike short acute visits that tend to be needed on the same day.

Some days that means my patients who want to see me are told I have no availability. They can still be seen in my office’s walk in clinic, but they can’t schedule with me.  I’d like to be able to see my patients when they want to be seen, but supply and demand ring true.

Unfortunately, these longer visits are relative money losers and they can be more emotionally draining for the physician due to the chronic nature of the conditions seen. Some days I wish to be able to see a straight forward earache or sore throat….

How much is a visit worth?

We use a billing system that identifies an office visit by complexity and time. This is set by regulations, not your doctor’s office -unless they’re a concierge cash based practice.

A typical sick visit that lasts about 10- 15 minutes is considered a 99213, which is valued at about $74. So two sick visits is therefore worth about $148.

If a visit is over 25 minutes or complex, it is considered a 99214, which is valued at $109. We therefore lose nearly $40 for every prolonged visit because we spend more time. If we saw two different patients in that same time, we’d bring more money into the practice.

Once in awhile this isn’t a big deal, but as more people go to urgent cares for routine illnesses, PCPs are left with mostly complex visits. This hurts the bottom line and is emotionally more draining for the physician. It’s hard to deal with serious issues all day long.

This isn’t about being greedy.

If I was in it for the money, I wouldn’t have picked pediatrics after medical school.

Pediatricians are consistently some of the lowest paid physicians.

I chose pediatrics because I love it. But I still have to pay the bills at the end of the day. We have to pay office rent (or mortgage), malpractice insurance, insurance on our vaccine supply and other inventory, salaries for all staff, health insurance for staff, IT equipment and management, ect.

Just like any business, it takes money coming in to stay in business.

Changes to the value of a visit?

There’s a proposal to change the way office visits are paid by insurance companies.

This is a proposal to have insurance companies set the relative value for each visit at the same payment rate. This means if you’re seen for 5 minutes the doctor gets paid the same as if they spend 45 minutes with you.

I see this being very detrimental for pediatric care because it will encourage many quick visits instead of a comprehensive visit. But if we spend too long with a patient, we can’t earn enough money to pay the bills at the end of the month, so it will be necessary to make visits short to be able to see enough patients at the end of the day to cover costs.

I worry that people will gloss over issues that need more time. Abdominal pain is commonly constipation, but can be many things. We just won’t have time to talk it all through in one short visit.

This is a proposal that will benefit the independent walk in clinics that tend to see many earaches, coughs, rashes, and other quick issues. It will not be good for those of us who manage a lot of mental and behavioral health.

Or our patients.

Free advice is bad for business

It gets worse. Pediatricians give away advice for free all the time.

People call us to ask how to manage symptoms and conditions throughout the day and night. Most of these calls are done for free, yet we pay for staff to take them.

Often parents call and we give advice on how to manage symptoms before following up in the office during business hours. It isn’t uncommon to learn that parents took their child to a late night urgent care instead of waiting.

Parents often call asking if the care given elsewhere is appropriate or if we can we write a school excuse or refill medications when we never even saw the child for the issue.

We can’t manage what we didn’t see.

If you bring your business elsewhere, only go where you trust that the provider has experience with children and can handle your child’s symptoms. When you have questions about their treatment plan, ask them. If you need a school or work excuse, ask them for it.

You’d never buy a Kia and then ask Toyota for parts or free repairs. You return to the original dealer, right? (I chose these brands because they’re the two in my garage now. I have nothing against either, but they’re different.)

Urgent cares don’t give away anything for free.

Stand alone urgent cares don’t cover questions 24/7.

Primary care offices are required to offer 24/7 phone availability. Either they staff it themselves or they pay someone else to do it.

This is just one more way that urgent cares have the business advantage. They don’t have this monetary cost or quality of life issue.

All these calls hurt a medical home’s bottom line because we’re paying our staff to talk to families – often back and forth calls. It’s a considerable amount of time. Time for a service that brings in no money, but we still must pay staff to do it.

Physician burnout

You might wonder what physician burnout has to do with a person choosing to go to an outside urgent care or their physician’s office.

A lot really.

There’s of course a financial loss when people go elsewhere, but it’s more than that.

As mentioned above, the more urgent cares are utilized, the more a PCP must handle more difficult chronic problems, which tend to be more emotionally draining.

PCPs now have to spend extensive time documenting review of outside provider notes. Insurance companies are setting many rules and protocols to reconcile charts and update the primary care record whenever our patients see other providers. In the paper chart days, I could quickly skim consultant notes, but now it takes a couple of hours per day of unpaid time to review them all.

Seriously. Hours. Every day.

I struggle to keep up. And I’m not alone.

New reports come in every day – even when we’re off.

I’m guilty of logging in even when I’m on vacation. This is not healthy for me mentally. I know that. It’s bad for what should be my personal and family time. It’s just easier to me though to spend this time logging in so I can “do a few charts” to keep me from being overwhelmed when I’m back to work. There’s no time to catch up when I have to see patients all day and continue to get new charts to review each day.

Our physicians try to help others out when we’re on vacation, but many charts really should be seen by the PCP, not the partner.

Every day I go to work before seeing patients and stay a couple hours after I’m finished seeing patients. I review charts as I eat lunch unless I have a meeting so I can get home to my family a little earlier each day.

Charting does not bring satisfaction.

One of the benefits of working in healthcare is the satisfaction of knowing that we help others. All the years in training. The sleepless nights. Missed kids activities. All of this is worth it when we feel like we make a difference in someone’s life.

Reviewing charts does not help me feel like I am taking good care of patients. It does update me on what’s going on with them, but it isn’t fulfilling like when I see a patient and help them.

There are so many clicks to review one chart and update it as expected – reconciling mediation lists, updating hospitalizations or the injury list, and more. It’s difficult to keep up.

If most care is done in the medical home, the chart is updated at the time of the visit and these chart reviews would be less. Sometimes it is not advisable to stay within the medical home. There are true emergencies and times that specialists should get involved. These are unavoidable and necessary.

Most urgent care trips are not really urgent. They break the medical home concept for convenience.

No wonder there’s so much physician burnout these days.

Not only do we need to see more difficult or chronically sick patients because the quick acute care illnesses go elsewhere, but we also must review their notes and incorporate them into the patient chart for zero reimbursement.

That’s asking for burnout!

Use the Medical Home

What can you do to help your physician avoid burnout and stay in business?

Be seen by them whenever possible. Let them see the volume of patients they need to see to cover costs. Use them for quick sick visits as well as routine physicals and following up of chronic issues. Avoid going elsewhere unless it’s really needed.

The reality is that many private practice physicians are selling out to (or simply joining) big corporations because they can’t make ends meet.

I’ve heard their patients complain about the loss of personalized service and added costs.

Please consider the long term effects when you use outside services.

What keeps patients in the medical home?

There are many things that have been tried to allow people to be seen in their medical home. Not all work.

Sometimes people just think another location is more convenient. I know this because I get reports from urgent cares that saw a patient of mine when we were open. Instead of calling for an appointment or coming to my office’s walk in, which is available all hours that we’re open, they go elsewhere.

Extended hours

I’ve heard time and time again from patients, other physicians, and medical administration types that extending hours is important to private practice.

Even this can be a problem.

We see patients use outside urgent cares when we have regular business hours. Maybe a 5 minute shorter drive makes a difference?

My office even tried extending hours beyond our already generous regular hours. We were already open longer than standard business hours and our regular hours include walk in for patients all day every weekday and half days on Saturdays, but we stayed open even later for awhile.

Staying open later increased our expenses in staff salaries, but we found that people still went to other urgent care centers. We lost money at that time of day. People had asked for later hours, but then didn’t use them.

Walk in

One of the most complimented aspects of my office is the availability of our walk in clinic. Our patients can be seen in our office by one of our staff any time we’re open by simply walking in.

This has many of the benefits of being seen in the medical home while offering the flexibility of other urgent cares.

It still has the downside of not being able to see your PCP. You will see whoever is staffing the walk in clinic at that time, and of course this person can always consult with your PCP if needed.

It also has lead to the schedule changes noted above, since most people prefer this convenience. We now have relatively few short sick visit slots in the schedule. This can lead to less availability when there are a number of parents who prefer a scheduled appointment on the same day.

Phone calls

As mentioned above, PCPs must be available 24/7 by phone.

A phone call can be used by parents to keep their kids out of urgent cares and ERs. We can offer advice to get through the night (or until the office opens).

Follow the advice, and if your child needs to be seen, try to do it in the medical home. Of course if your child is in uncontrollable pain, is struggling to breathe, is dehydrated, or has other significant issues, he should be seen immediately.

Many offices, my own included, offer a ton of free advice on our websites. This has been debated from a business standpoint since it’s free advice. From a quality of life standpoint, the clinicians in my office like having things easily accessible for parents. When we give advice on the phone or during an office visit, much is forgotten. Having it easily accessible for parents to review is a great resource for them and helps to decrease the number of return calls for clarification. This also helps the physician’s quality of life.

Telehealth

There is a general push toward providing virtual visits through secure video conferencing. Even my insurance company keeps pushing me to register so that I can easily be “seen” when I’m sick. (I haven’t.)

I think this is a very dangerous slippery slope. Many sick people need to be examined to be able to properly diagnose things that require prescription treatments. Yet I know they are happy to call and get a prescription, so if it’s available they will use it.

Again, getting what you want is not always what you need.

I do see great potential for telehealth in the medical home and to improve access to specialists. It can be used to follow up on many issues in an appropriate way.

I worry that people will use it to get poor care for common acute sick issues. When your baby’s fussy or has a fever, you just want help, right? Just because you can doesn’t mean you should use it.

I strongly believe that we need guidelines to use this as a way to bring care to people when they could benefit from it. But telehealth should be restricted to only appropriate uses.

Related posts

Don’t look for quick fixes for your cold!

Convenience Care

Help Us Help You! Make the most out of phone calls

Improper Use of Antibiotics: Don’t take the risk

Top 10 Tips for Going to an Urgent Care

Evolution of Illness

From Dr. Mick Connors in Contemporary Pediatrics: What happened to the pediatric medical home?

Flu Vaccine Season 2018-2019

What’s the new with the flu vaccine season 2018-2019? Who needs the vaccine? Should you get the shot or nosespray? Which one is preferred by experts?

Every year the flu vaccine season throws us something new and challenging. The buzz this year is pediatricians questioning what to recommend with the new version of FluMist.  So what’s new with the flu vaccine season 2018-2019?

If you tried to get a FluMist vaccine for the past couple of years, you know that it wasn’t available. It did not seem to be effective, so it was removed from use. It has been reconfigured to improve the efficacy. The CDC’s Advisory Committee on Immunization Practices (ACIP) is allowing it to be re-released for the 2018-2019 season.

There are many versions of the flu shot. Some contain 3 strains of flu protection, others have 4 strains. Use of each is dependent on age and other factors. There is only one version of nasal spray flu vaccine, the FluMist.

Flu Vaccine Season 2018- 2019 ACIP Recommendations:

    • Everyone over 6 months of age who does not have a contraindication to vaccination should get a flu vaccine.
    • No preference is given for one vaccine product over another, as long as it is age appropriate and there are no contraindications. (See Controversy for details on this.)
    • Children under 10 years of age who have never had a flu vaccine should get two doses this year.
    • If vaccine supply is limited, high risk people should get priority. This includes:
    •      children 6-59 months
    •      adults over 50 years
    •      those with chronic diseases
    •      immunocompromised persons
    •      pregnant women
    •      American Indians and Alaska Natives
    •      morbidly obese people
  •      residents of long term care facilities

For the full report of recommendations, see MMWR: Prevention and Control of Seasonal Influenza with Vaccines: Recommendations of the Advisory Committee on Immunization Practices—United States, 2018–19 Influenza Season.

The big questions that may be on your mind:

1. When’s the best time to get a flu vaccine?

The CDC recommends starting to vaccinate as soon as it’s available (usually August or September) and to have the vaccine given by Halloween.

It’s not hard to see the logistical problems of vaccinating essentially everyone in the two months of September and October.

Some of the problems getting masses vaccinated:
  • Getting the vaccine itself. Recently flu shots have started to be delivered around the country. They seemed to show up first at big chain pharmacies before doctor’s offices. There aren’t any shortages this year so far, but not everyone can get all their vaccine orders at once.
  • The FluMist hasn’t been approved for shipping yet, so no one has that at this time. If you’re hoping to get it, you’ll have to wait. No approval date has been announced as far as I know.
  • I’ve heard that some Vaccine For Children (VFC) programs haven’t even opened up their ordering for the year. (Most flu vaccines are ordered in January or February for the next vaccine season, but VFC programs are state run and vary in rules.) If your child will require a VFC vaccine, you will likely have to wait until your clinic has them in stock, even if they have other flu vaccines.
  • Many years there are shortages. Those are hard to anticipate, but are another reason not to turn down a vaccine if it’s offered.
  • Having extra personnel skilled in giving flu vaccines available is difficult when they’re needed to perform typical work. Giving vaccines takes time. There’s a lot behind the scenes that needs to be done and documented in addition to the time of getting people prepared for the shot itself. And we all have seen the kids who put up a good fight, which means the nurse can’t quickly give the shot.
  • There are always time conflicts getting to a place that offers flu shots.  Work, school and activity schedules are busy. It can be hard getting everyone in the family to a place that has the right vaccine for each person at a time that you’re not busy.
What if you aren’t vaccinated by Halloween?

There will be many who continue to be vaccinated in November and beyond. It is recommended to continue vaccinating until the vaccine supply is gone or the season ends. The flu season can possibly last through May in the Northern Hemisphere.

Will an early flu vaccine last long enough?

I’m asked this question often. I’ve been told by several parents that they want to wait to get the shot for their family until October to optimize the protection during flu season.

While this sounds good in theory, I’m afraid that some of these people may miss the opportunity to be vaccinated before the flu hits.

Although we say that it tends to hit in January in my area, it can hit at any time. I’ve already heard of one case of Flu A in another local pediatric practice.

All vaccines take time to become effective, so waiting until you hear that it’s in the community is already too late in some respects. We often have more than one peak of flu activity each year, so still get the vaccine!

The effectiveness of the flu vaccine does decrease over time, but it’s estimated to last about 6 months. Unfortunately our season can last up to 8 months, so there is no perfect time.

What if we got our flu shot later in the season last year? Is it still good?

Each year the strains in the flu vaccines are updated to reflect the anticipated strains of influenza that will circulate. It’s important to get a new flu vaccine each season. Even if your child got a flu shot in May 2018, he should get another this Fall or Winter.

Who needs a second vaccine?

It is not recommended to get a second flu shot later in the season for most people.

Children under 9 years of age getting vaccinated for the first time need their primer dose and a booster dose at least 4 weeks later. Children who have previously received ≥2 total doses of influenza vaccine at least 4 weeks apart before July 1, 2018, require only one dose for 2018–19. The 2 doses of influenza vaccine do not have to have been administered in the same season or consecutive seasons. If they had only 1 flu vaccine before July 1, 2018, they need 2 doses this season.

number of flu vaccines needed
Grohskopf LA, Sokolow LZ, Broder KR, Walter EB, Fry AM, Jernigan DB. Prevention and Control of Seasonal Influenza with Vaccines: Recommendations of the Advisory Committee on Immunization Practices—United States, 2018–19 Influenza Season. MMWR Recomm Rep 2018;67(No. RR-3):1–20. DOI: http://dx.doi.org/10.15585/mmwr.rr6703a1

2. Will FluMist work?

Unfortunately, we won’t really know until the season is well underway. Every year we must wait to learn if the flu vaccine is effective. The effectiveness varies from year to year.

FluMist History

The FluMist was first approved in 2003. It was a welcome addition to the flu vaccine lineup because there are no needles needed. It seemed to be very effective initially. In 2014, the CDC’s Advisory Committee on Immunization Practices (ACIP) even gave it preferential status because it seemed to be more effective than the flu shot version.

The very next year ACIP reversed its decision due to very poor performance of the H1N1 strain in the FluMist in the United States. (This didn’t seem to be a problem everywhere.) FluMist was removed from the market for two years as scientists tried to figure out why it didn’t work well so they could remedy the problem.

This Year’s FluMist

Testing of the new version shows that the new H1N1 LAIV strain (A/Slovenia) performed significantly better than the 2015-16 strain (A/Bolivia).  Does this mean that it will perform better this season? We really don’t know, but in February 2018, ACIP voted to bring back the newly formulated FluMist for the 2018-2019 season.

In years past it was recommended for anyone who had received the FluMist to avoid contact with immunocompromised people for 7 days. It is no longer considered to be a risk to most immunocompromised people to be around a recently vaccinated person. If the immunocompromised state is severe enough to require a protected environment, avoidance for 7 days after FluMist continues to be recommended.

Controversy

While most of the experts on the ACIP panel voted in favor to bring the FluMist back based on the study results, some members were not in agreement. They still worry that the FluMist may not perform well during the flu season.

The CDC official position states no preference between the FluMist and the shot version, as long as the vaccine is age appropriate and there are no contraindications, such as allergy or chronic disease. The shot is available for all ages over 6 months old, but the FluMist is only for 2 – 49 year olds.

The AAP (American Academy of Pediatrics) stance on the FluMist is that it should only be used when the shot version is refused or unavailable. They will continually monitor the flu vaccine effectiveness patterns and may change their recommendation. If your child is worried about giving the shot, check out ways to make shots less scary.

Interestingly, Dr. Paul Offit, one of our country’s leading vaccine experts, disagrees with the AAP.

So I think the AAP was wrong, frankly, to say that FluMist should only be used as a last-resort vaccine for influenza. Rather, they should have gone along with what the ACIP said, which was that these vaccines can now be used interchangeably for persons aged 2-49 years. ~ Dr. Paul Offit

3. What about egg allergy?

For several years now egg allergy is not considered a contraindication to flu vaccines. Despite this, people still think they cannot be vaccinated due to an allergy.

Severe allergic reactions to vaccines, although rare, can occur at any time, even in without a history of previous allergic reaction. The person giving flu vaccines should be able to identify and equipped to handle any allergic reaction.

Different influenza vaccines contain different amounts of egg components, so it is important to discuss the history of egg allergy with the person who will give the flu vaccine.

Recommendations for those with egg allergy:
  • People with a history of egg allergy who have only had hives after exposure to egg should receive influenza vaccine. Any version that is age appropriate can be used.
  • People who have required epinephrine after eating egg or who have had angioedema, respiratory distress, lightheadedness, or recurrent vomiting are considered higher risk with influenza vaccination. They still may receive an age appropriate influenza vaccine, but it should be done in a health care setting, such as a medical clinic or hospital. They should not get the vaccine at a community drive, such as in a school or church setting. Vaccine administration should be supervised by a health care provider who is able to recognize and manage severe allergic reactions.
  • A previous severe allergic reaction to influenza vaccine, regardless of the component suspected of being responsible for the reaction, is a contraindication to vaccinating with that vaccine in the future. This does not include the typical reactions of redness at the injection site, fever, or muscle aches.
  • No observation period is recommended specifically for egg-allergic people. If there is concern, a 15 minute observation period after any vaccine can be done. This is commonly done in the adolescent age group due to their high risk for passing out after any needle – shots or blood draws.

4. What if you’re traveling internationally?

Influenza season varies by location. In the US, we tend to think of it as a winter thing, but it can happen during our summer months elsewhere. Flu is seen in the fall and spring in addition to the winter months in Kansas.

In the Northern Hemisphere it tends to hit between October and May. The Southern Hemisphere’s season tends to be April through September.

Even the types of influenza that circulates can vary by location. These types affect the type of vaccine that is used in that location.

It’s recommended to be vaccinated against influenza at least 2 weeks before traveling to any location during their flu season. This can be difficult if there is not any flu vaccine in your area. It can also be difficult to find the correct strains of flu vaccine in your location.

Talk to your physician or a travel clinic to see what is needed and available.

5. Doesn’t the flu shot cause the flu?

No. No it doesn’t.

Flu is a very dangerous illness that results in many people requiring hospitalization. Each year previously healthy children and adults die from influenza.

The symptoms people get after flu shots often could be explained by many viruses. They are not the flu. If they really are flu symptoms, it is because the vaccine didn’t have time to take effect or it was a strain not included in the vaccine.

There is no plausible way that the injectable flu vaccine can cause the flu. There is no live virus in the injectable vaccine that can lead to flu disease. Injectable flu vaccines are made in two ways. Either the vaccine is made with flu vaccine viruses that have been ‘inactivated’ and are not infectious or with no flu vaccine viruses at all.

The most common side effects from the influenza shot are soreness, redness, tenderness or swelling where the shot was given. Low-grade fever, headache and muscle aches also may occur, but interestingly these same symptoms occur with placebo shots too.

How do we know it doesn’t cause illness?

Studies like this one in adults have compared side effects of a flu shot to side effects of a placebo with saline (salt water). The only differences in symptoms was increased soreness in the arm and redness at the injection site among people who got the flu shot. There were no differences in terms of body aches, fever, cough, runny nose or sore throat. These all can occur during the time frame that the flu vaccine is typically recommended. It’s just a coincidence if you “get sick” after getting the vaccine.

Studies in children are lacking. Ethically it is difficult to study this, since it would require not giving some children a potentially life saving vaccine if they receive the placebo.

What about the FluMist?

The FluMist is a live virus. It can cause congestion and symptoms like a very mild case of the flu.

FluMist can cause mild illness, but it prevents (or hopefully will prevent) significant flu disease symptoms.

6. What if you get the flu?

I’ll write separately about how to treat the flu and flu-like symptoms.

You can guess what it will say based on what I’ve written previously about fever being scary, how to treat coughs, and Tamiflu.

7. Why bother, since the flu shot isn’t effective.

The effectiveness of the flu vaccine is never perfect, but it’s better than nothing. For more on this, see The flu shot doesn’t work.

What's new for the flu vaccine season 2018-2019? Should we use the shot or nosespray?
This Flat Stanley spent time in our office one flu vaccine season. Given the paucity of good stock photos of people getting vaccines, I chose this one to highlight the point of few photo choices. And I think it’s fun.

New Car Safety Guidelines 2018

The #1 killer of our children over 4 years of age is vehicle crashes. New car safety guidelines are based on safety data to keep our kids safe.

The AAP recently released new car safety guidelines for kids. The number one killer of our children over 4 years of age is vehicle crashes. These new guidelines are based on safety data and research about how to keep our kids safe. They are not meant to keep kids happy. They will be hard to enforce at the beginning, but it’s worth it to keep our kids alive! Once kids know this is not negotiable, the fighting will decrease. Spread the word to your friends with kids so yours don’t feel like they’re the only ones who must stay in a safety seat. Plus you might save a life!

A big thank you to Molly Blair for the colorful photos!

General car safety tips

Car seat choice and maintenance

  • The best seat is not necessarily the most expensive. Choose a seat that fits your child and your car.
  • Car seats expire. Write when your seats are close to expiring on your calendar.
  • You should not buy a used car seat from anyone you don’t know. It is not possible to verify that it hasn’t been in an accident in this situation.
  • Register your car seat so you will be notified in case of recalls.
  • If you’re in an accident, your car seats may need to be replaced. Insurance may cover this cost.
  • Do not remove the stickers that provide important information, such as the height and weight limits of the seat.
  • Always review the size minimum and maximums of your car seat. Make it a habit to check the seat’s limitations after each well visit check to be sure your child’s height and weight still fit in the seat as it is being used.

Car seat use and mis-use

  • Bring your child and the car seat to a certified car seat installer with each change in seat and change in vehicle.
  • The most common mistake other than installing a seat improperly is to move a child to the next seat too quickly. Keep your child in the seat until they meet the height or weight limit. Each transition (from rear-facing to forward-facing, forward-facing to booster, and booster to lap/shoulder belt) lowers the child’s protection.
  • Do not use attachments, such as a head roll, in a seat unless it was tested and sold with your seat.
  • Keep bulky clothing and padding out of the car seat. Layer clothing if it’s cold. 
  • Rear facing allows the head and spine to be protected in case of a crash. It is the safest way to travel. The head, neck, and spine are all supported by the hard shell of the car safety seat. They all move together, with little relative movement between body parts.
  • When children ride forward-facing, their bodies are restrained by the harness straps, but their heads can be thrown forward in an accident. This can lead to more spine and head injuries.

potential problem with following the guidelines

  • If your child suffers from motion sickness (car sickness) when rear facing, talk to your pediatrician.
  • Kids will resist many things, including properly buckling up. It is worth it to insist that they’re safe. Try various parenting strategies.
          ~Model safe behavior by talking about what you’re doing as you buckle (since they can’t see you when they’re rear facing).

~Kids like choices, so offer choices about climbing in or getting put in the seat or if they want to help do the buckle. The choice is never whether or not to ride safely. Find acceptable choices that end with them properly buckled.

~There are more ideas in 5 Tricks to Get an Uncooperative Toddler Into Their Car Seat.

~Older kids can learn about why they need this level of safety seat to remain safe. I know my kids are both shorter than classmates, so it was a regular discussion in my house. They always ended up agreeing that it was necessary when we looked at age-appropriate crash pictures and safety data. (Do an online search to preview sites without your kids so they aren’t exposed to more than they can handle.) I ask kids in my office all the time if I should ride a motorcycle without a helmet – it’s legal in my state. They all say “no” and then seem to comprehend that just because it’s legal doesn’t make it safe.

Summary of the car safety guidelines

Infants through preschool years

Infants should always remain rear facing. Both rear-facing only seats and convertible seats can serve this purpose.

Infants should remain rear facing until they outgrow the limits of their car seat.

Rear-facing only seats

Rear-facing only seats are convenient because they can be snapped in and out of bases. This allows various drivers to have bases installed in their vehicle and the seat can be used in multiple vehicles.

Rear-facing only seats tend to have lesser weight and height allowances, but as infants become toddlers they do not need a carrying seat. Not to mention the safety issues with carrying a heavy kid in a heavy seat – we don’t need parents to hurt themselves!

Although these infant rear-facing carrying seats can be used to carry infants in and out of buildings to the vehicle, it is not recommended to use them long term outside of the vehicle. They are not approved for overnight sleeping.

Convertible seats

Convertible seats are able to be used rear facing until a child outgrows the weight or height maximum.

The minimum weight recommended to turn forward facing is now 40 pounds unless the seat has a lower maximum for rear facing.

This means most toddlers and preschoolers should be staying rear facing.

When kids turn forward in the car, they should stay in their harness.
When kids turn forward in the car, they should stay in their harness.

School aged kids

Convertible seats

Convertible seats will accommodate children rear facing until they are 40-90 pounds.

Keep ’em rear facing longer!

The earliest it is now recommended to turn kids forward facing is 40 pounds. I know kids will fight this, but it’s worth it based on the safety studies.

This means that kids who are school aged might still fit best rear facing.

Rear facing is the safest way to travel, and remember that the #1 killer of our kids over 4 years is automobile crashes. Let’s change that and keep kids rear facing longer.

When kids are over the rear-facing maximum of their seat, turn them around, but leave the harness on. There’s a reason race car drivers use a harness and not just a lap and shoulder belt. Harnesses are safer! Use it until your child outgrows the limits of the seat.

Race car drivers still use a harness seatbelt - your kids should use one too until they're big enough to fit without.
Race car drivers still use a harness seatbelt – your kids should use one too until they’re big enough to fit without.
Booster seats

Booster seats help keep the lap and shoulder belt positioned properly until a child is tall enough and old enough to not require it. It is generally around 4 foot 9 inches that kids are big enough to sit in most vehicles without a booster. Most kids are not this tall until 10-12 years of age, even though many state laws allow much younger kids to sit without a booster.

Age is not the main factor in deciding when a child should move out of  a booster. Use the 5 point test to see if your child fits properly in the vehicle. I always say it’s the size of the child as well as the size of the vehicle’s seat that matters.

Don't let kids move out of the booster seat too soon! Age doesn't matter as much as fit.
Don’t let kids move out of the booster seat too soon! Age doesn’t matter as much as fit.
Seat belt alone

When kids fit properly in the vehicle’s seat without a booster seat, they still should sit properly.

If your child cannot sit upright in the seat, a booster is still recommended to keep the belt properly positioned.

No one should slide their hips away from the back of the seat to slouch in the seat. This allows the seat belt to ride up onto the abdomen, which increases the risk of injury in a crash.

Use seat belts properly and have kids sit in the safest seat always! Only teens and adults should sit up front.
Use seat belts properly and have kids sit in the safest seat always! Only teens and adults should sit up front.
Front seat

All children less than 13 years of age should remain in the back seat.

It’s easy to remember that only teens and adults can sit up front.

This is not based only on height or weight. Physical maturity makes a difference as well.

And remember…

Don’t rush your kids to grow up too soon!

Top 10 Tips for Going to an Urgent Care

School’s back in session, which means sick season is approaching quickly! The pure volume of sick visits can be overwhelming for any clinic, whether visits are scheduled or walk in, but the nature of walk in clinics makes the volume unpredictable. Sometimes no one in walks in, other times several come at once. Urgent cares and walk in clinics are wonderful for the overall speed at which one can be seen, but how can you help streamline the process? How can you keep your primary care physician in the loop? Here are my top tips for a successful urgent care trip and knowing when to avoid them.

1.  Write down symptoms.

It sounds crazy to write down things since you know your child better than anyone, but if your child is sick you are probably sleep deprived and might forget important details.

Writing things down helps everyone summarize what is going on and get facts straight. The diagnosis often lies in the history, and if the person bringing the child in does not know symptoms well, it’s difficult to make a proper diagnosis.

This also forces you to think about the symptoms, and you might realize that you don’t know everything that’s going on. This is especially true if your child spends time away from you at school, daycare, or with another parent. It’s better to recognize that you need more of the story before you get to the clinic!

2.  Expect to be seen for one acute problem.

Illnesses typically have more than one symptom despite being a single illness. It’s appropriate to bring a child in for multiple symptoms, such as cough, fever, and sore throat.

It is not appropriate to bring them in for those issues as well as a wart and headache of 3 months off and on. If there are unrelated things, expect to deal with the most acute issue and then follow up with your usual physician to discuss the more chronic things at a scheduled appointment.

The nature of walk in clinics is that they move rapidly. The number of patients checking in at any given time can be large, so each visit must be quick. If you need more time to address many issues or one big condition, schedule an appointment.

3.  Don’t attempt to get care for a chronic issue.

Chronic issues are always best managed by your Primary Care Provider (PCP), but exacerbations of chronic issues might need to be seen quickly.

This means that sudden changes to a condition, such as wheezing in an asthmatic, can be addressed at an urgent care, but routine asthma management should be done during a scheduled visit. Your child can go to the walk in for the wheezing, but should follow up with the PCP with a scheduled appointment to discuss any changes needed to the daily medication regimen (Action Plan) to prevent further wheezing.

This is especially important if you went to another urgent care or ER for initial treatment so that your doctor knows about the recent exacerbation of a chronic issue.

4.  Do not add additional children to the visit.

Many parents bring additional kids to the visit and ask if we can “just take a peek” in their ears.

If you want them to be seen, check them in too. Again, walk in clinics move quickly and the “quick” peek often takes longer than you’d think because the child is running around the room or fighting the exam.

The quick peek also does not allow for documentation of findings in the medical record, which might be helpful in the future.

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

Streamline checking in by having everything ready.

It’s surprising to me how many people must return to their car for their wallet. For safety reasons, never leave a purse or wallet in your car.

6.  Try to bring only the child who is being seen.

It is difficult to focus on one sick child when another is running around the room, falling off the exam table, or constantly asking questions. This applies to scheduled as well as walk in visits.

I know this becomes a childcare issue, but it can really help focus on the child being seen if you leave additional children at home if at all possible. Think of friends who always offer to have a play date with the healthy child. Or maybe plan to bring one child when the other is at school.

If you must bring multiple kids, set the stage right by avoiding bringing tired and hungry kids. Don’t come at nap time if at all possible. Tired kids are miserable kids. Give them a healthy snack before going to the clinic. Don’t feed your kids at the office – another child could have a food allergy to whatever you’re feeding them, which can put other kids at risk. Bring books or toys that your kids can be entertained with during the visit.

7. Bring medications your child has recently taken.

Often parents have tried treatments at home, but are not sure what was in the bottle.

Bring all medications to help us advise on correct dosage and use of the medications. This includes prescription medicines as well as over the counter supplements, medicines, and natural therapies.

8. Use your regular doctor’s office if available.

I know not all doctor’s offices have walk in hours and most are not open all night long, but most walk in type visits are not emergent and they can wait until the next business day.

Treating symptoms with home remedies is quite acceptable for most illnesses for a couple days. This might even be beneficial to see how the symptoms change over time. Some kids are brought in at the first sign of fever, and look normal on exam, only to develop cough and earache over the next few days. When the symptoms change, so might the exam and treatments!

This is a very important issue and I’ll write more on it next week. Stay tuned! ***Check out Why Wait to See Your Regular Doctor ****

9.  Please don’t use walk in clinics to have health forms filled out.

I know it is tempting to get a quick physical to get a sports form or work physical signed, but doing so breaks the concept of a medical home.

If you get these forms completed outside your PCP’s office, you don’t get a comprehensive visit. The visit with your PCP should include reviewing growth, development, safety, immunization status, and more. It’s more than just filling out forms. You lose the opportunity to share what has happened in the past year and continue to build a trusting relationship.

If the medical home does all the well visits and vaccines, we have up to date records and can update them as needed. Some kids have missed school because vaccines were missed and they can’t return until they get them. Others have gotten extra doses of vaccines because a record of a shot was missing and parents can’t remember where they got the vaccine.

We request a well visit yearly in the medical home after age 3, more often for infants.  If in need of a well visit, please call the office to schedule!

10. Call first if you’re not sure!

If you’re not sure if it’s okay to tough it out at home overnight, call your doctor’s office.

We can often give tips on how to manage symptoms to save the emergency room co pay and germ exposure. Sometimes we do advise going to be seen. If there are concerns about dehydration, difficulty breathing, mental status changes, or other significant issues, waiting overnight is not appropriate.

Most urgent care visits are really not that urgent. They can be handled during normal business hours in your medical home!

Related posts

Don’t look for quick fixes for your cold!

Convenience Care

Help Us Help You! Make the most out of phone calls

Improper Use of Antibiotics: Don’t take the risk

Top 10 Tips for Going to an Urgent Care

Evolution of Illness

Why Wait to See Your Regular Doctor When the Urgent Care is Right There?