Archive for November 2011

Monthly Archive

Happy And Thankful

Happy and thankful. The holiday served up a great reminder. Time offline, outside, and away from work is absolutely priceless. We should use all of our vacation time. We should fight fiercely to protect it. Thanksgiving reminded me that I am just so happy and thankful. For the holiday, we traveled to see F & O’s grandparents and the boys had some real deal time with their cousins. We played with a lot of balls (tennis, basket, bocce, foot). Little did I know that having two boys would ensure a deluge of round things.

We went to a high school football game an

Pediatricians’ Conditional Comfort With Alternative Vaccine Schedules

I had coffee with Dr Doug Opel last week to discuss his study about pediatricians and alternative vaccine schedules that published today. I learned a lot while we spoke. There is great wisdom in what he said (below in the interview & on video) that extends far past what he learned in the study.

Dr Opel is one of those genuinely authentic, kind people. The kind of person you meet and wonder, gosh if only I could be a fly on the wall when he’s making decisions for his kids or decisions for his life or decisions for his patients–I’d be so much better off. Not just because I’d see the answer, but because I’d have a front row seat while he asked the questions. He’s just remarkably thoughtful so there is no wonder this study illuminated some helpful observations.

Dr Opel and his colleagues conducted a survey of WA State pediatricians to find out how often they were being asked about alternative vaccine schedules and how doctors felt about it. Seventy-seven percent of pediatricians reported they are regularly being asked to use an alternative vaccine schedule. And in general, the majority of pediatricians (61%) are comfortable with alternative schedules but only for particular vaccines. Meaning that although pediatricians are okay with parents’ request to delay some vaccines (Hepatitis B vaccine or Polio) they are not comfortable waiting on others (DTaP, Hib, or PCV). The reason, Dr Opel suggests, is that pediatricians are unwilling to leave kids unprotected for potentially devastating diseases that still circulate in our communities.

In this interview, Dr Opel lends insight to the culture of concern about vaccine safety, how the changing health care environment has shaped how we ask questions in the exam room, and how the concern about autism and vaccines is simply emblematic of concerns about vaccine safety in general. Read full post »

Establish Traditions: Seattle Mama Doc 101

Establishing traditions can be an incredible way to connect, mark time, and affirm a sense of well being in your family. You can establish any tradition you want–one of the rare perks of being a grown-up. Even if family circumstances change (a divorce or separation, a death in the family, a move to a new city) you can adapt, addend, and alter your traditions. Your kids can help you sort out new rules as necessary. Those traditions really may establish a sense of calm for your children.

And really, as you make or restart some traditions at home, don’t stress about extravagance. Sometimes the best traditions are the most simple and come with absolutely no price tag. A walk with a football after dinner each Thanksgiving. Unscheduled or unplugged time the same day every year. Eating pickles on Black Friday. Standing outside in the snow as the New Year arrives. Whatever it is, it can be all yours. And your children will remember.

Start or establish rituals this holiday season and then repeat, repeat, repeat. Share your favorite traditions; what can we all be doing that we haven’t thought of?

Create A Spirit of Giving

15 Meaningful Holiday Traditions

 

Pediatricians Who Refuse Families Who Don’t Immunize

I just responded to a New York Times “Armchair Ethicist” chat about pediatricians who refuse patients who don’t fully immunize. I realized my comment on their site belongs here on the blog. (my comment is number 79 but also copied below).

What do you think about pediatricians who refuse patients who don’t follow the AAP schedule? Do you disagree with me? Would you be more comfortable seeing a pediatrician who refused those families who chose not to immunize to protect your children? Have you, or someone you know, ever been kicked out of a pediatrician’s practice?

I’m a pediatrician (w a master’s degree in bioethics) and mother to 2. I will always keep my practice open to vaccine-hesitant families. However, the waiting room risk (unimmunized kids & risk to vulnerable populations–ie infants, those too young for vaccines, and immunocompromised children) is a good one and the only compelling reason to close to patients who refuse immunizations in my opinion.

But it’s not a good enough reason for me to send families away who have questions and hesitations about the AAP/CDC schedule. All children deserve a pediatrician versed in immunization benefit/risk & deserve an expert in conversation w their parents to foster insight & understanding. Frankly, if waiting room risk is the concern, there are ways to create separate waiting rooms for kids “up to date” and kids who are not.

Great thing is, only about 10% of families use alternative vaccine schedules. In a recent Pediatrics article, only 2% of families who used alternative schedules refused all vaccine altogether. So although this is a large issue in pediatrics and parenting, the majority of families do vaccinate on time or nearly on time. I don’t want to lose sight of that.

I practice in WA State. We lead the nation in exemptions for vaccines (over 10% of kids w exemptions vs only 2% nationally) and have recently put into place a law that requires families to consult with a health care provider prior to an exemption. It was designed to avoid exemptions out of convenience. This hopefully opens up the opportunities for discussions with parents & pediatricians!

We all want the same thing: healthy children, healthy communities. Fostering conversation and diminishing a context of “war” or opposition about immunizations is an important step. In my experience, most parents end up immunizing their children over time even when they start out as refusers. The group of full refusers is fairly small. So allowing all kids into my practice feels like a great opportunity.

Why Doctors Fail To Change Behavior

Earlier this week I wrote a post about raising heart healthy children. The data summarized in that post may be the most important data I discuss all year when you consider that heart disease kills more of us than anything else. Thing is, I’m not surprised many of you haven’t read it. I expected it.

It’s just so flipping hard to read, or have any interest, or take advice about health when the advice or data requires us to make big changes. Or when the advice (regardless if we trust it or not) seems intuitive and self-evident. Things like eating less, restricting salt, or exercising more don’t sound so new. Those are things we already know we should do, but we often just can’t find a way to implement change in our totally overwhelming and busy lives. Big changes regarding how much we exercise, what we eat, and how we model behavior for our children seem daunting, overwhelming, and somewhat paternalistic. I also think it’s uninspiring to read about preventing heart disease in our kids because it feels so far off (thinking of our child dying of a heart attack or stroke doesn’t really compute) and really, we often can’t see heart disease. Heart disease walks around us silently.

That’s where we physicians fail, I think. There is convincing data about preventative health care that urges us to help get our patients to change behaviors that cause them suffering and ultimately threaten their life. But we fail to convince our patients to make changes because we simply don’t make it relevant enough. Or easy enough. Or we’re not convincing because we don’t demonstrate that we follow our own advice. Many docs are constantly trying to figure out what works best. See this tweet from Dr Pourmassina, an internal medicine physician in Seattle.

I think about ways to improve our translation of research for our patients all the time. And I think telling stories really helps. But I didn’t begin that post about heart disease with a story. Although there are many.

Last weekend for example, I set out to exercise every single day (without fail) for 30 days. I haven’t had time to prioritize exercise (let’s be honest: since F was born) over the last 5 years. And in my quest for 1 month of change, already I’ve failed. I made it only 3 days. And not for a lack of motivation; I love to run. Read full post »

Live A Long Life: Avoiding Heart Disease

Late last week, The American Academy of Pediatrics (AAP) published a 43 page expert panel report addressing ways to reduce risk from cardiovascular (heart) disease beginning with interventions in childhood. The panel report is based on a huge review of current medical evidence, yet the press focused mostly on 1 sentence from the thick report:

All children should be screened for high cholesterol (via a blood test) at age 9-11 years and then again between 17 -21 years of age.

And although the recommendation for cholesterol screening is a huge one and represents a major shift in pediatric screening, the other 42 plus pages were loaded with additional wisdom founded in science. I’m doing my best to make sense of all the recommendations but as I get more overwhelmed by the sheer quantity of information in the report, I’m taking the advice of my husband, “Effective communication [about this report] lies somewhere between a tweet and those other 42 pages.”

Most primary care docs simply won’t have time to read the entire report but will likely incorporate the recommended changes into practice. And because heart disease kills more men and women than any other medical problem in our country, learning how to protect our children/prevent heart disease remains an essential part of my job description. Yours, too. Read full post »

The Saturday Box

We’re all looking for little tidbits and rituals to insert into our busy lives that actually help in that quest to have life run smoothly. I suspect The Saturday Box is one ritual worth considering.

I’m not saying that my parents did it all right (ahem….no), but circa 1983, I think the Saturday Box exceeded expectations. Our box inspired a sense of greater responsibility and established a democratic process for clean-up in our home. Less fighting, less let-down, less guilt, and less tension. More responsibility, more ownership, and more order. The genius: the box wasn’t just for my brother and me. Plenty of parental-garb ended up in our Saturday Box and the concept alone invoked a sense of equality. Not unexpectedly, we were occasionally feisty; I have a very clear memory of a family meeting being called after my father’s wallet landed in the Saturday Box….

Watch the video about the Saturday Box. What do you think? Have another successful tidbit to share? Will you do this and report back?

Four Hours On A School Bus

A good friend wrote a “secret, imaginary blog post” and sent it my way. I realized instantly it was a real blog post. But to protect her son and allow the imaginary (blog) to become real, she called upon her childhood and the beloved author Judy Blume, for help. She chose the pen name Veronica:

Then Nancy decided we should all have secret sensational names such as Alexandra, Veronica, Kimberly, and Mavis. Nancy got to be Alexandra. I was Mavis.
-Are You There God? It’s Me, Margaret by Judy Blume

Veronica is an awesome friend, a passionate researcher, and mom to two. Like all of us she has stumbled upon unexpected challenges in protecting her children from harm. In particular, protecting her son with severe food allergies. Her post helped me see more clearly what it is like to love and to care for and to support a child with severe and life-threatening food allergies. What it is like to wave good-bye for a day of school…and house worry. And really, what it is like to have no choice but to go well out of the way.

Enjoy her post. Tell us what you think. Share what you do to protect and support your own children with food allergies. If you’re looking for online information about food allergies, Veronica likes going to Food Allergy.org or Kids With Food Allergies:

Four Hours On A School Bus: Parenting & Severe Food Allergies

Read full post »

Avoiding Antibiotics Whenever Possible: Less Is More

I work hard (as do most doctors) to avoid prescribing antibiotics when unnecessary. The reason? I’m concerned about both the short term effects (diarrhea, rash, allergies) and long term effects (drug resistance, altered normal bacteria and microbes on our bodies) of antibiotic use in children. As we learn more about health and about the role of “good” bacteria in wellness preservation, I suspect we will feel more and more compelled to avoid antibiotics in children. Less is often more.

There are certain medical conditions that benefit greatly from antibiotics (Strep throat, pneumonia from bacteria, kidney infections, some severe skin infections, for example). Hands down, antibiotics save lives and prevent terrible infections when bacteria are to blame. But antibiotics are not without risk. And, we know that antibiotics do no good for children when viruses are the cause of the infection. The use of antibiotics when unnecessary, contributes to “unnecessary [health care] costs, avoidable adverse events, and the development of antibiotic-resistant infections” a study published today reminds.

The hard part for parents (and pediatricians) is knowing when bacteria are to blame and when they are not. Read full post »

How To Dose Acetaminophen or Ibuprofen

Earlier this year, the FDA recommended the discontinuation of infant acetaminophen drops. The goal was to minimize confusion by only making acetaminophen (aka Tylenol) in one universal liquid strength for both babies and older children. However, because the FDA provided a recommendation and not a mandate, there are currently two different liquid acetaminophen preparations on the shelves marketed for babies. And another liquid marketed for older children. Ultimately, it may be more confusing than ever. Thank goodness I just got a little help from my friends…

The pharmacists at The Everett Clinic (where I practice) created a beautiful handout designed to clarify dosing for infant and children’s over-the-counter (OTC) fever reducers/pain relievers. See the dosing chart below along with the renderings of typical dosing devices (syringe, dropper, or cap). Print it out and put it in your medicine cabinet. Review it with Grandma or the sitter or your partner. And remember, the most important way to avoid a dosing error is to keep the original dosing device with the actual OTC medication. Resist the urge to grab a kitchen spoon!

Check out a video I made last year about common OTC medication dosing problems. The numbers will surprise you (hint: nearly all pediatric OTC meds in the US had inconsistencies, superfluous, or confusing dosing instructions). Dosing medications for our children can be more complicated than we’d like. So let me know what else you want to know about dosing acetaminophen or ibuprofen.