Do you suffer from some sort of medical issue that requires regular attention? If you do, you are very much not alone. As a life-long member of this club, I can attest to the impact having of a chronic condition on one’s life. It truly dings your ability to work, play and parent…in addition to causing an annoying leak in one’s wallet!

I haven’t seen health reform benefit my life yet but I keep hoping that some plan will kick into place that works better than what we have now. One idea that I think has merit is to focus on our work environments and how employers can help.

Recently, I was shared a video put together by Harvard Pilgrim that drives this point home with some statistics and ideas that are worth considering:

Hopefully this will become a growing trend – if not for our benefit than for our kids as they enter their work lives.

A few years ago, I treated an adorable 6 month old infant girl in the ER for a cold.  The EMR (electronic medical record) highlighted that the family had recently been to the ER for a variety of other common complaints: diaper rashes, colic, sleep and breastfeeding problems – all issues that could have been handled in any pediatric office.

As this visit concluded, I mentioned that their pediatrician could help them with further issues.  The baby’s mother looked perplexed.  “We have an appointment tomorrow with her pediatrician but that’s for shots and measurements,” she mentioned.  That was my light-bulb moment with this family – they truly did not understand the full role of their pediatrician in their daughter’s life.  And, they are not alone.

People trek to emergency rooms for a variety of reasons:

• They are having a true emergencies or need urgent care after hours
• They are visiting the area and require medical care
• They falsely believe they will be seen quicker than calling their own doctor
• They don’t truly understand all the services their doctor’s office offers

Emergency rooms do treat all comers but the sickest get seen first and there is always a wait, in fact 4-6 hour on average.   Visiting the ER for simple matters instead of your primary care physician is like calling a repairman if your TV remote stops working. For a child, there are a few disadvantages to ER visits. The wait time can be very difficult for kids and lack of familiarity with the setting and staff disarming.  Luckily, most ERs are much more child-friendly than in the past but it is still a more intense experience for a child than visiting their own pediatrician.

Pediatricians are trained in the complete child – sickness and health. Knowing what your pediatrician is trained to offer you can help considerably in knowing what to do after-hours and in feeling comfortable with an ER visit should it be needed. Here’s an A to Z guide of the myriad of areas your pediatrician can help with for your kids:

a.     Anticipatory Guidance (informing you and your child of what’s to come next)

b.     Bullying (and cyberbullying): helping the bully and the victim

c.     Cell Phones and Computers: The Internet, Facebook, cyberbullying, sexting and everything else our kids and teens are doing with online and mobile technologies.

d.     Drugs and Alcohol Abuse: finding help and support.

e.     Eating and feeding issue – including eating disorders

f.      Fever and sick symptoms – sore throats, headaches, vomiting, diarrhea, rashes, ear aches, cough, and runny nose – and just about every sick symptom you can think of!

g.     Growth and development

h.     Hearing issues, Headaches

i.      Immunizations (shots)

j.      Journal articles and web sites to help you learn more about your child’s condition

k.     Kid-specific issues for all ages

l.      Laceration repair and suture removal

m.    Monitoring medical problems – new and chronic

n.     Negotiating the world of specialists – including the ER

o.     Orthopedic issues including injury treatment and sports participation

p.     Potty-Training and Puberty

q.     Queries about anything worrying you about your child

r.      Rashes

s.      School issues; Sexuality

t.      Travel advice

u.     Use of new technologies

v.     Vision issues

w.    Weight issues – too little, too much and eating disorders

x.     X-ray ordering (including acute injuries!)

y.     Your concerns about your child

z.     Zeroing in on what’s really important – our kids!

I bolded the new additions to the list since I first created it in 2006:  bullying and technology. Our world keeps evolving and as it does, so, too, does the role of the pediatrician in your kids’ lives. Anything your kids do that involves their growth and health, in either a positive or negative way, your pediatrician is there to help you with. And, as the person trained in the total child, is your best guide should an issue arise that puts your child’s health at risk.

So, if any issue arises with your child, think “call the pediatrician”. You’ll never go wrong by starting there, even if technology is concerned.

(Originally posted August 2006; Updated August 2011)

Thankfully most children are healthy and many will never need the care of a specialist. But should you find yourself in a situation that requires input beyond your pediatrician, there are some important issues to consider. Here’s a true story that will shed some light on the issues to consider.

A writing colleague’s two year old son developed a snoring problem so severe it interfered with his sleep, his family’s sleep, and his mood during the day. After exhausting all simple outpatient remedies, their pediatrician referred them to a local Ear-Nose-Throat (ENT) doctor who advised a tonsillectomy. Is this the end of the story, or should they dig a bit deeper?

At the heart of this issue is whether the advice we are given is what we should do. An equally important consideration is why we want the extra input. Is it because we are uncomfortable with the advice? Is it because we don’t like what we are hearing? Having a solid relationship with your pediatrician is what will help you find your answer. In fact, your pediatrician should be the person in the center of the entire consultant maze to help keep the focus on your child and to make sure you don’t end up in a black hole of referrals.

By knowing you well, your pediatrician  can help you find the answers you need in a way that works for your family; and  knowing your pediatrician will help you feel comfortable with following a course of action that you may not want to pursue emotionally but know you have to for your child.

Many times your pediatrician can get you more information by consulting a specialist by phone for you.  If that alone is not enough or you are facing a situation that requires an intervention, surgery or specialized care for a problem, then you may need to take your child to a specialist. Here are some questions to consider when contemplating obtaining a second opinion:

1. Are you comfortable with the initial advice? If you are not comfortable, why? Is it a hospital issue? A credentials issue? A bed-side manner issue? If at all uncomfortable, talk to another specialist.

2. Does the advice seem too conservative, or too aggressive, for the problem?  If so, a second opinion would be very valuable as a comparison.

3. Does it matter to you if the person helping your child is a pediatric sub-specialist? In many areas of the country, including the Boston-area, community physicians, particularly ENT specialists, have very large pediatric practices, particularly if they practice a distance from a major city. Moreover, the training of community physicians does include pediatrics.  So, unless your child is facing an unusual situation or something very pediatric-specific (a congenital problem, for example) either type of doctor would serve your child well.

4. What are the pediatric services of the specialist’s hospital?   The only difference between a full children’s hospital and a community hospital with elaborate pediatric services is the amount of the hospital dedicated to children.

5. How many similar cases has this specialist treated? This is particularly important if surgery is being considered.  The considerations are the same here as for #3 above.

6. Does the hospital have 24 hour coverage with residents or hospitalists? Having 24 hour in-house pediatric coverage often improves the level of care because there are always pediatric doctors in the hospital and available.

7. If your child is being treated at a community hospital, how close is the nearest children’s hospital should a higher level of care be needed?

8. What’s your pediatrician’s opinion on the specialist’s input?

9. How comfortable are you with not having a pediatric specialist treat your child?

10. What does your gut tell you?  Tell your pediatrician if you have any concerns or are uncomfortable with the advice.

Back to our story. The family did seek a second opinion from a pediatric ENT who happened to be on staff at a large community hospital with a huge in-house pediatric service.  The pediatric ENT doctor confirmed what the first ENT doctor had advised, that a tonsillectomy was needed to help their son’s snoring and breathing during sleep which would in turn allow him to get more restful sleep.

Now they had two similar opinions from doctors with slightly different training who practiced at two very different types of hospitals. For this family, the decision boiled down to the level of pediatric services at the hospital so they opted for the pediatric ENT. Another family faced with this exact scenario may have chosen the first doctor and had the exact same outcome for their child.

Their toddler’s snoring is now gone and the entire family is finally getting a good night’s sleep.  Happy ending for all.

(Originally posted September 2006; Updated December 2009)

Q)
Dr. Gwenn:

I have an 11month old son who weighs 20lbs. How much Tylenol or Motrin can I give him?

Thanks!

AC, Massachusetts

A)

Dear AC:

Great question.  Figuring out over the counter medications dosing can be confusing, especially since kid’s weights are constantly changing and dosing is based on weight. You’ll notice that dosing guidelines on the medication packaging include ranges by weight and age.  These are ok in a pinch but are not very accurate because they cover a wide range of weights and are not precise for your child.

In addition to talking to your health care provider or pharmacist, you can do a simple calculation yourself to determine your child’s more accurate dose by just knowing your child’s weight, in either pounds or kilograms.

Here are the formulas we use for both Tylenol(acemaminophen) and Motrin/Advil(ibuprofen):

Tylenol: 15mg/kg/dose or 7mg/pound/dose every 4 hours.

Dose = 15xweight(kg) or 7xweight(lb)

Motrin: 10mg/kg/dose or 4.5mg/pound/dose every 6hours.

Dose = 10xweighg(kg) or 4.5xweight(lb)

So, based on your son’s current weight of 20lbs,  here’s how’d you’d figure out his current dose:

Tylenol:   20 x 7 = 140mg of tylenol. Tylenol comes in 80mg droppers or 160mg teaspoon. So, to not over dose him, you’d give him the closest reasonable dose which is about 120mg or 1 1/2 droppers of infant Tylenol or 3/4 Teaspoon of Children’s Tylenol.  When in doubt, go a bit less than a bit more if you are between doses.

Motrin: 20 x 4.5 – 90mg. Motrin comes 50 mg in the Infant dropper or 100 mg per teaspoon in the Children’s elixir. So, just shy of 1 teaspoon or just about 2 droppers of the 50mg line would be your son’s dose of Motrin.

When children are infants and toddlers, their weights change rapidly so you’ll want to be sure you have an idea of your child’s current weight every month or so until your child is age 3.  After that, the weight gain slows down and you can get a weight every 6 months without much concern.

In a pinch, you can figure out your infant’s weight on any home scale by weighing yourself holding your infant and subtracting your weight. Home scales are very inaccurate for very teeny weights, such as 20ish pounds and less.

Finally, be sure you really need to give either medication before you give it. Your pediatrician can guide you best on that front if you are all uncertain.

Cheers,
Dr. Gwenn

Norman Rockwell’s Freedom From Want picture embodies the nostalgia so many of us feel each holiday season.  Every time I see that picture, images flash quickly between that image to my own grandparents’ kitchens.  Indeed, my grandparents played a huge role in my life growing up especially around large family functions. But compared to the involvement my parents have with my children, there is a dramatic qualitative difference.

My grandparents were almost spectators and our constant cheering section but knew little of the particulars of our lives. My children’s grandparents, like many of you, have a much more active role and pinch hit for me and my husband often.  So, they need to know all the details. Some details like homework and after school activities are not hard to figure out but health care is a different story. The world of pediatrics has changed so greatly since we were children that grandparents need a quick primer to catch up their databanks.

Here’s a run down of the most important health care and safety changes over the past century:

• Most of the diseases you recall as a child are all but eradicated: polio, measles, mumps, even chicken pox. This is all due to the amazing advances in immunizations.
• TB was rampant when you were a youth; today it is controllable and treatable.
• Our communities are cleaner with better public water supplies and sewage treatment. This has greatly decreased the amount of intestinal disorders you may recall many infants and small children succumbing to.
• We were give antibiotics for everything and nowadays they are used very sparingly. We now know that too much antibiotics fosters resistance, and that most illnesses kids get are viral.
• Like you, we had a great deal of unstructured playtime as children, yet our kids after-school lives allow very little. New studies are actually proving what you knew, kids need to play – just because. So the tide may be turning back on this important issue.
• We didn’t have TV, the internet and all this technology to the extent our kids now have. This is a blessing and a curse. Increased screen time is directly linked to childhood obesity and many shows expose kids to inappropriate material for their ages.
• We used to sleep on our tummies. Now we know that SIDS is greatly reduced if babies sleep on their backs.
• Infant seats were not common when we were young and are now mandatory.
• We rode bikes without helmets, as did you! Now we know the importance of protecting the brain during riding sports.
• Girls are involved in many more activities compared to when we were younger such as sports and cultural enrichment activities.
• We were all in walkers when babies, now we know they are not so great.
• More families have dual-income parents so kids are often cared for in afte rschool programs or by nannies.

This is just the tip of the iceberg. Every aspect of pediatric care has advanced from neonatology to the treatment of cancer. In many ways, the more things change, the more they stay the same. Raising kids still involves patience, love and a healthy sense of humor. And, despite what we may all want to think now that we are “adults”, you still hold the biggest trump card of them all: stories of your own kids’ childhoods to share with our kids to remind us that the apple does not fall too far from the tree, even if the tree is growing in a bit of a different way.  In that regard, the most important elements of Freedom From Want will always be timeless.