Author: All Pediatrics

This has been quite a week; things moved much faster than I had wanted (and hoped) they would.  I will address five topics in this post.

1.  What will happen in the short term?  This is the easiest.  The numbers will rise dramatically.  Part of this will be due to an increase in testing, but the vast majority of it will be because the disease is out there and spreading fast.  We are unfortunately starting to see more deaths in young adults, which was, however, not unexpected.  We are going to see more cases in children, and some will have serious illnesses.  However, even in countries which have been devastated, such as Italy, children have remained relatively spared, and I expect that to continue, for which I am thankful.

2.  What can you do to protect your child?  You’ve heard it before, but it’s still true:  keep your hands away from your face, WASH YOUR HANDS, and practice social distancing (and isolation/quarantine if you are ill).  If you do go out, say to a store, wear a face mask if you have one; despite initial reports, these are helpful.  For your child, no play dates.  However, it is spring.  Go outside with your child several hours a day. Go to the park (not the playground though), walk along creeks, toss a frisbee, ride bikes (with helmets of course), etc.  Indoors, do crafts, read books, play board games.  I know that electronic use will go up during this time, but still try to limit it. Healthychildren.org has a good page on developing a family media plan.

3.  What should I do if my child is ill?  The vast majority of children will do fine, and just need symptomatic care:  rest, fluids, fever relief, honey for coughs if over one year old, etc.  There are many treatments being advocated on the internet; be aware that this is an area ripe for scamming.  Chloroquine has been suggested as a possible treatment.  There is scanty evidence that it might be effective, enough that I think it is reasonable to give it to people who are truly ill, but not to others.  I have three reasons for not prescribing it for children who are mildly ill.  The first is that it is unproven, and although relatively safe, does have side effects; why chance making a child worse if there is no need?  The second is that we may run into a shortage, and we should have it available for those who truly need it.  The third is theoretical; if we allow the medicine to defeat the virus, rather than the child’s own body, it can blunt the immune response and leave the child susceptible for the next time it comes around.

4.  What is the long-term outlook?  It will eventually go away.  Optimistically, it would fade with warmer weather, as is true for the flu.  However, COVID-19 is not the flu, and this will probably not happen, although I can hope.  Thus, we will need to look to ourselves, and not nature, to take care of the problem.

The prototypical country to review here is South Korea.  South Korea was well prepared.  They had plenty of masks and gloves and sanitizer, jumped on testing and quarantine right away, got the word out to their people in a timely and consistent fashion, and had a population which, having lived through a SARS epidemic, took notice.  They hit their peak infection rate at two weeks into the pandemic after which it started to drop, and now, four weeks into it, their numbers are very manageable, although the virus is still active.

We are not going to duplicate that.  We are four weeks in and still climbing.  We have a nationwide shortage of masks and sanitizers and gloves.  We are unable to test everybody who would benefit from testing.  There are still plenty of pundits who feel that COVID-19 is a minor illness, or even a hoax.  We may have shut down our borders, and locked down some cities, but the virus is going to be with us for some time still, and will continue to travel within our country.

I am confident we will not be as badly hit as Italy, but we are still in for a long stretch.  Some institutions are planning on re-opening in mid-April; I think that is highly unlikely.  If someone could guarantee me that things would start to normalize by the end of April, I would take that. I think it is possible, but expect it will take longer.

5.  How will you know when the crisis is passing?  As I stated in my previous blog, I expect institutions to reopen later rather than earlier (e.g., Virginia schools).   Thus, if the state government (not the federal government – this is something that should be decided locally) feels that restaurants can reopen for regular business, although the virus will still be around at that time, and we will still need to exercise care, it will be manageable.  The most obvious sign that things are improving will be when the number of cases is clearly falling; this means looking at week-by-week numbers, not day-by-day; the latter are too variable.  For me, although morbid, I will take a clear drop in the absolute number of deaths per week as the most likely first positive sign that we are turning the corner.

My final thoughts:  wash your hands well, get outside as a family, and remember that this is not the end of the world.  Prudence, not panic.

We are excited to announce that you can now schedule your telehealth video visit right from our website.

Book a video visit!

When searching for an appointment please be aware that you may select any of our three offices. Please search all three to find the time that works best for you.

Please see our other news articles for assistance with setting up the Healow app and starting a televisit.

As our nation faces this unprecedented event, we at ALL Pediatrics are striving to provide the best care possible for your families.  Although you may have many questions, we have the answers! Video visits are a great way to alleviate your concerns and allow you to have a sick visit with one of our doctor’s right from your home.  

The concerns we can address through telemedicine include:

• Infant concerns such as:
     Teething
     Feeding
     Sleeping
     Cradle Cap
     Thrush
• Constipation
• Cuts or Scrapes
• Diarrhea
• Fever over 1 year of age < 48 hours (alone or with any other symptom on this list)
• Immunization Reaction – redness, swelling, sore at site of injection
• Hand/ Foot Mouth Disease
• Pink Eye/ Eye Discharge
• Pinworms
• Rash:
     Ringworm
     Eczema
     Dry Skin, Acne
     Diaper Rash
• Insect Bite
• Runny nose/Nasal Congestion/Cold symptoms
• Sty
• Vomiting and Diarrhea less than 24 hours (over 1 year of age)
• Behavioral and ADHD consultations

How to correctly associate multiple accounts with your Healow app

By default your app will sign you into the patient account you already have associated with your Healow app.

The common mistake made is that inside of that account, if you click on the patient’s name you will see an option to link another account as seen in the screen shot below.

This is not the route that you want to take in order to add another child to your app. This would be used to add another account for the same child at a different doctor’s office.

To add another child to your app you must click on the settings button in the top right corner and select log out as seen in the screen shot below.

This will bring you to the screen below where you can select begin now to add another child. As you can see this screen will list all accounts you have associated with your app.

Once you have multiple accounts associated, when you return to the app it will default to the account you were last logged into. 

Be sure that you are currently logged into the right account, If not go to settings, and logout to display the list of associated accounts. Your credentials will be stored and you should only have to use the pin that you setup to get into each account.

We ask that all patients use the Healow app for TeleVisits.

We ask that the app be installed on your phone, as we have had less technical difficulties with that vs. on a tablet or logging into the portal on your computer. 

Logging into TeleVisit from Healow app

1.       Download the Healow app from the Android or Apple App Store

2.       Search for our practice by using our practice code AIFFAA

3.       Log into Healow app with your patient portal credentials. (If you do not know your patient portal credentials our patient services staff can provide that for you).

4.       Once logged in click on appointments

5.       In the My Appointments section, click on the TeleVisit icon under the appointment time.

6.       Click on the Start TeleVisit button on the bottom of the screen

7.       You will now see a vitals screen. If you know your child’s height, weight and temperature please enter them. If not you may skip them as well as any other vitals and hit submit vitals.

8.       Once your vitals have been submitted you will see one more screen to where you have to hit start televisit.

Once clicking start televisit please wait for the provider.

 When the provider is ready your visit will begin.

As you are aware, there is a global pandemic disease with early symptoms that are similar to the common cold and flu.  Fortunately, children rarely experience more than mild illness.  The health department and the CDC are encouraging all individuals with cough and fever to stay home.  We all need to follow these guidelines to keep families safe.  If your child has a mild respiratory illness, our nurses can help you provide home care over the phone or we can schedule a telemedicine visit.

ALL Pediatrics is committed to providing a safe environment for our families, our employees and our physicians.  With this in mind, we have made changes to our schedules for the next four weeks.  Please read the information below carefully.

·       All patients will be screened for potential exposure to the coronavirus when scheduling any type of appointment.  We will perform the screening again when you arrive in the office.  If your child has a respiratory illness and is scheduled for a well check; please call our Triage Nurse before coming for well check visit.

·       We are cancelling all WALK-IN visits to allow for better screening and appropriate placement in the schedule.  ALL APPOINTMENTS MUST BE SCHEDULED BY PHONE. If you walk into the office without an appointment, you will be advised to return to your car to call our office.

·       We have disabled the ability for patients to self-schedule for sick visits via the portal or the sick widget in order to screen patients; you may still self-schedule for well visits. 

·       We will have block scheduling to separate well visits and sick visits by two hours.  The Lakeridge and Alexandria offices will see well children ONLY in the morning and sick children ONLY in the afternoon.  The Lorton office will see sick children ONLY in the morning and well children ONLY in the afternoon.

·       We will continue to see children for well visits in a safe environment free of our sick children.

It is very important to maintain regular well check appointments to ensure that all vaccines and screening tests are completed. 

·       We will have evening sick appointments at Alexandria on Tuesday and Thursday nights ONLY.

·       To minimize the number of people entering our offices and waiting areas; it is extremely important that you bring only the child with an appointment and one parent.  All other family members should remain at home.

·       As your family’s medical home, we want to partner with you to provide the best care for your child.  Please call us before taking your children to urgent care clinics.   At ALL Pediatrics, we are working to minimize any exposure to illness when you enter our office.  As coronavirus spreads throughout our community, urgent care clinics will not be able to separate patients. Help us help you.

·       If you feel that your child needs emergency care after our office closes, please call our afterhours line so that we may help you decide if this is necessary. Adult patients are significantly more contagious than children. Additionally, we expect that the hospital systems will be overwhelmed within the next few days and hospitals need to concentrate on caring for the severely ill patients in our community. 

Our May calendar is now available!

Our march schedule is now available for booking on the patient portal.

It will be available over the phone starting Dec 23rd.

Part one – newborns

I will start the discussion with infants.  Breast feeding is clearly best for numerous reasons, and we are strong advocates.  That having been said, if breast feeding is not for you, for whatever reason, in America today you will not be harming your child if you use formula. If you are unsure whether you want to breast feed or not, start off doing it, as you can always switch to a bottle later, while it is hard to do this the other way around.

To establish breast feeding, frequency is probably the most important factor.  Feeding for shorter periods every 2 hours is more helpful at getting milk flowing than marathon feeds every 4.  We recommend trying to feed 10-12 times per day (every 2-2.5 hours), 10 minutes per breast, and then ‘topping off’ for a few more minutes if the baby is still hungry.

Breast milk does not come in for a few days, during which time your baby will lose weight, up to 10 % or so in many cases.  This is normal, and not a cause for concern.  Well-meaning family and friends may suggest giving a bottle to the baby ‘just in case’. This is not necessary, and can interfere with breast feeding.  There are some medical indications for supplementing, but let us help decide that.

If you choose formula, there are a wide variety from which to choose, for gas/fussy/spit up and so forth.  All of the formulae nowadays are nutritionally complete (low-iron ones are no longer out there), and I am not convinced that there is much more than marketing, rather than science, that goes into these.   I therefore do not recommend any particular brand.  Along those lines, I have no problem with generic formula, which is often made by the company that produces brand names, and can be the same, except for the label.

Lastly, a word about gas and spitting up.  Just about all babies spit up some.   We may suggest changing formula, or the maternal diet, to see if that helps, as this is simple enough, and safe to do.  However, it will usually not work.  Most spitting up is due to the baby themselves, not the diet, and one waits for it to be outgrown.  As long as the baby is comfortable and gaining weight (a ‘happy spitter’), this is a laundry problem and not a medical one.

Part two- starting solids (4 months to one year)

When to start solids has varied over the years, but current thinking is as follows.  First, a healthy breastfed baby can be exclusively breast fed until six months of age, and a bottle-fed baby does not need solids until they are consistently taking 32 ounces of formula a day.  Second, however, a baby is developmentally ready for solids at around four months of age, in that they have the tongue and lip movement skills and co-ordination to safely take pureed foods.  Therefore, you may start solids at this age, if you wish.

Traditionally, rice cereal was the first food given to babies in this country. However, it is perfectly okay to start with whole grains, fruits, or vegetables.  We actually prefer not to begin with rice cereal nowadays, as there have been reports of arsenic in baby rice cereal; there is no evidence that this causes harm, but with other options out there, it seems prudent to start elsewhere (barley and oatmeal are other cereal options).

Whether to begin with fruits or vegetables first is not a question for which science has an answer.  Either is fine in my opinion, just be sensible – creamed spinach is not a good starting choice.  With a new food, it should be introduced in pure form, not mixed with other foods (you want the baby to learn that bananas taste like bananas, and not like oatmeal).  Your baby will let you know how thick to make it (they will spit it out or sputter if it is too thick), and how much they want; when they are full, they will get bored and stop eating.  Do not make them finish a meal.  Introduce only one new food at a time, for two reasons:  one, if they are allergic, I only want to have to worry about one possible food, and two, they do not always like a food right away.  If a food is rejected, offer it for several days in a row (but do not force it), and they will usually come around.

The most important point about early feeding is that it be fun:  it is for the experience, not the nutrition. Feed the baby in a relaxed manner, at a time when you are not rushed, and when you can fully engage with them – no TV in the background, no texting, etc.

The major change in infant feeding over the last years is when to introduce ‘allergic’ foods.  The recommendation had been to postpone this for years, but evidence shows, that, with peanuts at least, delay actually predisposes to allergies.  There is no reason to think that this will not be true with other foods.  Therefore, starting at six months of age, you can start to introduce your baby to a wide range of foods:  meats, eggs, peanuts, dairy products, etc.   Exceptions would be if there is a child or strong family history of eczema, in which case you should talk with us first about this.  The only foods we do not recommend before one year of age are pure cow’s milk, and pure honey (foods with cooked honey are acceptable).

You can advance the texture as your baby is able to tolerate it.  From experience, I know that most babies go from stage 2 to chewable table foods and often skip stage 3. If a food is soft/crumbly and not a choking hazard, the baby can have it regardless of teeth.  Major chewing is done by molars (front teeth are for ripping), which do not come in until after one year.

Lastly, you can start to introduce a sippy cup at around six months of age, as your baby will need to come off the bottle at around one year.  For breast fed babies, water is a fine choice for the cup.

Part 3:  ages 1 and up

After one year of age, a child can eat pretty much any food (as long as it is not a choking hazard), except that we still prefer whole milk until two years of age, after which one can switch to low-fat (preferably skim) milk.  Juices, even pure ones, are not good beverages as a rule, and should be limited to at most one per day (my preferred number is zero).

At around 18 months or so, children become picky eaters.  They may only eat one meal a day with the rest snacks, and will eat a balanced diet from week to week, not day to day. If you try and force them to eat a food, they will reject it now, and also when older. If there are doubts as to the variety of foods they are eating, you can give a multivitamin with minerals.  While on the subject of vitamins, getting enough vitamin D in is often a problem, especially for teenagers.  Our main natural source of vitamin D is sunlight, but we spend much more time indoors nowadays.  Milk is a good source of vitamin D, because the vitamin has been artificially added.  Other dairy products are good for calcium, but generally not for vitamin D. If your teenager is not much of a milk drinker, they will need a supplement.

There was an old advertising slogan that ‘breakfast is the most important meal of the day.’  I would not go that far, but it is in the top three.  Breakfast is often skipped because people are in a rush in the morning.  As such, it is useful to have easy-to-fix breakfasts good to go.  Examples include cereal (preferably unsweetened) with fruit, bagels/bread with cream cheese, hard boiled eggs (easy to prepare for the week), and instant oatmeal.

Lunch is often the least nutritious meal of the day; children make bad choices here.  For example, teenagers will happily go off campus for fast foods if allowed.  Preparing lunch the night before can insure that it is of high quality (e.g. low-salt meats with whole grain breads, fruit, pretzels), and will save quite a bit of money over time.

On the subject of poor food choices, I come down hard on the three “S” foods:  soda, salt and sugar.  Soda is a rare treat, not for every day use. It has no nutritional value.  Sugar free soda may be better than the alternative, but that does not make it healthy, just less horrible.  Salt is ubiquitous in the American diet, present in high amounts in nearly every prepared food you can come up with.  Read labels, and aim for lower salt content.  Try not to salt food during preparation, and there is essentially no reason why a salt shaker should be on the dining room table.  As for sugar, it is indeed a natural substance found in many foods (e.g. fruits), but, again, the American diet is loaded with artificially added sugars.  This is not to say that an occasional cookie, or scoop of ice cream, is bad, but this should not be the norm. Some products now list added sugar content on the label, but this is not yet a requirement.  On a label, look to see if a sugar product is one of the early ones listed in the ingredients (sugars end in ‘ose’, such as fructose, glucose, and dextrose).

Lastly, a word about dinner.  Studies have shown that family dinners promote better eating habits, can increase academic performance, and enhance family bonding. Make times for family dinners at least several times a week (even with your teenagers). All electronics must be off during this time, including phones and TV, and you should talk as a family; find a topic to share.  For example, in our household everyone had to report one good thing that happened to them that day.