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.

Believe it or not, and despite the fear and trepidation often associated with it, fever is often your child’s friend. Fever revs up the body’s immune system and activates it to fight off any viral or bacterial “invaders.” The ability to mount a fever has been shown to increase survival rates in animal species. So, when your child has a fever, it means her body is doing its job. That doesn’t make it easy to understand, though….

Let’s talk definitions first. Until as recently as 1868, there was no consensus on what was a normal body temperature or what was a fever, but now most pediatric experts agree: a fever is a temperature equal to or greater than 100.4 degrees Farenheit or 38 degrees Celsius. That’s why when you make an appointment for your child for a “fever” we sometimes push you on the details: 100.2 you say? Not a fever. Felt your child and thought he was hot but didn’t take the temperature? Might have been a fever, but might not have. We love to know, when possible, the actual temperature.

Your child’s temperature depends on a number of factors, including how you take it. The closer we get to the core of the body, the more accurate it is. That’s why, when we measure the temperature of a baby, we often want to take the temperature in the baby’s bottom. For older kids, a temperature taken in the mouth or the bottom is much more accurate than a temperature taken under the armpit.

A child’s age also matters a lot when it comes to fever. For infants under a month of age, even a really low-grade fever can signal a serious infection from a bacteria. Any child under a month of age needs to be evaluated by a doctor immediately if they have a fever, even if it only occurs once.

As kids get older and older, we pediatricians are less concerned about low-grade, fleeting fevers in otherwise healthy and vaccinated kids, but recommend an evaluation if your child has had a temperature for more than 2-3 days (or anytime you are concerned). About 30% of the visits parents make at pediatric offices for their children are for acute fever, so pediatricians are “fever doctors” a lot of the time!

Some things do worry us when it comes to fever. We worry when the fever lasts several days without a good explanation for it. We worry when your child becomes dehydrated. We worry when your child is lethargic. We worry when your child is not fully vaccinated. Most of all, we worry about how your child “looks” overall, which is why we pay a lot of attention to this when you call or come in. Some things worry us a little less than they worry you. Studies show that parents are often the most concerned when a child has a fever that they will have brain damage, but brain damage has NOT been associated with high fever, even fevers as high as 107 degrees. Sometimes a really high fever can help us figure out if a child’s illness is from a virus or bacteria but that’s not true until the fever gets as high as 106! There are plenty of viruses that give kids high fevers for a few days as well.

It also doesn’t matter if the Acetaminophen or Ibuprofen you’ve been giving to “treat” your child’s fever makes it go away and stay away. These medications are for your child’s comfort but don’t help to fight off the virus or bacteria your child has. If they don’t completely eliminate the fever, it doesn’t mean they aren’t working, just that they wore off like they are supposed to.

Fever can be scary, but knowing what a fever does for the body is helpful. On average, kids will have 4 to 6 acute episodes of fever from birth to 2 years of age, so fever is here to stay, whether we like it or not. Think of it as an (often annoying, but very helpful) friend.

Posted by Dr. Whitney Casares October, 2011

A study published in the journal Pediatrics this week revealed 13% parents surveyed vaccinate their children using an alternate schedule.  Even many of the parents who were following the recommended schedule thought that delaying vaccine doses was safer.  There are many theories about what started and has fueled this loss of confidence in vaccines.  I think it is now more important to help families understand the science so they can filter out the rumors and myths.

When parents decide to vaccinate using an alternative schedule they typically cite one of two concerns.  Either they worry that a young infant’s immune system is too vulnerable and should not be exposed to the vaccines, or they worry that there are too many vaccines to safely be given at such a young age.

A child’s vulnerable immunity is in fact one of the reasons for giving vaccines at a young age. That’s when children are most susceptible to the diseases vaccines prevent.  If a mother has Hepatitis B and doesn’t know about it when she gives birth, the infant has a 95% chance of becoming infected (unless they get the birth dose of the vaccine). Likewise, prior to the HiB and Prevnar vaccines, the average age for bacterial meningitis was 15 months old (that average includes people of all ages), showing infants were the vast majority of those who suffered from the infections.

I understand why a parent would see the number of vaccines and think it seems like a lot to give an infant.  What most don’t realize is that all of the vaccines combined are about 5% of what was in the vaccines when they were first developed.  The number of injections is more but what is in them has been purified to a bear minimum.

Here’s why: vaccines are made using parts of viruses or bacteria to stimulate ones immune system to become immune to a disease without having to suffer the risks of an infection. When analyzing how challenging something is to the immune system, we count the number of different things it has to respond to (called antigens). A piece of one protein from the surface of a virus is one antigen.  When first created, the DTP vaccine (against diphtheria, tetanus and whooping cough) had about 3,000 antigens in the one injection.  Today the vaccine we use for these three diseases has between 4 and 7 antigens (depending on the manufacturer).  As a matter of fact, if you look at the total number of antigens in all of the vaccines combined it is about 160, way less than previously used and way less than what a child encounters naturally each day.

The number of antigens a child’s body sees due to vaccines is significantly less than the number a child’s body sees day to day. When an infant is delivered from the sterile environment of their mother’s womb they very quickly become colonized with countless bacteria.  We estimate that a typical child is exposed to 2,000-6,000 antigens each day, just through normal life experiences.  The recommended injections for a 2 month old include diphtheria, tetanus, whooping cough, HiB, Pneumococcus, polio and hepatitis B.  The number of different antigens challenging their immune system adds up to only about 39.

For a better understanding of what our bodies are protecting us from everyday see here.

Regardless of the number of needle pokes at any doctor visit, vaccines are not overwhelming, and they are not too much too soon.  Children’s bodies handle thousands of antigens each day, but the antigens they handle from vaccines protect them from potentially harmful and sometimes fatal infections at a time when they are often most at-risk for those infections.

I repeat, and will continue to repeat, vaccines are safe, they prevent terrible diseases and they save lives.  My own children have been given all of the recommended vaccines, I cannot give a higher recommendation than that. 

But there is more to the story…..

Recently studies have looked for, and found the virus in other cancers.  A recent review found studies linking HPV to cancers of the mouth, throat, colon, lung and breast.  Since we refer to HPV as a sexually transmitted infection, many assumed the virus in these cancer cases was only being passed in “sexual” behaviors, but this is where the story gets interesting.  It turns out about 4.5% of healthy adults  have HPV detectable in their mouth. Studies also showed that when one spouse had HPV detectable in the mouth, they were more likely to infect their partner’s mouth HPV (and it did not correlate with oral sex in these couples).  Another study followed moms who had asymptomatic oral HPV infection and found their infants were 5 times more likely to get oral HPV.

Now that we know HPV is associated with more than just sexual transmission, more research is being done so we will know if the HPV vaccine will prevent cancers of the mouth or other sites.  Still, do not look to the pharmaceutical companies that make the vaccine to promote this information.  They are not allowed to by FDA rules.  They are only allowed to advertise for things they have proven the vaccine will do, not what it likely will do.

Our new understanding of HPV and the cancers it causes makes vaccinating children against HPV even more sensible.  Given the new research available, we can’t be sure that this virus is only passed through sexual contact and not through other activities, even activities as benign as kissing.  We also can’t predict when a pre-pubescent child will have exposure to this cancer-causing virus, either through sexual or non-sexual contact.

HPV is a cancer-causing virus, not just a sexually transmitted disease. We have a vaccine to fight against it. It is time to stop calling it the vaccine for sexually transmitted diseases and call it the cancer vaccine.

Yesterday the GOP candidates had a debate.  One topic raised was Governor Perry’s mandate for the HPV vaccine.  I believe that there are plenty of legitimate political discussions that can be had on this subject, but I will leave that to the politicians. What I won’t leave to the politicians is when good science and medicine that saves lives is attacked, in a public forum, in an uninformed and dangerous way. This is what happened today.  Michelle Bachmann (R-Minn) described the vaccine for HPV as “dangerous”.  Her support for this statement came from a conversation she had with a mother who blamed the vaccine for causing her daughter’s “retardation”.  The problem comes when a connection (or misconnection in this case) is made, on national television, between a well-supported and studied, safe, healthy, LIVE SAVING medicine and a disease it does not cause.

A lot is known about this vaccine, here is some of what we know.  HPV stands for the Human Pappilloma Virus.  It is actually a family of about 130 different viruses.  A handful of the strains have been found to cause cancer.  Cervical cancer was the first type associated with HPV.  It is almost impossible to get cervical cancer without the virus.  Since that discovery, scientists have looked for the virus in other cancers.  The list of cancers that are at least some times found to have HPV include; cervix, vulva, vagina, anus, penis, mouth, throat, colon, lung and breast. We know the vaccines for HPV prevent cancers of the cervix, vulva and vagina and more studies are being done to see if the vaccine will prevent these other cancers.

So, the next question is how is the virus contracted.  The answer depends on the type.  The genital types are transmitted sexually but the infections of the mouth and throat are passed through mouth-to-mouth contact.  The transmission of the other type are still under investigation.

I know that the pharmaceutical companies make money by selling vaccines but here in America that is legal.  The recommendation for vaccinating comes from the American Academy of Pediatrics, the American Academy of Family Physicians and the Centers for Disease Control, not the companies that make them.

Preventing HPV prevents cancer.  It does not cause retardation or any other neurologic disease.  This vaccine and this knowledge has already saved thousands of lives, by PREVENTING cancer, and as long as we keep ourselves educated, the vaccines will continue to save lives.

What’s a doctor to do? Modern western medicine considers it unethical to treat patients with a placebo. We are expected to use science-based evidence to only treat real conditions with proven safe and effective medications.

The problem is that we humans, not Vulcans of the Star Trek age. We think of ourselves as rational but are all subject to bias in our reasoning. We tend to make our decisions based on our “gut” or intuition, employing emotional responses. Then, we find the data to support our conclusion. People often assign causality to events that occur one after the other, even if it was coincidence. Many are superstitious.

I can’t count the number of times I’ve talked to families about the cause of the common cold being a virus, rather than rainy weather (the same viruses appear in winter in Arizona as in Oregon ; it is the season, not the rain). Such emotional responses can sometimes hinder how we treat viruses, illnesses and diseases.

A trip through the pharmacy aisle at any grocery store will reveal a vast selection of medicines, herbal remedies and homeopathic treatments for anything that ails you. For viral infections (like the common cold) most have never been shown to make anyone well faster. And, because we are emotional beings, we feel better if we do something rather than nothing.

Each year people in the U.S. spend more than $4 billion on cough and cold remedies. According to Mayo Clinic, “Over-the-counter cold and cough medications in older children and adults. Nonprescription decongestants and pain relievers offer some symptom relief, but they won’t prevent a cold or shorten its duration, and most have some side effects. If used for more than a few days, they can actually make symptoms worse.”

Most people who spend their money on these drugs will tell you that they believe that they work. However, when given placebo or one of these medications (and not told which) they work – or don’t work – equally well. People believe they work because they want to feel like they are doing something.

As a pediatrician, I am in a difficult position. Parents want something to help, even though nothing will change the illness or shorten its duration. When there is no medication to prescribe and knowing it is unethical to use placebo, I will continue to try to educate the parents. However, teaching someone out of an emotional belief is usually as productive as wishing for a sunny day in winter in Oregon.

Here are some additional resources that may be of interest.

Predictably Irrational: The Hidden Forces That Shape Our Decisions

By Dan Ariely – http://www.powells.com/biblio/17-9780061854545-1

Why People Believe Weird Things: Pseudoscience, Superstition, and Other Confusions of Our Time By Michael Shermer – http://www.powells.com/biblio/2-9780805070897-5