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Daily Dose

Waiting for the Doctor

1:30 to read

I just read a really good article from The Huffington Post that was written by a young woman from the UK.  She was discussing the issue of waiting for a doctor. She herself had been waiting for her doctor when she noticed another patient who was being very loud and quite verbal about waiting. He engaged her in conversation and said, “I bet that doctor is back there having a cup of tea”. He must have been stunned when she replied, “well, I certainly hope so”.  She knew that the doctors had recently seen her as an emergency when she began bleeding during her pregnancy. She knew that they had dropped everything to attend to her and her unborn baby and for that she was eternally grateful.  

I also “hate to wait” when I am seeing my own doctor, but I do know that he or she is not “back there eating bon-bons".  I also know that many patients have waited for me, sometimes for up to an hour.  I promise you that I know that I am running late and it makes me very anxious. But at the same time, I am doing the best that I can to treat each and every patient as if they were my own child or family member.  Sometimes a patient comes in with a more complicated or urgent problem and the time taken with that patient is much longer than was expected. Or, a child arrives wheezing and in respiratory distress without even having an appointment….they to will be “worked on” in front of everyone else…as they need a doctor immediately. 

The article continued to re-count how many times during her pregnancy that she had needed to be seen as she continued to have issues with bleeding, and each and every time, the doctors were there, no wait and no questions….they just did their job.

It is difficult to explain why doctors run late and I understand how patients are frustrated when they wait. But at the same time, how do you schedule the appropriate amount of time for a patient who calls for an appointment because their child is sick with a fever and a sore throat. But, while you are seeing their child they break down in your exam room and tell you that they have found out that their husband is “cheating on them” and that “he wants a divorce”.  As their pediatrician, do you tell them that you don’t “have the time” to listen to their problems. Do you just deal with their child’s sore throat and ignore the mother’s anguish. In my case, I choose to spend time with the mother, to empathize with her, and hope to help her.  I know that this reaction will make me late….but it is what I need and want to do for my patients and families.

Whenever I am talking to prospective patients I am perfectly honest when they ask me, “will I ever have to wait?”.  My response has changed over the years as I have come to realize that there will be times when they do wait….but it is not because I ever want to “run late” or make my patients wait. It is because, I have decided that my practice has just as many flaws as my parenting, not perfect. But similar to my children, at times one will need me more than another, and when they do I will spend more time with the one that needs me the most.  It may not seem “fair”, but how do you make it always be “fair”?  I hope that at the end of the 23-25 years I spend with these families they come to realize…it all evens out in the end…there are times that I spent too much time with them and then there are times that they waited.  But, just like parenting, you do the best that you can.  I will continue to practice that way as well. I promise, if you are waiting I am not having tea and bon-bons!!!   

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Daily Dose

Hot Car Deaths

1:30 to read

Did you know that heat stroke is the second leading cause of non-traffic fatalities among children, with the first being backover deaths.  As the summer temperatures are rising these tragic accidents become all too frequent.  

My home state of Texas leads the country in child vehicular heat stroke deaths, followed by Florida and California.  But children who are trapped in vehicles have died in milder climates as well. The temperatures outside may be as low as 60 degrees, but the inside of a car heats up quickly, with 80% of the increase in temperature happening in the first 10 minutes. The reason for this is due to physics.....the sun’s short-wave radiation is absorbed by dark dashboards and seats...the heated objects including child seats then emit long wave radiation which heats a vehicle’s interior air.  All of this leads to tragedy.

A child’s thermoregulatory system is not the same as an adult’s, and their body temperatures will warm 3 -5 times faster.  When a child’s body temperature rises to about 107 degrees or greater, their internal organs begin to shut down.This scenario can then lead to death. If you see a child who has been left in a hot car call 911...every minute matters.

The greatest percentage of these tragic deaths are totally unintentional.  These parents are not “bad parents” or “child abusers”, they are loving, good parents who simply forgot that their child was in the car. On average there have been around 37 deaths per year due to vehicular heat stroke and in most cases this is not due to reckless behavior but simply to forgetfulness.  Parents and caregivers both admit to “just forgetting” a child was in the car.  It truly can happen to anyone.

So, how can you remember that your precious, quiet, sleeping child is in back seat. Make it a routine to always look in the back seat before you lock and leave the car.  Try putting your purse, briefcase, or cell phone in the back seat as a reminder to look for your child. Lastly, if your child is in childcare, have a plan that the childcare provider will call you if you have not notified them that your child will not be coming to school,  and they don’t show up.

Daily Dose

The Heat is Taking a Toll on Many

1:15 to read

This is a follow up last week’s Daily Dose on the toddler who burned his feet after playing outside on a very hot day. He has been being treated with daily dressing changes and debridement of the skin from the blistering on his feet. HIs mother called to tell me that the first few days were “BRUTAL” and extremely painful as the doctors popped the blisters and removed dead skin and then would scrub the area to prevent infection. His mother was also doing bandage changes at home.

But after those first horrible days, he is no longer having to go for “burn therapy” and she is managing the dressing changes on her own. She is fortunate to be a nurse, but having to change your own child’s dressings is a daunting task for any parent, even one who has done dressing changes before.

Her son is also now off all pain medication except for over the counter acetaminophen and ibuprofen, and is smiling and playing with his older brother. He is still not walking and is being “carried to and fro”, it seems that he realizes his feet have tender new skin.  The doctors also feel as is he will not have any significant scarring over the long term.  

The triple digit heat is continuing in many parts of the country and I just read about another child in Texas who died after being left in a car.  Remember, put something in the front seat to remind yourself that your child is in the car with you. A sleeping quiet baby can be momentarily forgotten when a parent is distracted….and even minutes in a hot car may be deadly.

Be aware of the many risks associated with these extreme temperatures, and make sure that your children have shoes on whenever they are going to be outside!!  Hoping that these extreme temperatures will moderate over the next few weeks…especially as children are heading back to school!

Your Child

Are You Making Your Child More Anxious?

2.00 to read

When a child shows that he or she is anxious or in distress, a natural response is for a parent to want to remove whatever is causing the discomfort. However, according to a new study, it may not be the best reaction for your child in the long run.

Researchers call it the “protection trap.” Basically it means smothering children with too much attention or making the menace go away.

The research showed that certain parental coddling behaviors might actually boost anxiety in a child, although the study doesn't prove a cause-and-effect relationship.

"We found evidence that when parents try to help their anxious children they do a lot of things," said study co-author Armando Pina, an associate professor of child developmental psychology at Arizona State University. "Some of them are good, like promoting courage with warmth and kindness. Others are less helpful, like promoting avoidance by overprotecting, which many times leads to more anxiety."

Other experts have also weighed in on this topic.

"Left untreated, anxiety disorders in youth are associated with greater risk for other psychological problems such as depression and substance use problems," said Donna Pincus, director of research at the Child and Adolescent Fear and Anxiety Treatment Program at Boston University. Anxiety problems can also disrupt families and cause kids to perform worse in school, she added.

So what should a parent do or not do?

"When children are in distress or upset they need parental comfort, reassurance and extra love. This is good," said study lead author Lindsay Holly, a graduate student at Arizona State University. "Sometimes, however, parents end up providing excessive reassurance and doing things for the child, like making excuses for why a child who is anxious in social situations won't go to a birthday party or talking for the child by ordering at restaurants."

Here’s how the study was conducted.

Researchers examined the results of a survey of 70 kids aged 6 to 16 who were treated for anxiety and/or depression at a clinic. The kids were equally divided among boys and girls and among whites and Hispanic/Latinos.

The investigators found that some kids were more likely to have anxiety and depression symptoms if their parents reinforced or punished their anxiety through various approaches. Among the two ethnic groups, "the only difference was that Latino parents seemed to attend more frequently to their children's anxiety," Holly said.

Pina noted that previous research has indicated that a certain kind of therapy can help kids become less anxious and more resilient by teaching the importance of facing fears. One of the goals of the therapy is to teach parents how to promote courage in the kids through a combination of warmth and kindness, Pina said.

Some experts believe that by exposing children to anxious situations in a controlled, supportive environment, they can learn how to handle their anxiety better.

Holly suggests that parents encourage their children "to do brave things that are small and manageable." A child who's afraid of speaking in public, for instance, might be urged to answer a question about whether they want fries with their meal at a restaurant.

While every child is going to be anxious at one time or another, a more difficult situation is when children suffer from an anxiety disorder. That is a more serious problem where someone experiences fear, nervousness, and shyness so much so that they start to avoid places and activities.

According to the Anxiety and Depression Association of America, anxiety disorders affect one in eight children. Research shows that untreated children with anxiety disorders are at higher risk to perform poorly in school, miss out on important social experiences, and engage in substance abuse. Anxiety disorder often shows up alongside other disorders such as depression, eating disorders, and ADHD.

The good news is that with treatment and support, a child can learn how to successfully manage the symptoms and live a normal childhood.

The study conducted at Arizona State University, looked at typical child anxieties and how parent’s interactions either helped or prolonged the anxiousness.

The study was published recently in the journal Child Psychiatry and Human Development.

Sources: http://www.cbsnews.com/news/overprotective-parenting-could-worsen-kids-anxiety/

http://www.adaa.org/living-with-anxiety/children/childhood-anxiety-disorders

Your Teen

Study: ADHD Drugs Don’t Increase Heart Problems for Kids

1.30 to read

A new study suggests that Ritalin and similar drugs, used to treat attention deficient hyperactivity disorder (ADHD), do not raise the risk of serious heart problems, stroke or sudden death.

That’s very good news for children who take ADHD drugs and their parents.

In the new study, researchers looked at the diverse medical records of 1.2 million children, ages 2-24 years old. They checked health records for evidence of heart problems, including heart attacks, strokes and sudden cardiac deaths, in children who were currently taking the drugs or who had taken Ritalin or Adderall in the past.

"We don't see any evidence of increased risk," said Dr. William Cooper of Vanderbilt University, whose study was published in the New England Journal of Medicine.

In 2006, U.S. and Canadian regulators received a number of reports of heart attacks, strokes and sudden cardiac arrest in children taking ADHD medications. This study is the first of three commissioned by the Food and Drug Administration. Also because of concerns about possible heart related problems, the American Heart Association issued guidelines suggesting that children who were just starting to take the drugs should be tested for potential underlying heart problems.

"There's such strong feelings around these drug and whether they are overused in children who might be helped by behavioral therapy alone,” Cooper said. "The potential safety questions have added another layer of concern."

The study was aimed at resolving safety questions. The team found no increased risk of heart problems for either current or past users of the drugs. Yet because there were so few cases of serious heart problems -- just 81 -- the study may not have been large enough to detect it.

But even if there were a risk of heart problems, it is extremely slight, Cooper said.

In a guidance document issued on Tuesday, the FDA said it continues to recommend that the drugs not be used in patients with serious heart problems. It added that patients should be monitored for changes in heart rate or blood pressure.

More than 5 million children in the United States have been diagnosed with ADHD.  Whether children are being over medicated or should even be taking stimulants at all to treat ADHD has long been a controversial subject. Some organizations and parents believe that supplying children with stimulants to treat ADHD is harmful.

For those parents that believe ADHD drugs are helping their children focus better in school and live more productive lives, this recent study should offer some reassurance that the drugs do not contribute to heart problems.

 "This study would suggest that their risk is remarkably low. And that's good news," noted Dr. Cooper.

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Your Child

Kid’s Allergies Linked to Depression and Anxiety

2:00

According to the Asthma and Allergy Foundation of America, 40 percent of U.S. children suffer from allergies. It is the third most common chronic disease in kids under the age of 18.

A new study suggests that children who have allergies at an early age are more likely to have problems with anxiety and depression than those that do not.

One reason may be that children with allergies tend to keep their troubles to themselves or  “internalize” them.

“I think the surprising finding for us was that allergic rhinitis has the strongest association with abnormal anxiety/depression/internalizing scores compared to other allergic diseases,” said lead author Dr. Maya K. Nanda of the division of Asthma, Allergy, and Immunology, at Children’s Mercy Hospital in Kansas City, Missouri.

Rhinitis is more commonly called “hay fever” and includes symptoms such as a runny nose, sneezing, and itchy or watery eyes.

The researchers studied 546 children who had skin tests and exams at age one, two, three, four and seven and whose parents completed behavioral assessments at age seven. They looked for signs of sneezing and itchy eyes, wheezing or skin inflammation related to allergies.

Parents answered 160 questions about their child’s behaviors and emotions, including how often they seemed worried, nervous, fearful, or sad.

Researchers found that the four-year–old children with hay fever symptoms or persistent wheezing tended to have higher depressive or anxiety scores than others at age seven.

The more allergies a child had, the higher the anxiety and depression scores.

“This study can't prove causation. It only describes a significant association between these disorders, however we have hypotheses on why these diseases are associated,” Nanda told Reuters Health by email.

Another reason for the association may be that children with allergic diseases may be at increased risk for abnormal internalizing scores due to an underlying biological mechanism, or because they modify their behavior in response to the allergies, she said.

Other studies support the idea that that a biologic mechanism involving allergy antibodies trigger production of other substances that affect the parts of the brain that control emotions.

In a 2005 study, Teodor T. Postolache, MD, associate professor of psychiatry and director of the mood and anxiety program at the University of Maryland School of Medicine in Baltimore found that peaks of tree pollen increased with levels of suicide in women.

Postolache says allergic rhinitis is known to cause specialized cells in the nose to release cytokines, a kind of inflammatory protein. Animal and human studies alike suggest that cytokines can affect brain function, triggering sadness, malaise, poor concentration, and increased sleepiness.

The new study took race, gender and other factors into account, “so the strong association between allergic disease and internalizing disorder we found is definitely present,” Nanda said.

The severity of mental health symptoms varied in this study. Some children had anxiety and depression that needs treatment, while others were at risk and required monitoring, she said.

“We think this study calls for better screening by pediatricians, allergists, and parents of children with allergic disease,” Nanda said. “Too often in my clinic I see allergic children with clinical anxiety (or) depressive symptoms; however, they are receiving no care for these conditions.”

“We don't know how treatment for allergic diseases may effect or change the risk for internalizing disorders and we hope to study this in the future,” Nanda said.

Experts hope that if parents know that allergies may contribute to their child’s mood or behavior, they will be more likely to keep a closer eye on their child for signs of depression or anxiety and seek treatment if necessary.

The study was presented in The Journal of Pediatrics.

Sources: Kathryn Doyle, http://www.reuters.com/article/us-health-kids-allergies-depression-idUSKBN0UC1TW20151230

David Freeman, http://www.webmd.com/allergies/features/allergies-depression

 

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