Author: All Pediatrics

November schedule now open

Our November calendar is now open.

The best way to schedule your appointment is directly from our website at https://allpeds.com/for-parents/book-an-appointment/

If you are trying to schedule a double well child check and are unable to find consecutive spots with the same provider we ask that you please give us a call.

October schedule is now open

Our October calendar is now open.

The best way to schedule your appointment is directly from our website at https://allpeds.com/for-parents/book-an-appointment/

If you are trying to schedule a double well child check and are unable to find consecutive spots with the same provider we ask that you please give us a call.

How to Help Children Eat Well and Be Healthy

Many parents worry about their child’s eating habits. Maybe they only want mac and cheese for every meal, or they refuse to even touch vegetables. What can you do? One way to help your child eat well and help you worry less is to understand your job and your child’s job when it comes to food. Learn more about this concept and how to help your child eat well and be healthy.

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two kids eating healthy foods.

 

September schedule now open

Our September calendar is now open.

Please do not call our office on the 4th as we will have limited staff for emergency visits only. We will not be able to book any well check appointments over the phone until July 5th.

You can however schedule your appointment online today July 4th directly from our website at https://allpeds.com/for-parents/book-an-appointment/

If you are trying to schedule a double well child check and are unable to find consecutive spots with the same provider we ask that you please give us a call on July 5th.

August schedule now open

Our August calendar is now open.

The best way to schedule your appointment is directly from our website at https://allpeds.com/for-parents/book-an-appointment/

If you are trying to schedule a double well child check and are unable to find consecutive spots with the same provider we ask that you please give us a call.

July schedule now open

Our July calendar is now open

The best way to schedule your appointment is directly from our website at https://allpeds.com/for-parents/book-an-appointment/

If you are trying to schedule a double well child check and are unable to find consecutive spots with the same provider we ask that you please give us a call.

Blog: What is Normal Part III

What is Normal? Part three

Can a medical condition ever be normal?
Sometimes this is a matter of semantics. I would argue that technically, autism is not normal, in that it is clearly a statistical outlier. However, there are many adults with autism who are living fully independent lives, including raising a family of their own. For practical purposes, I consider such a person as ‘normal.’

The more important question for me, in deciding normalcy when there is a medical diagnosis, is whether treatment is required. Some have argued that autism should not necessarily be treated, and that making a child with autism ‘normal’ is a bad thing. However, the goal of treatment should not be to normalize someone, but to enhance functioning. If someone with autism can communicate their needs well, even if in a quirky fashion, that does not require treatment, but if they cannot communicate, they do. The goal is not to make the person normal, but to enable normal functioning.

How to decide if a condition requires treatment? My mantra is ‘it’s a problem if it’s a problem.’ Looking at myself, I was a clumsy child who did not like tags on the back of my shirt, or finger painting; nowadays that would be considered a sensory processing issue. We did not have occupational therapists back then, so how was this handled? My parents cut the tags out of my shirts, and the school said I could do a different arts project than finger painting. One area where I did need help was in writing, which was an essential skill back then: writing for me was a problem because it was a problem. I had to practice this often, and eventually my writing became, for a while, legible.
Even abnormal conditions for which we have medications do not necessarily mandate them. Perhaps the most common is ADHD. Most (but by no means all) children with ADHD have problems both in school and with some interpersonal interactions. We can treat ADHD with medicine, effectively in most cases; adding counselling works even better. However, if a child with ADHD is functioning well, getting by at school, making friends, etc., they do not require medicine, even if they are not ‘performing up to their potential’ (after all, does anybody truly perform up to their potential?). Medicine is not a cure here, but only treats symptoms, and it is also not useful as prophylaxis to prevent problems down the road. One can hold off on treating ADHD with medicine in such a child until problems warrant it later on, if ever.

Another abnormal condition we see in children is migraines. Some children may have a migraine twice a year. My recommendation for such children is to take ibuprofen, go into a dark room, try and fall asleep, and write the day off. Other children may get migraines once a week, which is clearly too often and disruptive, and for those children I prescribe medicine. How do I decide how often for a migraine is too often? I don’t – I let the family tell me, since they are the ones living with it, and migraines are not life threatening.

Many other conditions, especially ‘psychiatric’ ones, fall into the category of ‘it’s a problem if it’s a problem.’ If a child has an obsession and can only ride in the right rear seat in a car, that is unlikely to be unmanageable, and does not necessitate treatment; however, if they can only ride in a blue Volvo in a right rear seat with Daddy and nobody else driving, now it’s a problem. Is your child just shy, or do they have social anxiety? Are they prone to moods, or clinically depressed? For close calls, that’s for the family, not me, to decide.

Looking at the other side of the coin, are there pediatric conditions which are not causing any problems, but still need treatment? The answer is yes. I am going to circle back once more to perhaps the most important of these today, by looking at body mass index (BMI). Elevated BMI is a potential marker for prediabetes, an asymptomatic condition. However, many of these children will go on to develop diabetes, a serious condition with lifelong complications including liver, heart, kidney, and many, many other problems. It is much easier, and better, to try and prevent diabetes before it occurs, by dropping the BMI (and only slight changes here can often succeed).

Bottom line, when I look at children through the spectrum of normal/abnormal, my focus is not specifically on achieving ‘normalcy,’ although that concept does play a role in my thinking in many cases. Rather, what I am focusing on is trying to ensure that every child, to the greatest extent possible, is able to live as independent and healthy an adult life as they can; normal and abnormal are just useful constructs on the way to achieving that goal

June schedule now open

Our June calendar is now open.

The best way to schedule your appointment is directly from our website.

If you are trying to schedule a double well child check and are unable to find consecutive spots with the same provider we ask that you please give us a call.

May schedule now open

Our May scheduled is now open.

The best way to schedule your appointment is directly from our website at https://allpeds.com/for-parents/book-an-appointment/

If you are trying to schedule a double well child check and are unable to find consecutive spots with the same provider we ask that you please give us a call.

Blog: What is Normal Part two

What is Normal?

Part two: Lab work

In medicine, people often put great faith in testing and instruments. For example, studies have shown that for asthma, using an inhaler with a spacer is as effective as using a nebulizer. The former has the advantages of being easier to use, portability, and requiring less time. Nevertheless, many people, including many doctors, believe the latter is better, not because of any data, but simply because it uses a machine. So what about lab testing? This can give objective findings, and one assumes it will easy to determine normal from abnormal.
However, this is not always so. As with growth curves, abnormal is defined as a certain percentage of the population, regardless of health status. Furthermore, if you run large numbers of tests on a healthy person, the odds increase that at least one of them will fall outside the ‘normal’ range. What we are often looking for is the degree of abnormality. Suppose I am concerned that your child may have a liver disorder, and his liver enzyme test comes back at 32, with 30 being the upper limit of normal. Is that a concern? Almost certainly not, whereas a finding of 150 would be.

Blood testing for food allergies is another common area where testing is not as definitive as you might expect. If a random allergy panel is ordered, many children will have abnormal results, yet the child can tolerate those foods without difficulty. Without clinical correlation of symptoms, the tests are often worthless, and do not warrant avoiding those foods.

A similar area, undergoing further revision at present, is with vitamin D levels. Until recently, levels below 30 were felt to need treatment, but newer studies have called this into question. Thus, if there is any concern about vitamin D, it makes more sense to make sure your child is taking in enough, usually by milk (which has vitamin D added to it), or a vitamin supplement (non-milk dairy products are good sources of calcium, but usually do not have added vitamin D), rather than measuring a level.

When I first started doing pediatrics, we used to do many tests routinely, such as a yearly urine. We no longer do this, because it has been shown to be of little value. Thus, we would often find protein in the urine, a marker for a condition called nephrotic syndrome. However, protein can be found normally in children if they have been up and about during the day. If we found protein in the urine on a random sample, we would have the parents collect a urine first thing in the morning. This would invariably be negative, and then we would not worry about it. I have seen many patients with nephrotic syndrome over the years, but never one found by a ‘routine’ urine specimen; they always had clinical findings which directed me to look for it.

Compounding the situation further, no test is perfect, and results can be misleading. This comes up particularly when we consider Bayes’ theorem. You can find the mathematics behind this on-line, but basically, if your child has almost zero probability of having a given disease, a positive test changes that to just being very improbable. Results are similar if a child is very likely to have a condition, but the test is negative. Testing is most valuable when the physician is uncertain.

We can look at Lyme disease as a specific example. If your child comes to the office in the summer with the classic rash (Erythema Chronicum Marginatum), I will treat for Lyme disease, regardless of what a test showed, so there is no need to test. Conversely, testing for Lyme disease in someone with vague, non-Lyme complaints is not a good idea; a positive test would be a false positive, not indicative of Lyme disease. I remember one patient in particular, who I felt was depressed. The parents did not agree with the diagnosis, and went to see a self-proclaimed ‘chronic Lyme expert.’ The child’s Lyme test was negative, but he tested positive for a tick disease seen only on the west coast, a place he had never visited. The child wound up leaving the practice to be treated with long-term antibiotics by the ‘expert’ for a disease he almost certainly did not have; I doubt it helped.

Even when a test is correct, it may still not mean anything. For example, some children are strep carriers. They always have strep in their throat, living with it just fine, not contagious, and not needing treatment. However, if I were to randomly culture them, I would find strep. We don’t do such random cultures, of course. Now suppose that same child came to the office with a runny nose, cough, no fever, no vomiting, no enlarged lymph glands, and a scratchy throat. They do not have a ‘strep throat’ either, but if I were to culture them, ‘just to be sure,’ the test would be positive. This would then mean the child needed to be quarantined for a bit, and take ten days of antibiotics (which will usually not eradicate the strep in a carrier), all for nothing.

Is there a role for any routine testing nowadays in pediatrics? Yes. Many infants are anemic, so we test their blood at 9 months. We are seeing more cholesterol problems, and so we recommend testing for this somewhere between the 9–11-year visit. Lastly, I harken back to elevated BMI (see part one of this series). With the increase we are seeing in type 2 diabetes, even in children, current thinking is to look for this. The test is a hemoglobin A1C, and I order it in older children who are above the 95th percentile in BMI, or the 85th percentile with other factors (e.g., a positive family history).

Next up: medical disorders