Practical at home tips for illnesses

When your family gets sick, what can you do before running to the ER or clinic?

When cold and flu season is in full gear, it’s helpful to know common things that can help us prevent and treat whatever is in town. Many of the viruses that run around each season don’t have specific treatments, but there are things that we can do at home to treat symptoms and keep people more comfortable. There are also things we can all do to prevent the spread to other family members or back into our community.

What can be done to feel better?

Remember that nothing can be done to treat most viruses. Our body’s immune system will take care of that, but we can do things that help us feel better during the illness.

It’s hard to make them better, but we can make them feel better

Most cough and colds last several weeks. Vomiting and diarrhea can last a couple weeks as well.

During the cold and flu season, it can seem like kids are sick every day for months because they catch one on top of the other. Some of these days they might simply have a runny nose, and those days can last most of the year in young kids.

It’s when they seem uncomfortable or distressed that we need to do more. Treat the symptoms that bother them.

Identify the symptoms that are concerning, such as difficulty breathing or dehydration, and seek treatment at your doctor’s office for those.

What about fever?

Notice I did not list fever as one of those symptoms.

Doctors don’t do anything special for fever in vaccinated children over 2 months of age.

Fever can accompany other symptoms that may be concerning, but it in itself is not the concern unless it is a newborn, unvaccinated child, or one with a chronic condition that you’ve been warned has increased risks.

Comfort measures

Pain control with acetaminophen or ibuprofen may be helpful. Follow the package directions for weight. Dosing for kids under 2 years of age can be found on my office website or you can ask your physician.

Remember the goal is not to bring temperatures to normal, but to keep kids comfortable. If they’re in pain from sinus pressure, a headache, sore throat, body aches, or earaches, it is okay to give a pain reliever even with a normal temperature.

Get the mucus out

Suction your infant’s nose before feeding and before putting him down to sleep. This helps clear the mucus from the airway and makes breathing easier. Encourage nose blowing for those old enough to know how to blow.

Use saline to irrigate the nose. They sell drops, sprays, and nasal wash systems to be used, depending on age and personal preference.

Hydrate

Encourage your family members over 6 months of age to drink more water than normal when sick. Kids often won’t eat well when they’re sick. That’s okay. It is important that they drink well though so they can stay hydrated.

Young infants should not drink water, but you can encourage more of their milk or formula when they have cough and colds.

If your child has vomiting or diarrhea, avoid cow’s milk products. These often lead to more vomiting. Breast milk can be offered in small amounts frequently to infants who are breastfeeding. Electrolyte solutions (with sugars and salts) can be given to infants and children for hydration.

Clean air

DO NOT let anyone smoke around your child or in your home. Smoke can make the wheezing and coughing worse, even if done in a separate room in the home.

Smoke residue on hair and clothing can cause irritation to your child’s airways. I can usually identify smokers or people who spend time with smokers when they’re in my clinic. (Thankfully that isn’t often.) It isn’t unusual for me to start coughing when they’re in a clinic room with me. If you must smoke, go outside and wear a jacket that can be removed to minimize what is on your shirt when you go inside and hold your baby.

I’ve even started coughing when around someone who was vaping. I know people claim that the vapor is safe around others, but my lungs don’t like it. Keep it away from your kids. Talk to your kids about the risks of vaping so they don’t start the habit.

Rest

Encourage those who are sick to get extra rest. We often sleep poorly at night and need daytime naps to get enough sleep when we’re sick.

Dry air

A cool mist vaporizer or humidifier can help your child breathe easier. Change the water every day. Clean the machine per the manufacturer recommendations.

Infection control

It just isn’t possible to keep kids from being contagious when they have a virus. They love to touch everything and share germs, so keep them home until they’re well enough to return to normal daily activities.

Stay home!

Our health department now recommends that everyone with influenza stays home for 7 days following the start of symptoms.

You can return to work, school, and activities with other illnesses when the fever is gone (without using fever reducers) for 24 hours, there’s no vomiting or diarrhea, and you’re generally feeling well enough to return. If not, stay home and rest or visit your doctor.

Cover the cough!

Cover your cough properly - don't use your hands! www.questforhealthkc.com

Teach kids to sneeze and cough into their elbow or a tissue. Wash hands after handling tissues.

Wash, wash, wash

Good handwashing can help decrease the spread of viruses.

Wash hands often. If soap and water isn’t available, use hand sanitizer. The more things you touch, the more often you should wash.

Teach kids to wash properly. Have them rub soap on their hands for 15 – 20 seconds- be sure they scrub palms, backs of hands, fingers, spaces between the fingers and even under the fingernails.

Wash

Before preparing food
After toileting or changing a diaper
When they’re obviously soiled
Before eating
After sneezing or coughing into hands or wiping nose
Before and after touching eyes
When taking care of a wound wash your hands before and after washing and treating the wound
Often when taking care of someone who is sick
After touching trash or soiled objects

Consider having separate towels for each family member in your bathrooms to decrease the spread of germs when they wipe their mouth after brushing their teeth.

Hand sanitizer is a good option when washing isn’t available, but it is not helpful against some germs, so handwashing is preferred.

Use lotion as needed to keep your skin moisturized. Dry skin damages the barrier that helps prevent germs from getting into our bodies.

Germs can live on objects and surfaces for 2 or 3 hours – sometimes longer. Clean your child’s toys often with soap and water.

Don’t touch your face. Eyes, ears, and noses are the doors into our body.

Avoid handshakes and other hand to hand contact. Try a fist bump or wave!

Help prevent the spread of germs. Don't shake hands. Offer a fist bump or wave. #infectionpreventiontip

Avoid taking young children to large groups of people during the cold and flu season, especially if people are showing signs of illness.

Vaccinate.

We can help prevent many of the most serious illnesses by staying up to date on our vaccines.

Everyone over 6 months of age should get a flu vaccine. There are very few contraindications to a flu vaccine and many benefits. Really.

And finally… avoid kisses that spread illness!

For more:

Fever Is

When is a fever too high

Tamiflu

Evolution of illness

Cough Medicine: which one’s best?

Cough sounds

How long will a cough or cold last?

RSV has a bad rap… for good reason

Strep throat: new school guidelines

Sore throat: strep vs viral

How to use nose sprays correctly

Improper use of antibiotics

Why wait to see your usual doctor?

Developmental Age in ADHD

I’ve been asked what the single best parenting tip I’ve gotten as the parent of a child with ADHD is. After a lot of consideration, I’ve decided that it involves setting expectations. When we re-frame things that are appropriate for their developmental age, it alleviates so many fights and frustrations. These expectations can vary if they’re on medication at the time, how much sleep they’ve had, and more.

What is developmental age?

Kids with ADHD have a delay in brain development that affects the ways they organize, process, and act upon information.

Chronologic age

We typically measure a child’s age by how long it’s been since they were born. This is their chronologic age.

We assume that kids will be able to understand more complex ideas and master new tasks as they get older. There are certain milestones that are associated with various ages, such as a social smile by 2 months or walking by 15 months of age.

Developmental age

Your pediatrician will ask developmental questions at routine well visits to be sure your baby is on track.

These questions help us to identify if your child is developing at a normal rate or if there is a delay. At some ages there are specific standardized developmental screening tools to be administered.

As long as a child meets expectations, their developmental age and chronological age match. If they are delayed, we can give a developmental age to help identify their stage of development.

We know that ADHD is one cause of delay of areas of the brain that are important in executive functioning. At this time there are no standard screening tool recommended at all well visits to assess this development. It is important to bring up any concerns from home or school with your physician.

What are executive functioning skills?

Executive functions are the things we use to help us use and act upon information.

Understood is a great resource for many things related to learning, attention, and behavior. They have a great page about what executive functioning problems look like at different ages – from preschool to high school.

But my child’s smart, not delayed!

Being delayed in executive functioning areas of the brain is not the same as being academically delayed or having a low IQ. Parts of our brains grow at different rates.

Even your child that excels in certain areas can be delayed in others.

A child who can do math several grades ahead of classmates might not be able to remember something as simple as turning the homework in the next day.

Another child who reads grade levels ahead might not be able understand why a certain behavior is considered undesirable.

A child who is gifted in the arts can struggle significantly remembering all the things that must happen to get ready to leave the house in the morning on time.

It’s easy to get angry at kids for having missing assignments, when they forget to brush their teeth, or when they’re always running late. It can be difficult to help kids understand why they cannot blurt out answers or tell others what to do or how to do it.

Negative feedback leads to increasing problems

Unfortunately, kids with ADHD often hear negative feedback when they fail to do what’s expected, which can lead to rejection sensitivity.

Kids often develop unproductive ways to buffer the negativity that follows their failures. They can act out, become the “class clown,” decide to stop trying because of the fear of failure, and more.

Setting expectations

I’m asked all the time how to set expectations with kids, especially those with ADHD.

It’s understandably difficult to parent when your child, who otherwise looks and acts like kids of the same age, doesn’t have the same abilities in areas of focus, organizing, prioritizing, completing tasks, and self care issues.

Visible differences are easy to spot

When kids look different due to a genetic or physical condition, it’s easy to see what accommodations are needed.

If a child has an obvious trait that makes it difficult to do a task, we modify our expectations. A wheelchair bound child would never be expected to run upstairs to grab something.

Invisible differences still exist

For those who look “normal” but are neurodevelopmentally different, it’s easy to fall into the trap of setting an expectation based on the typical expectation for their age, not their level of development.

A child who has problems with working memory might also struggle to run upstairs to grab something. It’s not a form of defiance when they go upstairs and forget what they’re supposed to be getting or when they don’t return because they get distracted by something else.

Many kids are simply not there yet.

They can’t act their age because that part of their brain is not at that stage.

Most will get there, but it takes them longer.

Set appropriate expectations, and when they struggle, show patience and help them learn. This is much more effective than setting the bar too high, resulting in punishments and anger.

Delays of executive functioning

Dr. Richard Barkley has shown that kids tend to develop executive functioning skills about 30% slower than neurotypical peers. This adds up to about 3-5 years at most ages.

This might mean that your 12 year old might struggle doing what another 12 year old has already mastered. They might only be able to handle things expected of an 8 year old.

Set expectations according to skills, not age

The single tip that helps de-stress parenting more than any other that I’ve heard is to adjust expectations by skill.

Chronologic age is less important when deciding what a child is capable of and what they’re ready to learn.

this doesn’t mean letting them get by with anything…

As a child grows, you will watch their successes and failures.

You learn what they can and cannot handle. Help them with the things they cannot do while letting them do as much as they can.

SEt expectations and supports

One child can be expected to get dressed and brush teeth without reminders.

Another child of the same age will need a chart listing all the routine things that need to be done.

And yet another child of the same age may need reminders to look at the chart.

All of these same age kids can be smart and have good intentions, but they need different levels of reminders.

RSV has a bad rap, for good reason

Bronchiolitis (often called RSV) is an infection of the respiratory tract that leads to wheezing and difficulty breathing. Learn why it’s scary to many parents and what you can do about it.

Bronchiolitis is an infection of the respiratory tract that leads to wheezing and difficulty breathing, most often in infants and children under 2 years of age. It’s often called simply “RSV.” While it’s often caused by a virus called Respiratory Syncytial Virus (RSV), it’s not always. Let’s talk about what it is and what we can do about it.

Symptoms of bronchiolitis

Bronchiolitis often starts off just like a common cold, with a runny nose or congestion. In older children and adults it progresses just like a cold. Because it is.

In infants and young children symptoms can progress to make them more significantly sick. Day 3-5 of illness often is the worst.

Symptoms include (but not everyone has all):

Rapid heavy breathing (more than 60 breaths per minute – always count for a full minute in babies because they can pant or hold their breath, which throws the count off)
Wheezing (tight breathing with a whistling sound)
Retractions (the skin between ribs suck in during inspiration)
Nasal flaring (where the nostrils widen with breathing)
Belly breathing (the abdomen moves up and down more than usual)
Fever
Cough (which can occasionally cause vomiting)
Lots of mucus from the nose and mouth (lots!)
Decreased appetite (which can lead to dehydration, so offer frequent liquid feedings)

If you’re wondering what type of cough your child has, check out The sounds of coughing.

Causes of bronchiolitis

Most cases of bronchiolitis are due to viruses.

RSV is a common cause, which is why the condition is often simply called RSV. Most of us have had RSV by the time we’re 3 years old. It doesn’t always cause the symptoms of bronchiolitis. Sometimes it just looks like a common cold, especially in older kids and adults. This is why it’s really important to protect young infants around people who are just a little sick.

Bronchiolitis can be caused by many of the viruses that cause upper respiratory tract infections. Rhinovirus, metapneumovirus, adenovirus, influenza, parainfluenza, and coronavirus are some of the other culprits.

Who’s at risk?

Symptoms tend to be worst in babies who are higher risk. This includes infants who were born prematurely, those who have certain heart defects, the very young, or those with other chronic conditions.

Infants are more at risk of having simple cold viruses cause the more severe symptoms of bronchiolitis. Their narrow airways contribute to this because they become plugged with mucus more easily than larger airways.

All viral illnesses are more common among infants who are in daycare or around lots of people. The more people, the more likely they’ll be exposed to a person sharing germs. Infants also put their hands and toys in their mouth often, which helps them get germs into their body.

Those who are around cigarette smoke are also more at risk because of the chronic airway irritation caused by smoke. Even babies who are around people who smoke prior to being with the child can get third hand smoke exposure from hair and clothing.

Prevention

Standard infection control protocols can help avoid spread.

Wash hands frequently or use hand sanitizer. Teach kids to get all parts of their hands clean. Wash hands even when you’re not feeling sick… we share germs before we know we have them and we need to protect ourselves from catching new ones!

Avoid being around people who are sick and when you’re sick, stay home! If you’re the one who’s sick, check out Help! I’m sick and have a baby at home.

Have separate towels (or disposable towels) in the bathroom. After brushing your teeth, you don’t want to wipe on a towel that was used by someone who’s brewing germs!

Don’t kiss babies on their face, hands, or feet. The top of the head is best!

Stop the spread of germs! Don't kiss the face!

Avoid cigarette smoke – even second hand and third hand smoke (on surfaces) can cause airway irritation. This irritation makes it harder to fend off germs, which leads to more infections.

Germs can live on surfaces and objects for 2 or 3 hours or longer. It’s a good idea not to share toys because babies put them in their mouth all the time. Clean your child’s toys often with soap and water.

Cover coughs and sneezes properly.

Testing

Virus testing

There are tests that can be done on mucus from the nose to see which virus is the culprit, but they aren’t usually required.

Knowing if it’s RSV or another virus doesn’t make the symptoms change. We treat symptoms.

Testing can be used for infection control measures when babies are admitted to the hospital, but aren’t always necessary.

Tests are expensive, and unless they change something we’ll do, they aren’t generally recommended. Why waste your money? (Even if you think insurance will cover it, the money comes from somewhere… you’ll pay more in premiums if you spend more.)

Oxygen levels

It is common to check oxygen levels when kids (and adults) are sick. Pulse oximeters are an inexpensive tool to help us assess how well a person is compensating when having trouble breathing.

Chest x-ray

Most infants and children with bronchiolitis do not need a chest x-ray, but they are sometimes used to assess for pneumonia or foreign bodies (such as a swallowed coin) that can cause wheezing.

Blood work

Blood tests are not usually needed to diagnose or treat bronchiolitis but they can help to identify if there’s a need for antibiotics due to a bacterial infection. Sometimes we check blood if we’re worried about dehydration.

Treatments

The virus must run its course and symptoms can last several weeks, so what can you do to help ease symptoms?

Home treatments

Comfort measures

You can use fever reducers if your baby is uncomfortable. These include acetaminophen if your baby is over 2-3 months and ibuprofen or acetaminophen if your baby is over 6 months. I don’t recommend fever reducers before babies get their 2 month vaccines because you can mask symptoms of serious disease. See your physician if your unimmunized child has a fever!

Remember that a fever is the body’s immune system at work, so your goal is comfort, not getting rid of the fever.

More on how to recognize if a fever is too high and the scary facts of fever.

Suck out the snot!

Babies with bronchiolitis often seem as if their nose is a faucet. All that mucus interferes with breathing and feeding. They can’t blow their nose, but you can suck it out!

I’m not a fan of bulb syringes as a nasal aspirator. I find that they have too narrow of a tip to get an effective seal in the nostril until you force it up so far that it causes trauma in the nose. They also run out of suction power before the mucus is all out, which means you must break the seal, empty it out, and resume. This gives your child a chance to suck back some of the mucus you brought forward. Not to mention some of the really gross photos I’ve seen of what grows inside those things!

Here’s a review of various nasal aspirator types and brands. I like the review in general and have no ties to it. She does link to sales, but you can buy from your favorite retailer.

Use one of the aspirators to suction your infant’s nose as they need it. It’s especially helpful before feeding and before they go to sleep, but think of how often you blow your nose when you’re sick. It can be helpful quite often!

Use saline

Saline can help thin out mucus and decrease the swelling of nasal tissues.

It can be used with or without sucking afterward. I talk a bit more about the benefits of saline in How to use nose sprays correctly.

Elevate the head

Raise the head of the bed to help with drainage of mucus. Don’t put your infant on a pillow because that can obstruct breathing. Raise the head of the bed by putting something solid under the legs of the bed or roll a blanket or towel and place it under the mattress at the head of the bed.

I remember many nights of sitting up holding my children when they were sick so they could be upright and sleep. That doesn’t mean I slept well, but that’s what moms do sometimes. You do need to be careful with this – babies can be dropped if a parent falls asleep holding them.

Fluids

Encourage your child to drink fluids in small amounts. This can be breast milk or formula, or water for older infants and children.

Many babies tire out drinking, so they need to drink more frequently than normal to get in a decent volume.

If your baby isn’t drinking well and looks dehydrated, talk to your physician.

Humidify the air

A cool mist vaporizer or humidifier can help your child breathe easier.

Change the water every day.

Clean the machine per the manufacturer recommendations to prevent it being a source of germs.

Things to avoid

Never use menthol products around infants. They have been shown to increase mucus production and worsen symptoms, especially in children under 2 years.

Don’t demand antibiotics. It cannot be cured with antibiotics. No viral illness can.

Decongestants thicken mucus and can lead to more difficulty breathing, sleep disturbances and irritability.

Hospital treatments

Historically we have tried medical treatments when infants present with bronchiolitis. These include breathing treatments with bronchodilators, steroids, and more.

A single treatment with a bronchodilator can be used to see if there’s response to decrease wheezing, but should not be continued if there’s no benefit.

Steroids have not been shown to help unless there’s a history of asthma.

Oxygen is a standard treatment that can help if the oxygen level is low or to ease the work of breathing.

Intravenous (iv) fluids are often required if hydration from feedings is not successful.

Suctioning is a primary treatment in the hospital setting, much like at home.

When should kids be seen?

Infants and children should be seen relatively quickly if the following criteria are met:

Infants under 2 months of age should be assessed by a physician. They often require hospitalization because of the risk of apnea. Apnea is when they stop breathing and is a risk of very young infants with bronchiolitis.
Respiratory rate over 60 breaths/minute consistently. It’s common to breathe faster with a fever, so if you can bring it down and their breathing is less labored, that’s okay. They also temporarily breathe faster after eating or crying. Again, if it slows within a few minutes, that’s okay.
Dehydration. Signs of dehydration include no tears, thick/pasty or no saliva, or fewer than 3 wet diapers in 24 hours.
The color of the child’s lips or skin looks blue.
The infant looks uncomfortable or is inconsolable.
Infants under 3 months (or an under-vaccinated child) with a temperature over 100.4F.

If your child simply isn’t getting better after several days or if earache develops, make an appointment during regular office hours.

Pharmacogenetic Testing: Personalized Medicine

Pharmacogenetic testing involves testing a person’s genetics to find out how a certain drug would work in that person. Learn the pros and cons of this testing.

I’ve recently seen increasing numbers of parents who want testing to decide which medication to use for their child’s condition before trying any medicines. Many admit that they don’t know much about it and want to learn more. Pharmacogenetic testing involves testing a person’s genetics to find out how a certain drug would work in that person. While that sounds like it would be fantastic to know, it has many limitations. We’ll talk about the pros and cons below.

Traditional dosing of medicines

Before they can be approved to be used, drugs are tested in large groups of people.

Dosing schedules are determined based on safety and efficacy of the medicine, but this is in a group. It relies on information gathered from a mass of people, and majority rules. This means that whatever works for most people is what becomes the recommendations.

Although this works for most people, any individual can have a variation that is not seen with the large numbers in a group. We all know people that can’t tolerate certain medicines. In the past we use family patterns to help predict tolerability. If a family member (or especially if multiple family members) report that certain medicines require lower or higher doses to be tolerated and effective, then we use that in our decision making for prescribing medicines. Of course it isn’t a perfect way to do things, but it can help.

What is pharmacogenetic testing?

Pharmacogenomics is the study of how genes affect a person’s response to drugs. It’s a growing field that involves using what we know about the person’s genetic make up and how they will metabolize a medication. This can allow the prescriber to use certain medicines and not others, or begin with overall higher or lower doses than standard recommendations suggest.

It is personalized to a person’s genetic makeup, so it’s often called personalized medicine or precision medicine.

Many medicines work well for most people, but there are people who will metabolize certain things slowly, allowing the medicine to build up to toxic levels when dosed per standard amounts. Other people may require higher doses due to a very rapid metabolism. Some people should avoid certain medications all together. Knowing these dose adjustments and risks before even starting a medicine could be very beneficial!

Certain proteins affect how drugs work. Pharmacogenetic testing looks at differences in genes for these proteins. These proteins include liver enzymes that chemically change drugs. These changes can make the drugs more or less active. Even small differences in the genes for these liver enzymes can have a significant impact on a drug’s safety or effectiveness.

What are some uses in general pediatrics?

I’m limiting this discussion to uses that a general physician would use this type of testing. There are other uses for chronic diseases that are managed by specialists and beyond my scope.

Please realize that these are the commonly requested uses, not recommended uses.

ADHD

The most common time that I’m asked about this type of testing is for kids with ADHD.

Many parents are afraid of side effects of stimulants and have heard of other children who needed many adjustments of medication, both type of drug and dosing.

Starting a new stimulant medication can be frustrating, especially if it takes weeks or months to find what works. Parents would like to avoid that and start with the best.

Unfortunately the tests currently available do not predict which medicine will be most effective. They test how it will be metabolized.

Many people who show best tolerability for a certain drug may find that drug ineffective in managing their symptoms. This is due to many factors, but in the end still leaves us with the need to do a trial of various medicines to find the best one.

Failure to find a beneficial medicine based on these trials may lead to reassessment to be sure the diagnosis is correct. Proper diagnosis is not tested with the pharmocogenetic tests.

Anxiety and depression

Anxiety and depression medications are another type of medicine that has many options, and some respond to one better than another.

The traditional way to start is to look at family history (which is also a study of genetics, although included in the cost of your visit and doesn’t include a lab). Unfortunately, many people do not know of family member’s specific health details, especially what medicines they were on and what their reactions were.

When we pick a medicine, we start with low doses, and increase as tolerated and needed. If the first medication doesn’t work or isn’t tolerated, it is stopped and another is tried. This can prolong the time it takes to feel better, which is significant, and likely the reason people want a quick answer with a lab test.

Unfortunately, much like the ADHD testing mentioned above, the tests don’t predict which medicine will manage symptoms best. They only predict how they will be metabolized.

Should you get tested?

I am excited for the future of personalized medicine.

We may no longer need to try multiple medicines to be able to see which are better tolerated. Starting near the target dose, rather than starting at a low dose and titrating up, which prolongs the time it takes to get to an effective dose, would be welcomed in many people.

Unfortunately, I think psychopharmalogical testing is not yet for prime time.

The FDA agrees. They’ve sent out warnings that these tests should not be used to help choose a medicine.

Just because your body will metabolize a medicine more slowly or rapidly doesn’t predict if it will be effective to treat your symptoms.

It is still very costly and insurance companies resist paying for it. With high deductible plans, many people must pay the cost. With the new FDA warning, it is unlikely that insurance companies will cover the cost of these tests anytime soon.

It is being widely used in cancer and HIV patients and has helped to prevent significant side effects that often lead to hospitalization. From an insurance company standpoint, they’re saving money by covering the test for these purposes. From a patient standpoint, they have added security that they will respond well to the treatment.

For more:

Pharmacogenomics and Personalized Medicine By: Jill U. Adams, Ph.D. (Freelance science writer in Albany, NY) © 2008 Nature Education Citation: Adams, J. (2008) Pharmacogenomics and personalized medicine. Nature Education1(1):194

ADHD Medicines: Starting out and titrating

Can pharmacogenetic testing save time and money when choosing a new medicine? Personalized medicine is exciting, but is it ready for prime time?

Addendum: 10/3/19

The New AAP ADHD Guidelines were released this week.

Pediatrics October 2019, VOLUME 144 / ISSUE 4 From the American Academy of Pediatrics Clinical Practice Guideline

Clinical Practice Guideline for the Diagnosis, Evaluation, and Treatment of Attention-Deficit/Hyperactivity Disorder in Children and Adolescents

Mark L. Wolraich, Joseph F. Hagan Jr, Carla Allan, Eugenia Chan, Dale Davison, Marian Earls, Steven W. Evans, Susan K. Flinn, Tanya Froehlich, Jennifer Frost, Joseph R. Holbrook, Christoph Ulrich Lehmann, Herschel Robert Lessin, Kymika Okechukwu, Karen L. Pierce, Jonathan D. Winner, William Zurhellen, SUBCOMMITTEE ON CHILDREN AND ADOLESCENTS WITH ATTENTION-DEFICIT/HYPERACTIVE DISORDER

The authors specifically state that this testing is NOT recommended.

The available scientific literature does not provide sufficient evidence to recommend genetic testing for ADHD medication management. @pediatricskc

10. Help! I’m sick and I have a baby at home!

Parenting is a tough job, even when you’re not sick. When you have an infant and you’re sick, not only do you have extra sleep needs, but you have to try to keep your baby healthy despite being around your germs. What can you do when you’re sick with a baby at home?

9. Top 10 reasons a child or teen is tired.

We all know the jokes about that teens sleep past noon, but the truth is they need to catch up on sleep deprivation. Learn the top 10 reasons a child or teen is tired.

8. Summer Penile Syndrome

During the summer months one of the most uncomfortable reasons I see boys is that their penis and/or scrotum is swollen significantly. Learn what Summer Penile Syndrome is and what to do about it.

7. Dark Under Eye Circles

When kids have circles under their eyes, parents worry that something’s wrong. Sometimes there’s a treatable reason, sometimes not. Learn all the most common causes of under eye circles and what to do about them.

6. The flu shot doesn’t work

I’m pro-vaccine, so this title might surprise you. I hear the argument that the flu shot doesn’t work so often that it deserves to be addressed.

5. Flu Season Fears: What should you do?

Every flu season as we start to hear reports of kids dying from influenza the fear surfaces. This was written during one of the worst outbreaks in recent history. Be protected against each flu’s season fear with a flu vaccine and healthy habits!

4. Antibiotic Allergy or Just a Rash?

We see rashes all the time when kids are on antibiotics, but thankfully most do not mean a child is allergic. Learn when to suspect antibiotic allergy versus just a rash.

3. Lip Licker’s Dermatitis

When saliva gets on our skin, it breaks it down. Licking the lips leads to increased cracking and bleeding. Some kids have a wide ring of dry skin around their mouth from lip licker’s dermatitis. Learn what you can do to help them heal their smile.

2. What happens if a vaccine booster is delayed?

There are many reasons that people fall behind on their vaccines. Some are intentional, some due to circumstance. Regardless of the cause, what happens if a vaccine booster is delayed?

1. Bumps, ridges, and soft spots on a baby’s head. When should you worry?

I wrote this because I hear concern about bumps, ridges, and soft spots on baby’s (and older kid’s) heads quite often. Learn when you should worry and when it’s okay.

What was your favorite?

I’m surprised at the popularity of a few of these and sad that some of my personal favorites didn’t make the list.

I wish more people would read what fever is so they worry less about a number. Learning the evolution of illness might also help parents understand why exam findings are different on different days. I hear far too often that an ear infection was missed, but it’s more likely that they developed since the first exam.

I’ve also written a little on insurance and the business of medicine, but it doesn’t surprise me that those are not as popular. Sadly, we all need to understand the intricacies of billing and insurance as well as how the business of medicine works. As more and more private practice physicians sell out to large corporations, we’ll all feel the negative impacts.

Nip it in the bud?

When kids start to get sick, don’t you wish you could nip it in the bud before it gets worse?

If your kids have ever been sick, you know it can go from an annoyance to a fairly scary ordeal pretty quickly. When should you bring your kids to the doctor so we can prevent their symptoms from getting worse? We all want to know when we can nip it in the bud!

Can we prevent progression and spread of illness?

Mom: We’re here because my little one has a cold. It always settles in her ears, so I want to get on top of things and nip it in the bud this time.

Me: Her ears look great today, so keep doing what you’re doing. I’m glad you’ve started giving extra fluids, using saline in her nose, and letting her stay home from preschool to rest.

Mom: But we have family coming into town. They have a new baby, so I don’t want the baby to get sick. Can’t we just have an antibiotic now to help everyone?

Me: There’s no sign of a bacterial infection. She has what’s most likely a cold from a virus. Antibiotics don’t help.

Mom: But can’t we just try? She always gets an ear infection.

Me: It doesn’t work that way. Antibiotics don’t prevent ear infections. They don’t even treat the large majority of ear infections, since they’re viral.

Mom: But we’ll be around a baby.

Me: An antibiotic would give a false sense of security. Your daughter would still be contagious from the virus. Viruses can be very serious in newborns. Your daughter shouldn’t be around the new baby until she’s well.

Mom: But …

This circular conversation can continue indefinately.

I hear requests like this all the time. Unfortunately, illness doesn’t work that way. We don’t give antibiotics to prevent ear infections. They don’t stop the spread of most infections because most are from viruses.

If your doctor gave you antibiotics for your last cold “just in case” and you felt better, it’s likely you would have felt better anyway. That’s what happens with colds.

I realize when your baby has had several ear infections it seems tempting to give a treatment to prevent this cold from turning into another ear infection. But it doesn’t work that way.

But she always gets and ear infection...

Antibiotics don’t:

Prevent the spread of viral illnesses.
Keep an illness from changing from a virus to a bacteria.
Make all sinus infections go away.
Treat all ear infections.
Make people feel better immediately.
Come without risk.

Antibiotics usually aren't needed for sinus pressure, which is typically from a virus or allergies.

You take risks every time you use an antibiotic.

We need to use antibiotics wisely. Antibiotics are generally safe and most of us tolerate them well. But sometimes they lead to side effects, such as rashes and diarrhea. They can also cause true allergic reactions.

Over time bacteria can learn how to avoid being killed by antibiotics, called developing resistance. This can put us all at risk of deadly bacterial infections that have no cure.

You take risks every time you take an antibiotic. Use them only when necessary.

But we have to get better fast!

Your teen has finals.
You must get back to work.
The baby being up all night fussing is wearing you down.
Your family has a big trip coming up.
You’re pregnant and you don’t want a sick family member in the home.

Whatever the circumstance, we can’t make someone not contagious anymore. It takes time for the symptoms of a virus to go away. There’s just no short cut. No way to prevent the natural course and progression.

Up next…

Next week we’ll talk about what to do when you or your family is sick and how to prevent illness in the first place. (Prevention is always best!)

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!

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.

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

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.

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?

What can be done to feel better?

It’s hard to make them better, but we can make them feel better

What about fever?

Comfort measures

Get the mucus out

Hydrate

Clean air

Rest

Dry air

Infection control

Stay home!

Cover the cough!

Wash, wash, wash

Vaccinate.

And finally… avoid kisses that spread illness!

For more:

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What is developmental age?

Chronologic age

Developmental age

What are executive functioning skills?

But my child’s smart, not delayed!

Even your child that excels in certain areas can be delayed in others.

Negative feedback leads to increasing problems

Setting expectations

Visible differences are easy to spot

Invisible differences still exist

Many kids are simply not there yet.

Delays of executive functioning

Set expectations according to skills, not age

this doesn’t mean letting them get by with anything…

SEt expectations and supports

Recommended Video

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Symptoms of bronchiolitis

Causes of bronchiolitis

Who’s at risk?

Prevention

Testing

Virus testing

Oxygen levels

Chest x-ray

Blood work

Treatments

Home treatments

Comfort measures

Suck out the snot!

Use saline

Elevate the head

Fluids

Humidify the air

Things to avoid

Hospital treatments

When should kids be seen?

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Traditional dosing of medicines

What is pharmacogenetic testing?

What are some uses in general pediatrics?

ADHD

Anxiety and depression

Should you get tested?

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Addendum: 10/3/19

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9. Top 10 reasons a child or teen is tired.

8. Summer Penile Syndrome

7. Dark Under Eye Circles

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4. Antibiotic Allergy or Just a Rash?

3. Lip Licker’s Dermatitis

2. What happens if a vaccine booster is delayed?

1. Bumps, ridges, and soft spots on a baby’s head. When should you worry?

What was your favorite?

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