Bright Steps Blog

Where did this bill come from?

May 20, 2015

“While you’re looking at little Jimmy for his physical, can you take a look at his knee? And he’s been fighting with other kids in his class at school. And he wakes up during the night and wants to find us before he can fall back to sleep.”

As a primary provider, I see patients with a wide range of illnesses and also for their wellness exams, many times with both overlapping on the same day. My goal is to address each and every concern.

Lately, with changes in insurance policies and coverage, including insurances putting more responsibility on patients and their families and transitioning to deductible plans from full-coverage plans, I’ve been fielding a number of questions. Why am I being charged an extra fee on top of a wellness visit? Why are we being charged for my child’s hearing test? Why am I being charged for my child’s visit (including medication checks, weight checks, behavioral concerns), when my child wasn’t sick?

Insurances are changing- unfortunately there is no simple policy which covers all care anymore. Billing for any exam is getting more and more complex and complicated for everyone involved.

I found this blog online which addresses many of these issues:
https://survivorpediatrics.wordpress.com/2011/08/21/what-i-wish-parents-knew-about-medical-billing/

Please take a few minutes to read over the above blog to help answer some of your concerns.

Enterovirus D68

September 18, 2014

enterovirus68cdcconfirmeds_657252

 

Enterovirus D68

 

 

What is this new virus popping up in the news?  Should I be worried about my child?  What do I do if I think my child has this virus?  What should I look for?  How do I protect my child?

These are all excellent questions I’ve heard in the last few days!  Let’s go through a bit about what is known so far:

What is the Enterovirus D68?

It is a virus in a group called enterovirus, which include polio and non-polio type viruses (which include coxsackieviruses, echoviruses, and other enteroviruses).  You may have heard of coxsackieviruses before, if your child had hand-foot-mouth disease.  That particular group of viruses is easily transmitted from person to person, but the symptoms can vary depending on your child’s age and health.  Enterovirus D68 was first discovered in 1962, but until recently has only been seen to cause small pockets of disease.  Typical enteroviruses cause 10-15 million infections each year, with this type of Enterovirus only being a tiny number of those in the past.

Why is it showing up now?

Typical enteroviral season is summer through fall.  This recent spread of D68 seemed to coincide with the start of the school year, when all the students are back together- touching door knobs, toys, counters, etc.  With this particular virus only being seen in small outbreaks in its history, it leaves many children vulnerable to illness as not many children have immunity from either being ill with it before or being exposed to someone with it in the past.

What should I look for?

With most viruses, we see fever, cough, runny nose and body aches.  Similar symptoms are seen with D68, although it seems to be hitting harder in the respiratory system, causing difficulty breathing and wheezing.

What do I do if I think my child has symptoms?

With mild symptoms, low-grade fever, runny nose, cough- treat their illness like you would with any other viral illness- rest, fluids, and fever-reducer if needed.

If your child has a history of asthma or other wheezing illness, keep a close watch for worse respiratory symptoms.  Make sure your child is taking their asthma medications and check for an up-to-date asthma action plan.  If you notice any labored or rapid breathing, wheezing, or other signs of respiratory distress, call your doctor.

Is there treatment?

There is no vaccine for Enterovirus D68 and because it is a viral infection, antibiotics will not help either.  For healthy children, hydration and fever control.  For children with asthma and other respiratory symptoms, they may need to be hospitalized for extra support with their breathing and supplemental oxygen.

How can I protect my child?

The best way to protect your child is reducing the risk of infection- wash hands often with soap and water, avoid touching eyes/nose/mouth with unwashed hands, avoid close contact with those who are ill, and frequent cleaning of surfaces- doorknobs, counters, toys, sink knobs, etc.  Practice having your child cough/sneeze into a tissue or their elbow instead of their hand.  Call your physician if you have any questions.

There are confirmed cases in NY now and 17 other states and cases are starting to be seen in Canada too.

For more information:

http://www.cdc.gov/non-polio-enterovirus/about/EV-D68.html

Back-to-School Sleep Clocks

August 25, 2014

SleepingBabyCartoon

 

 

The countdown to the start of another school year has begun!  How do you get your youngster adjusted to the new sleep schedule?  Especially your teenager??

Getting back into the school routine is tough!

  1. Do not wait until the night before school starts to adjust their bed time.  Start today!  It takes a good week to switch their internal clock, like jet-lag.  Start by pushing bedtime 10-15 minutes earlier each night, until your goal time is met.
  2. How much sleep do they need?  Preschool age children need 11-13 hours of sleep each night. Elementary-school age children need a bit less, 10-11 hours of sleep each night.  “Tweens” need about 10 hours of sleep and teens need at least 9 hours.
  3. Start winding down ~30 minutes before bed, no “screens”- no TV, computer, phone, iPad.  It’s a good time to read, brush teeth, and take a bath.
  4. Avoid caffeine after lunch.
  5. Keep their rooms dark for sleeping.  Open those blinds in the morning- the light will help with waking up.
  6. Eat a healthy dinner and limit sugary snacks before bed.
  7. If your child is having trouble waking in the morning after a few weeks of school or falling asleep in school, he or she may need more sleep.

Heat-Related Illnesses

June 26, 2014

 

sweat1-thumb

With the weather in the next few days approaching the high 80’s and summer vacation beginning, it seems like a good time to talk about heat-related illness.  Did you know that children and adolescents adjust more slowly than adults do to changes in environmental temperature?  They also sweat less than adults- sweating is an important cooling mechanism for the body.  And they don’t always want to stop playing or having fun to drink enough fluids either.  Did you know that athletes can evaporate from 1 ½-3 liters of fluid an hour??

What are the three types of heat-related illness?

  • Heat Cramps
  • Heat Exhaustion
  • Heat Stroke

What is the difference between them?

  • Heat Cramps
    • The mildest form of heat injury and shows up with muscle cramps and spasms that happen during or after exercise and sweating, usually much worse in high heat.
    • Symptoms include flushed, moist skin and painful muscle cramps, most commonly in the legs.
  • Heat Exhaustion
    • More severe that heat cramps and is caused by loss of both water and salts/electrolytes from the body.
    • It happens after excessive sweating in extreme heat without fluids and salt replacement.
    • The body is unable to successfully cool itself and if untreated can lead to heat stroke.
    • Symptoms include pale, moist skin and fever (usually 100-104F).
    • Your child may also have a headache, nausea, vomiting or diarrhea and may be tired and dizzy.
  • Heat Stroke
    • The most severe of the heat-related illness with the body’s cooling system being overwhelmed.
    • It is life-threatening and needs immediate medical attention.
    • Symptoms include warm, dry skin, high temperature (over 104F), and rapid heart rate.
    • Similar symptoms to heat exhaustion with nausea and vomiting may be present too.
    • They also may be confused or agitated and may have a seizure.
    • If it progresses, it can lead to shock and coma and even death.

How do we treat heat-related illness?

  • With heat cramps and heat exhaustion, treatment is the same:
    • Always move your child to a cool, shady place and let them sit and rest.
    • Remove extra clothing and place cool cloths on the skin.
    • Give them sips of cool fluids, water is ok but fluids with salt and sugar are even better!
    • If your child does not seem to improve, seek medical care, as heat exhaustion can progress into heat stroke.
  • With heat stroke, immediate medical care is needed:
    • Call 911 or your local ambulance.
    • Move your child to a cool place and also remove excess clothing.
    • Place bags with ice under the armpits and along the groin.
    • Offer cool fluids if your child is alert enough to drink.

How can I help my child stay cool in the heat?

  • Drink lots of fluids- water, sports drinks, lemonade are all good choices!  Avoid anything with caffeine, as it will dehydrate your child further.
  • Make sure your child is wearing light, loose clothing on hot days.
  • With vigorous play, try to get outside more in the morning and evening when it’s cooler and take lots of breaks to rest.
  • Exercise produces 10-20 times more heat in your child’s muscle than rest!  So be careful with letting your child attend sports practice without proper fluids and frequent rest/rehydration breaks.
  • Kiddie pools and sprinklers are great for hot days!  Teens can use a spray bottle to mist themselves in the heat too.
  • Keep an eye on the humidity!  It it’s hot and humid, your child’s sweating and cooling system is working even harder and it’s more difficult to stay cool.
  • Infants and children are even more susceptible to heat than adolescents, as they have smaller bodies and those tiny arms and legs aren’t able to sweat enough to cool down.
  • It takes time to adjust to the heat!  8-10 days are needed to “adjust” to the higher temperatures, so be cautious with starting sports in the summer and even vacationing somewhere warm during the winter.
  • If it’s hot and humid outside, find somewhere cool to go if you don’t have air conditioning- the mall, the movies, the library, or go visit family!
  • Also make sure your child is not spending time unattended in your car, which we will talk about next!

Here is a chart with heat index, from ambient temperature and humidity:

heatindex

Teaching Your Child to Love Reading

May 2, 2014

 

children-reading

 

 

 

 

 

One of my favorite hobbies is reading.  Ever since I was little, I can remember going to my grandparent’s house and sitting on the couch all day, reading the newest treasure I had picked off the shelf in the upstairs hallway.  Raising readers helps in multiple ways!

  • Imagination- You have to create the images in your mind of what you are reading. How did you picture Harry Potter?
  • Empathy- Connecting with a character can help your child understand other children and family members.
  • Connection- If multiple family members read the same book, you can talk about concepts and ideas in the book. Even simple children’s books, like the Very Hungry Caterpillar, have discussion points- why did the caterpillar go into a cocoon? Why did he eat so much food first?
  • Writing- If your child reads a lot, they will also be better writers!  Exposure to vocabulary and written text will help your child with their future career and self-expression.

What’s better than a quiet afternoon with no one complaining that they’re bored?

In honor of National Library Week, although few weeks late, I have a few hints for helping your child enjoy books too!

  • Surround your child with books!  Keep books in every room in the house.  Give your children books instead of more toys for their birthday.  Go to the library. Buy used books.
  • Read for your own pleasure in front of your child.  Kids model their parents- what better habit to pick up from mom or dad than reading?
  • Read aloud to your child.  A quiet activity before bed will help your child wind down and connect with you for a few minutes at the end of a hectic day.
  • Discuss books with your children.  Talk about the pictures.  Think about what happens next.  What is a different way the book could end?
  • Limit time with electronics.  Turn off the TV one night a week and work on a longer book than the usual bedtime story.  Read chapter books to your older children- they can help too!
  • Explore fiction and non-fiction books.  Maybe you have a budding scientist?  Or a mechanic? Read about volcanoes and building trucks!

With texting and e-readers and computers, there’s a vast electronic world out there!  But nothing feels better than a well-read book in your hands with pages to turn and pictures to see!

For a quiz to see how you are doing in teaching your child to love reading, check out:

http://www.babycenter.com/0_quiz-are-you-teaching-your-child-to-love-reading_64488.bc

National Children’s Dental Health Month, Part 2

February 28, 2014

Toothache_Cartoon_Character_clipart_image-copy

 

 

 

To bring Dental Health Month to a close, we’ll talk about a few emergency tooth topics for your older child.

 

My child sucks their thumb, what do I do??

  • Infant and young children find sucking to be soothing and will often put their finger, thumb, pacifier, or other object in their mouth.  It’s a primitive reflex, even seen in some species of monkey!
  • Most children stop by age 4 years, when they still have their baby teeth.
  • If it still continues when they have their permanent teeth, then it becomes a problem, not only for their teeth but also it’s an infection risk, with their thumbs being covered in bacteria, and their friends may begin to tease them.
  • The American Dental Association recommends:
    • Praise children for not sucking, instead of scolding them when they do.
    • If a child is sucking its thumb when feeling insecure or needing comfort, focus instead on correcting the cause of the anxiety and provide comfort to your child.
    • If a child is sucking on its thumb because of boredom, try getting the child’s attention with a fun activity.
    • Involve older children in the selection of a means to cease thumb sucking.
    • The pediatric dentist can offer encouragement to a child and explain what could happen to its teeth if it does not stop sucking.
    • Only if these tips are ineffective, remind the child of its habit by bandaging the thumb or putting a sock/glove on the hand at night.

My child got hit in the face and their tooth is knocked out, now what?

  • First, find the tooth! Handle it carefully; try not to touch the root.
  • If it’s clean, place it back in the socket.  Have your child bite on a piece of gauze to keep it in place.
  • Rinse it with water if it’s dirty, but no soap, no scrubbing, and no drying!  If it cannot go back into the socket, place it in milk or, if your child is old enough not to swallow it, between their cheek and gums.  Do not place in tap water!
  • Then call your dentist right away!  Most teeth can be saved if seen, ideally, in less than 30 minutes.

What if my child chips their tooth?

  • Rinse their mouth with warm water- cold water will feel worse on any exposed root!
  • Put a cold compress against the chipped area or on the face to help with swelling and pain.
  • Then call your dentist!

For more information about dental emergencies, click here:

http://www.mouthhealthy.org/en/az-topics/d/dental-emergencies

 

National Children’s Dental Health Month, Part 1

February 10, 2014

2977_smiling_superhero_tooth_with_toothbrushWhat do you think of when you hear February?  Blizzards?  Valentine’s Day?  Groundhog day?  Chocolate candy?  It’s also National Children’s Dental Health Month!

 As a pediatrician, we’re often the first one to look in your child’s mouth and take a look at erupting teeth, besides you! 

 

 

Here are a few tooth concerns for the younger child; we’ll talk about older children in the next blog! 

 When do teeth appear? 

  • Typically around 6 months, although that’s an average, so there is quite a range for the first one to poke through, usually from 6-10 months of age. 

 When do I need to start brushing?

  • You can start cleaning your baby’s gums when they’re newborns with a clean, damp washcloth or gauze.  Once a tooth is showing, you can start using a child-sized toothbrush and water or fluoride-free toothpaste.

 When can I switch to toothpaste with fluoride?

  • Once your child can spit!  Usually around age 2 years.  Use a pea-sized amount on their toothbrush and make sure to brush twice a day. You can let your child brush their teeth themselves first, but always make sure you finish the job to get into all those nooks and crannies!

 When do I start flossing?

  • When you see two teeth that touch!  Then there’s a pocked between them for food particles and decay to occur. 

 What can I do about teething?

  • During the first few years of your child’s life, they will have teeth erupting; ultimately 20 baby teeth will push through those sensitive gums, usually before the age of 3 years.  It’s normal for your child to be grumpy, sleepless, lose their appetite and be covered in drool!  But it’s not normal to have fever, diarrhea, or runny nose with teething- those are more likely illnesses.   For pain, you can try a frozen washcloth or teething ring or even a frozen bagel for your child to chew on. 

 When do I see the dentist for the first visit?

  • Most family dentists will start seeing children at age 3 years.  Some pediatric dentists will start at age 1 year, or younger if there are concerns.  Your pediatrician is a good resource for keeping an eye on your child’s teeth when they are young and can recommend a good provider for your children’s dental health.

 What happens at the first visit?

  • The dentist will look at your child’s teeth- checking for injuries, decay, and other problems.  Your child’s teeth will be cleaned and counted.  Pacifier use and thumb sucking will be discussed too.

 When do baby teeth start to fall out?

  • Here’s a nice diagram (click on it to enlarge):

 

teeth_eruption_chart 

 We’ll talk more about dental concerns for your older child- injuries, sealants, wisdom teeth, etc., in the next installment!

Handwashing

January 10, 2014

sinksoap

 

 

It’s illness season- between coughs, colds, the flu and stomach bugs, there are lots of contagious sicknesses out there! What is the best way to protect yourself and your children?

 

Wash your  hands!

When should you wash your hands?

  • Before eating
  • Before, during and after preparing food
  • After using the toilet or helping your child use the toilet
  • After diaper changes
  • After touching your pet and even your pet’s food
  • Before and after caring for someone who is sick or injured
  • After blowing your nose, coughing or sneezing
  • After touching garbage or other waste

How should I teach my child to wash their hands?

  • Be a good role model!
  • Wet hands with clean, running water- even cold is ok
  • Apply soap and lather the whole hand, including between fingers
  • Scrub for at least 20 seconds- you can sing Twinkle, Twinkle Little Star or Happy Birthday twice
  • Rinse under clean, running water
  • Dry your hands well with a clean towel or air dry them

What about hand sanitizer?

  • It definitely helps reduce the number of germs on your hands, although it does not eliminate all germs.
  • It doesn’t work as well as soap and water when hands are greasy or have visible dirt.
  • Look for one with at least 60% alcohol

Why is handwashing so important?

  • Germs enter your body through your mouth, nose, eyes.  Watch the people around you- how often are they touching their mouth, nose or eyes?
  • Germs can stick on objects, like railings, door handles, phones, toys and then get transferred to your hands.
  • Lots of people rinse their hands with water- make sure you use soap!  It removes many more of the germs.  Liquid soap is better than bar soap as germs can grow on bar soap and spread from person to person, but is ok to use in your household if there are no skin infections on any of your family members.

Don’t underestimate the illness-fighting power of simple soap and water!  The minute you spend washing can help keep you and your family healthy!

For more information:

http://www.cdc.gov/handwashing/index.html

http://kidshealth.org/parent/general/sick/hand_washing.html#

Cold-weather tips

December 16, 2013

706176-tn_Baby019Winter is here in the northeast….brrrrr! I had a question from a parent, when is it too cold to take your child outside? My gut response is not to take them out when it’s too cold for you to be out! Here are some suggestions for clothing and temperature guidelines:

What should your child wear?

Layers are key! Multiple thin layers are better than one very heavy coat, that way layers can be removed if your child starts to overheat. Check the back of your child’s neck- if it’s warm or sweaty, he/she might be too hot. The rule of thumb is that older babies and young children should wear one more layer than you would wear. Turtlenecks, thermal underwear, and tights are good options for little ones. Try to avoid 100% cotton for the inner layer, as it can absorb perspiration and can cause your child to get wet and then cold.

Don’t forget warm boots, hats and mittens/gloves. Try a neck warmer instead of a scarf to reduce the strangulation risk. Your child’s coat should be water and wind resistant.

What is hypothermia?

It’s a condition that develops when your child’s body temperature falls below normal, due to exposure to cold. It happens when your child is playing outside in extreme cold or when their clothing gets wet- whether from melting snow or perspiration. It happens more quickly in children, especially under 2 years, than adults. The first signs include shivering and clumsiness. Next your child may begin to slur their speech and become lethargic. If you notice any of these signs, call 911 and get your child inside- remove wet clothing and wrap them in warm blankets/clothing, you can pre-warm them in the dryer for a few minutes.

What is frostbite?

Frostbite happens when the skin and outer tissues become frozen. It is usually seen on fingers, toes, ears and noses. Initially the skin may feel numb or it may burn and may look pale and grey. If you notice these signs, get your child inside, soak the area in warm (not hot) water. Do not rub the areas. Give your child a warm drink and cover them with warm blankets and clothing.

1st degree frostbite or “frost-nip” is very common in children. They’ll have red skin with white patches and the skin may itch or feel prickly. Treat with soaking in warm water.
2nd degree frostbite is more dangerous, with white or blue, hard-feeling skin. The areas often blister and you should seek medical care to avoid further injury to the skin.
3rd degree frostbite is the most dangerous, we usually hear about this with mountain climbers needing fingers/toes amputated due to the tissue damage. Fortunately this is very rare in children.

Don’t forget sunscreen when your child is playing outside! The sun can reflect off the snow and cause sun damage, even on cold days.

Don’t be afraid to get outside and enjoy playing in the snow! It’s ok to go outside as long as it’s not uncomfortably cold or windy outside. Just use caution with staying outside too long and keep an eye on your child for signs, such as blue lips or pale nose/fingers/ears, that they are ready to go back inside to warm up! Take lots of breaks to let your child thaw- there’s nothing better than a cup of hot chocolate!

Here is a very helpful table from the Iowa Department of Public Health that shows dangerous temperatures, both hot and cold (with wind chill and heat index), for your child to go outside. Clink on image twice to enlarge it:

Fluoride

October 14, 2013

Boy drinking glass of water

 

What’s so important about fluoride? 

In honor of National Dental Hygienist month, and with Halloween approaching, I thought a tooth topic was appropriate!

 

 

What is fluoride?

It’s a mineral that naturally exists in water sources. It helps protect teeth from the acid made from sugars in our diet and the bacteria that live in our mouths. Fluoride is incorporated into developing teeth- both permanent and baby teeth, to strengthen the enamel or the protective layer.  It also helps reverse tooth decay produced by the acid eating away at the enamel on our teeth.

How does my child get fluoride?

It’s in controlled amounts in city water and is often in well water, although the well water should be tested periodically to make sure the level is safe and not too high or low.  If you only use bottled, unfluoridated, water, your child may need a supplement, which comes as drops or a tablet.  It’s also in toothpaste, many foods and drinks.

How much dose my child need?

Optimal levels in drinking water are monitored by your water authority.  Recommended levels are between 0.7-1.2 ppm (parts per million).  The Monroe County Water Authority prints an annual report, for 2012 the concentration was 0.2-1.3 ppm, which meets the EPA (Environmental Protection Agency) standards.

Children less than 6 months old do not need a supplement.  Between 6 months and 16 years, a supplement is recommended if you live in a nonfluoridated area or drink nonfluoridated bottled water.

Can my child have too much fluoride?

Yes, too much fluoride can cause fluorosis, which in mild cases causes white streaks or spots on the teeth, in more severe cases causes permanent discoloration of the teeth.  Too much fluoride can be seen in children taking a fluoride supplement, drinking fluorinated water and having unsupervised access to toothpaste or mouth rinse also with fluoride.

When is the risk of fluorosis over?

Once your child’s permanent teeth come in, around the age of 8 years.

When can my child start using toothpaste with fluoride?

Under the age of 2 years, they can do a tiny “smear” of toothpaste twice a day.  Ages 2-5 years can use a “pea-sized” amount.  After age 5, they usually are able to brush and spit out the excess toothpaste and can use a larger amount, about the size of a kidney bean.  Always supervise your child while they are brushing their teeth and “inspect” their teeth, getting those back ones!, until they around ~7-8 years old and can reliably brush well.

When can my child start going to the dentist?

Usually between ages 1-3 years, depending on where you live and when the local dentists start seeing young children.  If you have a family history of early cavities, it’s wise to call and see if your dentist will see your child when they are young- especially if you notice any discoloration or sensitivity with chewing. Until then, your pediatrician will check out your children’s teeth, as part of their wellness exam.  Another good reason to practice having your child say “ah”!

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