Friday, July 23, 2010

Why Bother with a Regular Check-up?

It's summer! In my office there is less coughing, and more bug bites. Poison ivy, sunburn, heat rash, cuts, scrapes, swimmer's ear, allergies, and swimmer's itch all make themselves known again. While in the winter months I have to move fast in order to tend to a larger group of younger sick children, in the summer I have more time scheduled to devote to physical exams for school-age children and teenagers.

Regular check-ups are important. They establish a good doctor-patient relationship, empower children by helping them understand their bodies, screen for important health problems, monitor ongoing illnesses, and address new concerns.

I love having the opportunity to spend more time with my patients and listen to their concerns. I think that seeing usually healthy children and teens regularly (at least every two years after age five) gives me the chance to establish a solid, health-enhancing relationship with my patients. A relationship like this is based on familiarity, good communication, accurate expectations of what will happen in the office visit, and trust.

For a perfectly healthy child a physical exam can be a boost to her self-esteem by showing how well she grew and gained weight over the last year or two. It can be interesting to find out what the blood pressure means, and that a normal blood pressure is a good sign that her heart is healthy. These very personal bits of data can make a child feel strong and healthy, proud of himself and his ability to take care of his body. I believe that regular, positive interactions with his own doctor can be empowering for a child, laying the footing for him taking responsibility for his own health for a lifetime.

At a regular check-up I can reinforce what many parents are already telling their children. I emphasize the importance of eating fruits and vegetables, and of limiting time in front of a TV or other "screens". I talk about safety, such as wearing a bike helmet or seat belt. For older children and teens I might discuss how the choices they make and the influence of their peer group can affect their health. I also talk about hygiene! Including deodorant, showers, washing hair and faces, and shaving.

I talk about puberty at check-ups. Most pre-teens and teens want to know if their body is developing normally, how it compares to other kids their age, whether things are too big or too small, if it's starting too early or too late, or when certain events are likely to happen. Normally, for girls, I talk with parents at their daughter's age of seven about the eventuality of breast development--something that can start to happen close to age nine. At nine I start talking to girls directly about this topic, at whatever level they might need (maybe their friends are wearing bras, maybe they need a bra, maybe they don't know where to get a bra, why they might want to wear one, etc.). And my discussion becomes more advanced as the patient gets older.

A check-up involves checking all parts of the body. If a child has been having regular check-ups with me from the beginning, this is not a surprise to them. After all, I've been checking their private parts since they were born, why would I stop checking once they are five, or seven, or nine, or eleven, or thirteen..? They know I will make sure they have privacy, are covered up, and have only agreed-upon family members in the room. They know how I will check them, how long it will take (usually seconds), and they probably know exactly what I will say. If puberty has started I can also give them an idea of how far into it they are and what will come next.

At my office a check-up includes an external genitalia exam only. Girls would be referred to a gynecologist for a pelvic exam and pap smear if there are problems identified, within two years of becoming sexually active, or by age twenty-one.

One important screening that takes place at a regular check-up is the examination of the spine for scoliosis. Ideally we should identify scoliosis before a child's rapid growth spurt occurs. If I see a child at age five, and then not again until they need a sports physical for high school, it might be too late to treat scoliosis. Screening for normal blood pressure, vision, and growth can identify problems early, as well. Starting at age three we calculate a body mass index (BMI) for every patient during their well visit. This can identify children at risk for obesity. The child's immunization record is reviewed, and anything needed will be given at the end of the check-up.

For a child who has a chronic illness, or takes regular medication for a condition, a check-up will include a review of that condition. I will look at the impact of that condition on the child's health over the last year, evaluate the severity of the condition and the need for any further evaluation or adjustment in treatment. I will refill necessary medications.

Sometimes a patient has a new problem being brought up during a regular well exam. The detail involved in the well exam helps establish a better context for the problem. Sometimes the regular questions and information provided in an otherwise healthy child well exam must be abbreviated to properly address the new problem. There is no specific formula for this, we will do what we must do to address the most important concerns. The complete physical exam would still be performed.

Sports physicals are done along with a regular physical exam. I do not have a separate appointment for a sports physical available. If a teen is there for a sports physical we will do the whole physical exam. Parents and patients will notice that the checklist on the sports physical form is quite comprehensive, and includes all body parts, anyway! If needed, I will complete the forms at the time of the check-up, or up to twenty-four months after the check-up if there have been no changes in health or injury status during that time, and there are no chronic illnesses we have been monitoring.

I have one more thought for you as a parent helping your child on his or her journey to a lifetime of personal responsibility for good health. When do you think you should encourage your child to have a few minutes to talk to the doctor on her own? Usually I have initiated this at age 13, encouraging parents to wait in the waiting room (not just the hallway) while I do the physical examination part of the visit.

By high school I really think it is a good idea for the teenager to have a little time with the doctor without a parent present. Teenagers, who are now thinking for themselves, need to learn how to talk to, and listen to a doctor. Parents, this means you might have to trust me to talk to your teen alone. Why would you bring your child to me if you don't trust me? When I talk to your teen the discussion will be focused on establishing rapport, on physical and mental health, on making good choices, and on bringing family and parent-teen relationships together. By having you (the parent) out of the room it is very likely that I will be reinforcing things you have already discussed with your teen. You will look much smarter and more reliable to your teen if he realizes the same information is coming from the doctor!

So, call and schedule your child's well exam soon. Get on at least an every other year schedule (every year for monitoring chronic conditions). Let's think long term about promoting a healthy life for your child. And yes, I will read those little notes you pass to me secretly before the check-up and along with my usual advice I will emphasize whatever health rule you think needs a little extra reinforcement at home.

Wednesday, July 21, 2010

Swimmers' Ear

What do you get when you combine kids with hot weather and non-stop swimming? The answer is Swimmer's Ear, also known as Otitis Externa. In my office the conversation goes something like this:

Mom: "I think he has an ear infection."
Me: "Does your ear hurt?"
Swimmer: "Yes, my right ear. It hurts to touch it or lay on it. Plus I can't hear out of it very well"
Me: "Have you been swimming a lot?"
Mom: "We were just on vacation at a lake"
Me: "Do you have a runny nose or a cold?"
Mom & Swimmer: "Not really"

This is repeated multiple times a day in my office, all summer long. I see it even more often when the weather is hot, like it is right now. Some days I see so many kids with Swimmer's Ear that I have dreams about it. Really, I do.

Swimmers' Ear, or Otitis Externa, is completely different from what most people think of when they say "I think my child has an ear infection." Swimmers' Ear is an infection of the ear canal, which starts at the hole in your ear and ends at the ear drum. The skin in the ear canal becomes red and swollen, and can even produce pus. Anything that moves the ear canal (touch, pressure, and sometimes even chewing) can cause pain.

Swimmers' Ear is usually associated with getting the ear canal wet and is more commonly seen in people who put their heads under water (school age children and up). The name Otitis Externa would also apply to other skin conditions and infections in the ear canal. For my purposes, however, I am focusing on the most common condition caused by getting the ear canal wet.

The standard ear infection (or Otitis Media) takes place behind the ear drum (tympanic membrane). The usually hollow, air-filled chamber becomes full of fluid and pus. This hardly ever has anything to do with swimming (the tympanic membrane protects the middle ear chamber from water outside the ear), tends to be associated with congestion and nasal drainage, and is more commonly seen in younger children and infants. Many parents worry that their baby or toddler's otitis media is caused by swimming lessons or by getting the baby's ears wet during bathing. This is not very likely.

Swimmer's Ear happens when the normal protective barriers in the ear canal are broken down. A healthy environment in the ear canal is dry, acidic, with a light protective coating of wax. When the canal is constantly wet the skin becomes soft, the pH in the canal becomes alkaline, and the wax is less protective. Bacteria like to grow in the skin in this wet, alkaline environment.

First the ear will get itchy, and feel funny. Scratching or digging at the ear may follow. The ear canal becomes inflamed and will look red. Then it swells and produces pus. It can be very painful.

There are several approaches to preventing Swimmer's Ear. You can try to keep the ear dry, using ear plugs or petroleum jelly coated cotton balls. In my experience kids don't put up with that for very long. You can dry out the ears after swimming, by tapping the side of the head to let the water out, using a cool blow dryer 12 inches from the ear, or placing 3 to 4 drops of isopropyl alcohol in each ear canal when swimming is done (or several times through the day if it's an all day long swim). You can make a mixture of 50% isopropyl alcohol and 50% white vinegar (to both dry the ears and re-acidify them) to use throughout the day or after swimming (3 to 4 drops in each ear). You can buy your own dropper at the pharmacy, or just drip the drops in from a medicine syringe. Instead of that homemade mixture you could use commercially available drops (such as auro-dri, or swim-ease).

Treatment of Swimmer's Ear involves a prescription for antibiotic ear drops to be used 2 to 3 times a day for a week to ten days. You will first need a doctor's appointment to determine what kind of ear infection your child has, and how severe it is. It would be unusual for this diagnosis to be made, or treatment prescribed without first seeing your child in the office. Your child will need to keep her ears dry during the initial part of this treatment.

Very early in the course of this illness you might be able to get things under control at home simply by keeping the ears dry and using the commercially available drops, or the mixture of isopropyl alcohol and white vinegar mentioned previously. If that does not work in a few days, or your child gets worse, then you should make an appointment in our office.

On a side note, the worst cases of Swimmer's Ear that I have seen have all been in teenagers. I have always wondered if they are trying to tough it out, or just don't have time for a doctor's appointment. Also, it doesn't seem to matter if you have been swimming in a lake or a pool, or just dunking your head under water in the bath tub. In my experience the type of water is not the important part, it's just the presence of moisture in the canal that matters.

Remember that wax in the ears is protective. No one should put cotton swabs (or anything other than drops) into their ear canals at home.

Please remember that the purpose of this blog is to provide you with more information and insight into how I personally think about health and illness. I am not trying to personally diagnose or treat your child. For that you need to discuss the problem with your medical professional. Other sources of information on the web could include, or

Saturday, July 10, 2010

"Blood owies" or What do I want for my patients?

What are "blood owies"? you ask. Keep reading, I'll get to that later. What do I want for my patients and my own children? I want many things for them, so this could be a difficult question to answer. However, there is one thing I come back to, over and over. I want my patients to grow up feeling confident and in control over their bodies and minds. I want them to know that their bodies are strong and capable of fighting disease, and that they have control over the choices that help keep them healthy.

Of course parents help children BE healthy. We love them, feed them, and keep them safe. We give them a sense of right and wrong. We try to influence their choices. Most of all we love them. I believe that parents play a crucial role in helping children FEEL healthy, too.

So what does that mean, anyway? A little anecdote might help you understand what I am talking about. At my daughters' daycare the kids used to have a saying for their little cuts and scrapes that happened throughout the day. A skinned knee that didn't bleed was just an "owie", really no big deal. But a skinned knee that BLED was a "blood owie", which was very impressive to all.

I would receive tales of "blood owies" when the kids arrived home each summer day. It was a major event, as if the life force of the affected child was draining onto the ground. This kind of owie seemed to have a mystical power in my daughters' lives. Rose, our daycare provider, and my dear friend, normalized these "blood owies" for my children. She always had a hug and a band-aid ready, and she seemed to always convey to them that this was no problem, and would get better fast with that band-aid. I would look at the ravaged knee with the princess band-aid perched on top, hide a shudder and smile big at how great the owie looked now. My injured daughter would walk away feeling strong and proud of herself.

Of course most illnesses are more serious than a skinned knee! But how great would it be if we, as parents, could help our children be confident in knowing that most aches, pains, colds, flu, viruses, rashes, bug bites, etc. are common and happen to lots of people who get over them with no problem.

Preschoolers and adolescents, especially, seem to notice lots of bumps and aches all over their bodies. Don't you, too? Our children need us to explain these things to them. They don't know if these things are important, or not. "Too bad your tummy hurts, maybe you have to go potty?", or "I'm sorry to hear you have a stomachache, do you think you had too much milk? Or that you are worried about your exam?" "That happens to me sometimes, it usually just goes away after a while." "Let's try some pain reliever, and go to bed early tonight, maybe you're just tired."

But what if you miss something this way? Aren't some stomachaches and other symptoms important? Yes they are sometimes important, I'm not advocating ignoring symptoms. What I am saying is that I think the parent should be the one guiding the attitude about the illness.

The ultimate message that I want kids to receive is that their bodies and minds are amazing, strong, resilient, normal, and capable of healing. And that their parents will help them stay that way. As a pediatrician I definitely have a role in shaping this attitude, but I think parental influence is greater. Think about this. Let me know what you think.