Every three months, all the employees of Pediatric Associates get  together and spend a few hours working on ideas to make our medical practice a better one. During these sessions we often give voice to things that frustrate our parents and patients. These we take most seriously and spend a lot of our time trying to remedy or cure. Although we fix a lot of them, there are always some problems that are special to the natural running of a medical office. In this blog, I provide for you some insider tips to working with our office to save you time and effort.

1. The Phones: Between the hours of 5 p.m. and 8:15 a.m., kids get sick! This is, of course, no surprise. So, when the phone schedulers sit down at their desks at 8:15 am, there are a lot of worried parents waiting to schedule appointments. For those parents, to save time consider using our online scheduling service (http://www.portlandpediatric.com/). Also, if you know you don’t want an appointment until the later afternoon, try calling around 10 a.m. when the phone lines become quieter.

For the other parents calling for advice, consider using our website medical advisor. It is easily found in the “medical advisor” section of our website. You won’t get the same awesome attention as our providers and nurses but you can get good advice and save yourself some time. Also, when you leave a message with our front desk staff for our advice nurses or providers, be brief. The receptionist passes on the message to the nurse who then calls you for more details.

For the parent who is hoping to avoid listening to our phone message: On our website, in the “Contact Us” section there is a list of the common extensions.

1. Refilling Prescriptions: Nothing drives parents crazier than the refill process. Rather than talking to our phone personnel, you have a lot of less time-consuming options. First, leave a message – once you hear the greeting on our phone press #8. This will take you directly to our refills message station. This station is checked every few hours and quickly sent on to your provider. Second, send an email. On our portal you can send an email refill request which will get to your provider as quickly as leaving a phone message! Third, if your refill is not a controlled substance, call the pharmacy and request a refill. They will send us electronic refill request which we will fill pronto.
2. In the Office: Don’t show up late. Showing up late is the most guaranteed way to have to wait as we work you back into the schedule (or sadly reschedule your appointment). Don’t show up way early. Although we appreciate anyone who shows up early, we still go by the schedule, so showing up way early can force a wait for you.
3. Co-pay Confusion: There is no doubt that insurance plans are extremely confusing. If you are watching your dollars and cents carefully (I know I am), then call your insurance carrier before you come to the office to find out exactly how much you can expect to pay out of pocket for your visit to our office.
4. Paperwork, paperwork, and more paperwork: Rather than show up at the office and start filling out paperwork, download it from our website and bring them in. In the “Patient Information” section of our website there are new patient forms, registration forms, sport participation forms, and developmental screening forms.  Download them! Print them! Time saved in the office.
5. Medical Records: Many people call the office or email their provider with medical records needs. The provider then takes the request to our medical records personnel who then calls the parents and sorts out the need. Quite the two step! So, call medical records directly and you can have your needs taken care of more quickly.

That is all I have you at present. Don’t hesitate to pass on time saving measures to our staff. We are all in this together.

The streets in my neighborhood are littered with pink and white confetti from the trees that line the sidewalks – a sign of spring – and of seasonal allergies.

Seasonal allergies, also known as “hay fever,” are most commonly caused by the body’s reaction to pollens (from trees, grasses or weeds) or to mold spores (these grow in humid, damp or wet weather). Normally, people breathe in these substances and don’t have issues but, when a person has a seasonal allergy, his or her immune system acts like the substance will do damage to the body, even if it won’t. This causes symptoms, like:

Stuffy nose, sneezing or runny nose
Itchy or red eyes
Sore throat or itchy throat/ears

The symptoms are often confused with a cold or with a bacterial infection of the eyes or sinuses.

Seasonal allergies can run in families, but aren’t always hereditary. Lots of people first get seasonal allergies when they are kids and symptoms can get better or worse over time. For some, the allergies slowly go away but for others, seasonal allergies are a life-long problem.

Some people have allergy symptoms that last throughout the seasons. Year-round symptoms can be caused by:

Furry animals, like cats and dogs
Mold spores
Insects, like dust mites and cockroaches
Toys with animal fur

There is testing that can be done for severe seasonal allergies, especially if patients have asthma and certain allergens make their asthma worse. Testing is most often done in an allergist’s office using “skin testing.” If a skin test is performed, a doctor will put a drop of the potentially-allergic substance on your child’s skin/will make a tiny prick in the skin and will watch the skin to see if it turns red and bumpy.

You can also help prevent allergy symptoms by avoiding the things your child is allergic to. For example, people who are allergic to pollen can use air conditioners to lessen exposure to pollen in the home and car. For those with mold allergies, avoid playing in piles of dead leaves in the fall – molds like to hang out in areas of decaying vegetation. Also, pay attention to bedding, rugs and upholstered furniture. That’s where dust mites are usually found because they can find food there (for example, human skin flakes). It can also help to encase mattresses, box springs and pillows in zippable, allergen-proof covers. Wash linens and other bedding (like blankets) every 2-3 weeks in hot water. That kills the dust mites.

There are a number of treatments for allergies, including nose rinses, steroid nose sprays, antihistamines and decongestants, many of which are over the counter. For those with severe allergies, sometimes allergy doctors will use allergy shots to reduce symptoms. It’s important to talk with your child’s pediatrician before using allergy medications. There are risks and benefits to all of the medications we give our children and we want to make sure the medications they take are safe and effective.

Soon (but not soon enough for some) the colorful confetti and the sneezes that go with it will be lessened with the changing of seasons. Until then, knowing more about seasonal allergies can help to make this beautiful season more comfortable.

Spring Break is here for most Oregon kids! For some, that means travel to warmer places for the week. We often get calls during Spring Break about 2 major problems: sunburns and swimmer’s ear.

Sunburn and Sunscreen:

All kids over six months should use sunscreen, even when the weather is cloudy. Pick one that has “broad spectrum” on the label – a broad spectrum sunscreen helps protect against sunburns and skin cancer. The sunscreen should have an SPF of at least 15 and needs to be applied 30 minutes before going outside so it has time to absorb into the skin. Rub it in well and make sure to get all of the areas that will be exposed so that your child is fully protected.  Reapply sunscreen every 2 hours or any time after swimming or sweating.

Babies under six months don’t need sunscreen. They shouldn’t be in the sun long enough to need it! Applying sunscreen can give parents a false sense of security that their baby is protected against sun exposure and studies show they are more likely to be exposed to sun than those young babies without sunscreen. For these little ones, make sure that they are in full shade under an umbrella, a stroller canopy or a tree. Don’t forget hands and feet. If their hands and feet are not covered, they can get burned, too!

You can help prevent sunburns by following these rules as well:

1. Limit sun exposure between the hours of 10 am and 4 pm – that’s when the UV rays are the strongest.
2. As much as possible, dress kids in cool, comfortable clothes that cover the body – a tightly woven fabric will protect better than a loosely woven fabric.
3. Wear a hat/cap with a brim and sunglasses to protect the face and eyes. Sunglasses should have at least 99% UV protection.

If your child does get a burn, you can treat it yourself if it is mild. Apply cool compresses to the burned areas. You also can give acetaminophen (make sure the dosing is correct for his or her weight) to help relieve the pain.

You should talk with a health professional if the sunburn causes headache, fevers, chills or blisters. Severe, extensive sunburns can sometimes require hospitalization and must be treated like any other serious burn. The blisters can also become infected, requiring antibiotics, and really bad sunburns can lead to dehydration.

Swimmer’s Ear:

Swimmer’s ear is an infection or irritation of the skin lining the ear canal. It can happen when water gets trapped in the ear canal. The lining gets swollen and wet, making it more likely for a superficial ear canal infection to develop. Swimmer’s ear is not contagious.

Kids with swimmer’s ear often feel like their ears are itchy or plugged and they can have a small amount of clear discharge in the ear.

Children that have severe or constant ear pain, fever, redness/swelling of the outer ear or yellow ear discharge need to be seen right away by a health professional to make sure there is not an inner ear infection, a bad skin infection, or a really bad swimmer’s ear that can’t be managed with home treatment.

For mild swimmer’s ear with none of the signs mentioned above, parents can try white vinegar rinses for pain and symptom control. Take a break from swimming while the ear recovers and try to towel off ears after swimming, taking a shower or washing hair.

No children with ear tubes or a hole in their eardrum should use vinegar rinses.

To rinse the ear with vinegar:

Rinse the ear canals twice daily with ½ strength white vinegar (dilute with equal parts warm water):

1. Have your child lie down with the ear bothering them facing up
2. Fill the ear canal with the solution
3. Wait 5 minutes, then remove the vinegar by turning the head and moving the ear

Swimmer’s ear and sunburns are common issues kids face on vacation. Protect your children against sunburn and be on the lookout for swimmer’s ear. We hope you have a safe and happy Spring Break!

This is a question we often hear when discussing the Hepatitis B vaccine with new parents.

The simple answer? The vaccine is safe and prevents kids from being infected by a potentially deadly virus.

So why so young? It isn’t that we are worried about a newborn’s future sexual activity (yet), but rather the possibility the mother has the infection and does not know it.

The CDC estimates that more than 1,000,000 people in the US are chronic carriers of hepatitis B, and the majority denies having any risk factors for the disease.  That means that they were infected at some point and the virus remains active in their bodies but they don’t know about it.

If a baby does become infected with hepatitis B, it can be a lifelong, potentially fatal problem. Three out of four infants born to mothers with hepatitis B will become infected. That is unless they receive a dose of the vaccine.  If a newborn is given their vaccine in the first day of life it is 70-95% effective in preventing perinatal hepatitis B infection.

However, if a newborn contracts the virus in the birth process there is >90% likelihood they will become chronic hepatitis B carriers. Compare that to adults and the statistics are staggering– only 5% of adults will become chronically infected if they contract hepatitis B.

Chronic carriers can infect others and approximately 25% will die prematurely from cirrhosis or liver cancer.

So what is in the vaccine?  Since the mid 1980’s the vaccine has been made using baker’s yeast that have been given the gene for one hepatitis B surface protein.  There are no blood products used, no virus, no bacteria and nothing else that can cause an infection.

The Hepatitis B vaccine is safe and effective. It prevents a potentially deadly disease in infancy and protects young adults far beyond the time of vaccination (when they do become sexually active).

You’ve been changing your child’s diapers since the day they we’re born and you’re ready for a little reprieve? Your youngster is ready to head off to pre-school and the school prefers that all of the attendees be able to use the toilet? Whatever the impetus, knowing the most important toilet training principles will make it less stressful and more successful for you both. Here are some guidelines to make the transition easier:

Do’s

1. Do make sure he or she is ready. A child has to be developmentally ready in order to potty train. Some kids show signs of readiness at 18-24 months but many kids may not be ready to potty train until they are over 30 months old. Most kids have bowel and bladder control during the day by the time they are three to four but it can be longer before they stay dry through the night. Check out the American Academy of Pediatrics’ healthychildren.org for more help with determining if it’s the right time for you to start the process.
2. Do watch the signs. Look for times when your child goes behind a chair or crouches down to have a bowel movement. Watch for them to get red-faced, make a grunting noise or stop playing momentarily. Let your child know these signs mean he or she is going to the bathroom. Praise them when they tell you that they stooled/urinated and gently suggest they can let you know in advance.
3. Do make a habit to take kids into the bathroom to have a bowel movement or urinate. It’s okay if they don’t actually go in the toilet. It’s a good first step for them to just associate the potty with potty business.
4. Do be a good example. If kids realize the bathroom is where parents and older siblings urinate or have a bowel movement, it can encourage them to do the same. It’s also a good opportunity to teach about proper hygiene: wiping front to back for girls and good hand washing for both boys and girls.
5. Do help your child physically by either using a potty chair or setting their feet on a stool while on the “big” toilet so that they can get leverage for pushing. We adults take for granted the extra help we get with bowel movements from having our feet firmly planted on a hard surface.

Don’ts

1. Don’t let em’ see you sweat. If you make potty training a huge deal, it will put more stress on your child and may make it more difficult for them to succeed. Consistently praise for movements in the right direction: telling you they went, telling you they’re going to go, going in the bathroom and going on the toilet, but don’t punish or be negative if they make a mistake or if they do well at it one day and seem to go completely backward for the next two weeks. It can be a process – at times a slow process – but a process.
2. Don’t be surprised if a major life change derails you efforts for potty training. A big move, a new baby, a family crisis – all things that can hinder potty training and that may be a reason to hold off on starting if you’ve found your child to be particularly sensitive to changes in the past.
3. Above all, don’t make toilet training a power struggle or a discipline tool. Potty training can be scary for young kids who can be afraid of being flushed away or are ashamed they are not able to complete a task you put so much pressure on. It’s never right to punish a child for not potty training, for having difficulties with potty training or for not potty training on your timetable.

1.  Making an appointment: The Old Way – telephone or email.

The New Way – online in real time.  In the second quarter of 2012 we will start using a system where a parent or patient can log in to our website and make an appointment for their well or sick child for that day or a future one.

2.  Seeking medical advice: The Old Way – telephone us or search the web.
The New Way – send your provider an email. Almost 2 years ago we started having email access with response within 24-48 hours for medical questions. Now all the providers are on board and the response times are getting faster and faster.  Those urgent questions will still need a phone call but who knows what the future holds. Also, pictures and documents can be attached to emails making our advice more accurate.

3.  Checking in for an appointment: The Old Way – lots of paper to fill out and time spent in the waiting room.
The New Way – electronic signature.  Why fill out the same old stuff again when you can just check it of the computer and electronically sign it. We have started this process and should have it fully in place by the end of 2012. And, since there are no more paper charts to obtain and shuffle around, there is less time waiting around.

4.  In the exam room: The Old Way – provider scribbling notes of paper.

The New Way – Provider scribbling notes on computer. We converted to a paperless office over 3 years ago and the benefits for office, patient, and environment are enormous. Providers have access to patient records day and night making us more capable when you call us after office hours.  Need a copy of the immunization record or a note for school? No problem, one click and it’s sitting on the printer.

5.  Prescriptions: The Old Way – Medical chicken scratch on paper and phone calls to the pharmacy.

The New Way – Electronic prescriptions. Whether printed or electronically transmitted to the pharmacy, these prescriptions are more accurate, readable, and harder to lose. We have been using this system for over 2 years.

6.  Painful procedures: The Old Way – Parent or Provider working hard to distract the child while we fix the cut or give the shot.

The New Way – We pull out our iPad and show the kid a movie or let them play a game. It is strangely effective. Of course, we still use the numbing medicines too.

7.  Checking Out: The Old Way – You walk to the front desk, make a new appointment and get a card with the date.

The New Way – A medical assistant comes to the room with her computer, makes you an appointment and then sends you an instant text or email reminder. You import it to your calendar and have it forever. No more lost cards or wrong times/dates written down.  This system will be started in the second quarter of 2012.

8.  Appointments: The Old Way – Get in your car and drive to our office.

The New way – Online visit! Got a simple rash? Want to visit with your provider about a behavioral problem? Pediatric associates is already doing online visits and soon we will be able to do online video visits (like a Skype call). You can access this through our website.

So there you have it – The future of technology in our pediatric office. We hope you are impressed or at least excited for a little more convenience offered in a medical system fraught with inconvenience.

Snotty noses. Coughs. Sneezes. It’s time for the common cold to take full effect in doctor’s offices around the country. There’s no exception here in the Pacific Northwest. Questions about how to deal, what to give and when to see the doctor? We have the answers.

1. What is the cold and how do I know if it’s something more serious?

The cold is caused by a number of different viruses, the most common being rhinoviruses. Other viruses like adenoviruses, influenza viruses, enteroviruses, Respiratory Syncytial Virus (RSV) and coronaviruses can also cause colds. Sometimes viruses that cause the common cold end up leading to more specific syndromes. For example, the RSV virus can lead to a syndrome called Bronchiolitis, where the lower parts of the lungs become inflamed and irritated. Adenovirus can sometimes affect the eyes and cause inflammation in the conjunctiva, called conjunctivitis.

Your child’s appearance is the best predictor of how serious his or her illness is. We care the most about how easily kids are breathing , their hydration status and if they become lethargic. We also like to see kids if they develop severe ear pain, facial swelling or severe sore throat with fever. These things can make us worried there is a secondary bacterial infection, though it’s not always the case.

Even though it’s frustrating, the common cold can last at least 10 days and 14 days of cold symptoms is not out of the normal range. Kids can also be more tired and have more difficulty sleeping as a result of their colds. The average child under the age of 6 has at least six colds per year, with slightly less frequency as they get older. That’s about 1 cold per month for the winter months. No wonder you feel like they’re constantly sick!

2. How do I treat it? Is there anything that works?

A trip down the drug store’s cough and cold aisle makes most parents’ heads spin. So many products, so many choices… what to do? The basics of cold care are comfort, comfort and more comfort. Mom really was right when she recommended chicken noodle soup, but mostly because it is a warm liquid that works to thin secretions. Of course, being careful to keep liquid temperatures in a safe range for your child is always important. Honey has also been proven to soothe the throat in kids over the age of 1. Some families find humidifiers, saline drops with bulb suction and elevating the head of the bed helpful though studies aren’t conclusive that they work on every child.

Most cough and cold remedies sold over the counter are combination products that have the potential for accidental ingestion, inadvertent overdose or adverse side effects. We recommend talking to your pediatrician if you are considering using one of these products for your child.

The common cold is, at least for the near future, a problem that is here to stay. Understanding just how common it is, how long it can last and when to worry can help you be prepared to face this winter season.

All across the United States, millions of families prepare to sit at the family dinner table every night and eat a lovingly-prepared, wholesome meal as they discuss the happenings of the day and experience good family nutrition.

Doesn’t sound familiar? Maybe more like a 1940s Norman Rockwell painting?
If this does sound like the way dinners are shared daily in your household, congratulations. If the concept of family dinners shared across a table sounds foreign, you’re not alone. According to a 2011 study published in the medical journal, Pediatrics, only about 52% of families share meals 5-7 nights per week, 31% share 1 to 4 meals together and 14% don’t share any meals as a group, a decrease from just a few years ago.

Why bother eating together? After all, family meals are hard to make a habit. Soccer practice, school play rehearsal, mom rushing home from work and dad late at a meeting almost every night is stressful enough as it is. We’re lucky enough even to pack our kids a healthy lunch or to bring some wholesome snacks along with us as we hop from activity to activity. We have time constraints and scheduling pressures that put eating well and eating together on the back burner. Add in the cost and time associated with home made food and it can seem impossible to make this “should do task” a “can do” priority.

The benefits of family meals, though, are overwhelming. Kids and teens who eat meals with their families at least 3 times per week are more likely to have a normal weight and to make better nutrition choices than those who eat less often with their families. The frequency of family meals has also been shown to be inversely relate to soft drink and high-fat food intake. Eating together discourages disordered eating, as well.

Family meals also help build communication between family members, are tied to better school performance and are associated with healthy psychological development.

Even more importantly, family meals allow you to model and teach wise nutrition consistently. Research shows that the food choices we make while pregnant and lactating affect the nutritional choices of our children. Even more overwhelming is the evidence that the foods your kids watch you choose, eat and enjoy are the foods your kids will pick as they grow older too. When you sit down at table with them to eat a healthy meal, you are teaching them a healthy behavior. When you rush to the drive through for a big mac with cheese, large fries and a coke, you are teaching them, well…. a bad one.

All of us have barriers to eating well for our selves and to providing the best food options to our children in the healthiest settings but, by prioritizing family meals, you are promoting a lifetime of healthy nutrition choices for your family. Not only are you more likely to eat healthy food yourself, your kids are too.

Chicken pox used to be a rite of passage.  Before the routine use of vaccine there were an estimated 4 million cases with 11,000 hospitalizations and about 100 deaths annually in the US.  Most adults remember having the chicken pox as a child and most cases were generally mild.  Chicken pox is usually spread by breathing infected droplets coughed by a sick person. The typical course would have fever to 102 degrees for the first 2-3 days while breaking out with 200-500 itchy blisters all over the body.  Each of the blisters would open and then crust over 3-4 days.  Anyone with chicken pox would be isolated until after they stopped getting new lesions, and the newest crusted and dried (usually 1 week).

Complications from chicken pox (or varicella) infection are more likely in infants less than a year, but even higher in people over 20 years old. Anyone with chicken pox can get a secondary bacterial infection in each of the blisters. Once someone gets the chicken pox, the varicella virus stays around in the nerve cells and can become reactivated, which we call Zoster. This can happen any time, but especially in times of stress or with illness. Zoster shows up as an extremely painful rash that can last weeks and can be dangerous in people whose immune systems don’t work well.

Given the fact that chicken pox is usually worse when patients are older, many parents in the past tried to make sure their children had chicken pox as toddlers.  The typical method of getting kids infected at this age was to have a well-child play with one that had just come down with the chicken pox.  These were known as chicken pox parties.

Recently it was revealed that not only are some parents choosing to continue this outdated tradition, but given the rarity of the disease now, they are also taking more extreme measures.  Parents of acutely infected children have the sick child suck on a sucker and then sell it to others (via US mail).  Why is this a bad idea? Not only is this illegal, it is also more likely to infect the children who suck on the sucker with diseases other than chicken pox.

Understanding how the chicken pox vaccine is made also helps us understand why chicken pox suckers and chicken pox parties are bad ideas. In the early 1970’s a Japanese scientist swabbed the active pox from an otherwise healthy child with chicken pox.  The virus was then grown in different kinds of cells, over and over, until it grew well in the lab but not well in humans.  This is called the Oka strain of the varicella virus.  When a child is vaccinated for chicken pox we inject a measured amount of live Oka varicella virus. Because we inject a strain of virus that doesn’t grow well in children, it makes it so that children don’t get the symptoms of chicken pox when they are exposed to the vaccine.

This means that parents do have a choice of pox parties.  Parents can go to a friend’s house and let their child play with an infectious playmate, getting an uncontrolled amount of virus, suffering through a week of itchy pox, each one a potential site of infection, or they can infect them with the strain that is too weak to cause the illness but doesn’t have the risk of the disease.

As a pediatrician it is always my goal to protect children from dangers.  When it comes to the chicken pox the vaccine isn’t perfect (what is?) but it offers good immunity without having to suffer through the disease with all of the risks associated.

One lesson taught to most middle school students is the scientific method, also known as scientific inquiry.  When they learn it, students may see it as just one more concept they have to memorize for a test.  However, it is crucial for adults to use this method when listening to the media coverage about  the findings of “the latest” studies.

Wikipedia succinctly presents the key steps  of this method of study

1. Define the question

2. Observe and gather information and resources

3. Form hypothesis

4. Perform experiment and collect data

5. Analyze data

6. Interpret data and draw conclusions that serve as a starting point for new hypothesis

7. Publish results

8. Retest

The key to understanding the importance and relevance of  a particular study lay in the details.  How well the study was done can have a significant impact on the likelihood the conclusion reflects an actual cause and effect relationship.  One example is knowing the size of the sample tested.  Relatively small sample sizes may skew results.

Unfortunately, public health can be impacted by the hype some studies receive.

For example, a report was published looking at 12 autistic children asking how many had their MMR vaccinations in the months prior to noticing the symptoms.  Eight of the 12 families reported that the MMR shot series  was given in the months leading up to their autism.  A study of this size and scope should be interpreted very cautiously.

There are many details that could influence the findings.  How were the children selected to be included in the study?  Had the families already come to conclusions about the cause of autism before participating?  If we ask survivors of heart attacks how many had eaten a banana in the week before, would it be help us understand heart attacks if eight of the 12 answered yes?

This is why we need our scientific method to help us understand media reports of new findings.  Most scientific and medical studies are used to help build a base of knowledge to understand things we observe and hypothesize to be true; they are not intended to be the final answer.

The last step in the method listed above is “retest” (different from “rinse and repeat”). How might we compare a study looking for a link between the MMR  series and autism if it looked at 500,000 individuals instead of 12?  How do we use both studies to find clues as to what the “real” association might be?  Did the author of the paper have any biases that might influence their findings?

Medicine should rarely change recommendations based on a single study.  If it did,  we would be starting, stopping and changing treatments every day. Most of these changes would not lead to improved care, and often it would be worse.

The following are three tweets from about a 12 minute period:

-          “Screen-Watching Children Have Narrow Blood Vessels in Eyes, Study Finds http://nyti.ms/egsCiS”

-          “Botox blunts emotional understanding, study finds http://lat.ms/g1VMsO”

-          “Tai chi appears to benefit quality of life for patients with chronic heart failure, study finds http://dlvr.it/PpWTm”

So before I unplug the TV, start tai chi and give up my botox (not really), I would want to know more about the studies, or at least look for other studies conducted by other research groups found the same thing.  A brief review of the literature I was able to find showed that the tai chi helped but studies have also found yoga, or even listening to soothing music to help chronically ill patients helped equally, as well.