All of our offices now have flu vaccine! All times below are by appointment only.
Please call 703 436 1200 to schedule an appointment for your child. Space is limited.
Alexandria Office
11/29 8-3pm
Woodbridge Office
11/30 8AM – 5:00 PM
Lorton Office
Mondays from 8:00 AM – 12:00 PM,
Thursday from 12:00 PM – 5:00 PM
Fridays from 1:30 PM – 5:00 PM
Evenings from 5:30 PM – 8:00 PM on 10/22, and 10/24.
Saturdays: 9:00 AM – 12:00 PM on 10/13, 10/27,11/3, and 11/10.
Here are items 6 – 10 of the top 10 concerns at the newborn visit. Please see part one of this blog post for items 1-5.
6. Sleeping: Sleep is a topic that parents and pediatricians talk about for 18+ years but with regard to newborns, I have a few specific comments. Newborns can sleep 18-22 hours per day waking to eat every 2-3 hours then going right back to sleep. They will start to have more awake and alert periods about 2 weeks of age. They are also nocturnal. This means mean they will sleep more during the day and be awake more at night similar to when they were in-utero and mother’s daytime activities lulled them to sleep. The circadian rhythms that help them differentiate between day and night become more active after several weeks and things do get better. In the meantime, offer lots of environmental cues to the newborn. During the day, exposure her to increased stimulation such as talking and singing, normal daytime light/sunlight and routine daytime noises. At nighttime, keep it all business. The sleeping space should be dark and you should tend to the newborn’s basic needs while being mindful to not over stimulate. Lastly, the safest place for a newborn to sleep is in the parents’ room in her own separate sleeping space on her back.
7. Stooling issues: I very commonly get concerns during this time period about stooling that include questions about frequency, consistency, infant straining and grunting and stool color. I always tell parents that normal newborn stools (especially an exclusively breastfed infant) are what you and I think are diarrhea. Breastfed infants can have 8-10 yellowish liquid stools a day. This is nature’s way of letting you know the infant is getting enough given you cannot quantify what the infant is taking right from the breast. Rest assured, lots of poop usually means lots of breastmilk ingested. Formula fed newborns still have loose stools but at a frequency of about 2-3 times per day. Just to add more confusion to this challenging time, some newborns can have bowel movements once every 7-10 days which can also be normal. To help reassure, I again revert back to the infant’s comfort level. If they are content after eating, happy in between bowel movements, eating well, passing gas and not vomiting (spitting up is OK – see below) then there is no need to panic. I recommend you continue frequent feedings and contact the pediatrician during regular business hours to discuss concerns.
8. Spitting up: Pediatricians have the term “happy spitter”. This is an infant that effortlessly turns his head to expel a mouthful (or two) or milk without much drama during or afterward. This can happen with every feed. During the first few weeks of life, as the infant’s stomach size stretches out (from about the size of a grape to the size of a ping pong ball), spitting up usually lessens. Be careful about offering too large a volume of milk to a newborn infant given this small size of the stomach. An adequate volume during the first few days of life is about 15-30 ml per feed. This can gradually be increased depending on how full the infant seems and amount of spitting up. As long as there is no perceived discomfort with spitting up and the newborn is content and appears to gaining weight *, continue frequent feedings and monitor closely. (*With adequate weight gain in early life, the newborns tummy appears large and distended. It is usually a sharp contrast between the tiny hips and often a source of concern for families when they change their newborns diaper. Use this sign as affirmation that your infant is thriving).
9. Bowed legs: This is an easy one…..normal in the newborn period due to cramped quarters and being folded in half x 9 months. The legs will straighten with time.
10. Finger nails: The nails are paper thin and almost seem to be connected to the tips of the fingers until they begin to harden at about 2 weeks of life. Given this, it is difficult to clip them with a nail clipper early on. I recommend using a file or simply covering the hands with newborns mittens or layette gowns.
This blog is by no way a comprehensive discussion of all 10 topics but more of a quick reference guide to hopefully help in the stressful first few days home from the hospital or between the first few pediatrician visits. I encourage families to use their family/friends support systems and trust their guts with regard to their newborns care. Look at your newborn, he or she will let you know if they are comfortable or not. And try not to second guess yourself. After years of practicing pediatrics, I have come to realize that despite often lacking confidence, parents, new and old, can instinctively tell when something is amiss with their child. Trust yourself and enjoy your baby and this amazing one of a kind experience.
Please join our dietitian Jennifer Littau for a Facebook Live event on September 26th at 8 PM. Jennifer will be sharing details of an upcoming Free Family Fitness Bootcamp, scheduled for October 24th at 7 PM in the Lorton office. This will be a fun-filled spooky evening as we invite parents and children ages 6-12 to wear their costumes and enjoy learning new, fun ways to stay active!
I completed my pediatric residency in July 2000 and found out I was pregnant with my first daughter shortly thereafter. One of the pediatricians I worked with at that time said, “You know the final step in becoming a good pediatrician is having a child”. Eighteen years later, I often think about what he said and how true a statement it is. The ability to identify with the parents of our patients, as well as our patients, and the ability to feel the emotional as well as intellectual component of what we do is a very essential part of the job.
My daughter was born premature at 34 weeks and 5 days. She weighed 5 pounds and spent 12 days in the NICU. Now I had training as a doctor and a mom in this arena. I dutifully played the mom role and even took the CPR course required before discharge! I had an eventful maternity leave filled with reflux, colic and lots of fussiness and eventually returned to work. Those first few weeks back, I had an intense connection with the newborns I saw and their families and realized things had changed. In an effort to convey this connection, I often started visits by asking new moms “How are you doing?” followed by “I found the first few weeks very emotionally and physically trying.” I indeed connected and most of the mothers winded up breaking down into tears when given this empathy and window of opportunity. I’m sure all parents can identify with the uncertainty and the lack of confidence felt when you bring your first newborn home which brings me to this ALL Pediatrics Blog topic. The following are my take on the top 10 concerns (in no specific order) raised by parents at the newborn visit. This visit usually takes place when the baby is about 3 days old and about 1-2 days after leaving the hospital.
1. Newborn rashes: A newborns skin is not smooth and silky. There is an extra layer of skin that protected the infant while bathing in the amniotic fluid that needs to shed in the first weeks of life. This is often mistaken for “dry skin”. The closer to term the infant is, the more “dry”and wrinkled the skin appears -almost like soaking in a bath too long. No lotion is needed and usually the extra layer is shed by 2-3 weeks of age. Two other skin issues are also frequently a cause of parental concern: Erythema toxicum: a completely benign bumpy rash that changes location over the body for the first 2-3 weeks and often looks like insect bites. Text books call it a “fried egg appearance” with the yolk of the egg being the center bump which often has a yellowish hue and the white of the egg being an irregularly shaped reddened area. It does not cause any discomfort or itch and there is no treatment needed. Infant acne: basically pimples where you would expect pimples to be – face, upper chest, upper back. Infant acne starts at about 2 weeks of age and is related to maternal hormones circulating in the infant. It usually resolves by 6-8 weeks of age but can worsen before it gets better. It can also appear to fluctuate in severity day to day and even hour to hour which is often a source of concern for new parents. No special treatment is needed. I recommend just regular bathing and washing with water or a mild infant soap.
2. Noisy breathing: Other than crying, newborns make many concerning noises the first few weeks of life. They seem congested (another result of bathing in the amniotic fluid for 9 months) and snort, squeak, snore and generally seem like they need to perpetually clear their throat. Much of this is due to benign issues such as reflux or immature, less strong airways and eventually goes away. When is a parent to worry? Any perceived difficulty feeding (sweating or unable to eat) or increased effort of breathing (pulling in chest or abdominal breathing) should prompt a call to the pediatrician. In addition, it is reassuring if the noises come and go and aren’t constantly present when the infant inhales and exhales. Lastly, assess the infants comfort level. If he is sleeping peacefully despite the cacophony of noises that are disrupting your rest more than his, this is a good sign.
3. Umbilical cord drainage: The umbilical cord drains mucus like material as well as old dark blood while it is separating and for several days after it falls off. The drainage can even be somewhat foul smelling. At the time of discharge, the hospital recommends that parents put nothing on the cord and I agree with this. However, it is OK to wipe away some of the foul drainage with a damp cloth trying your best not to get the cord wet. Once the cord falls off, it is also OK to wipe away the drainage. If there is copious drainage requiring you to clean more than 1-2 times per day, this is concerning. If there is redness and warmth to the skin (like a sunburn) surrounding the umbilical cord or umbilicus (belly button), this is concerning. If there is drainage that persists for more than 7 days after the umbilical cord has separated, this is concerning. The above three scenarios should prompt a call to your pediatrician.
4. Eye drainage: A blocked tear duct is the most common reason a newborn has eye drainage. In this case, the drainage comes and goes – somedays seem better and other days worse. The white part of the eye is clear (not red) and there is minimal swelling or redness to the eyelids and surrounding eye area. As with the umbilical cord, copious drainage requiring you to wipe the eyes every 1-2 hours or increased redness to the eye is worrisome and you should contact your pediatrician. With a blocked tear duct, the drainage is most often significant after a prolonged period of sleep (first thing in the morning) and the eye itself can appear to be stuck shut. However, once the drainage/crusting is gently wiped away with a warm cloth, the eye is not red or swollen. A homeopathic treatment commonly recommended for a blocked tear duct is to drop some breast milk in the eye. Breast milk is filled with lots of good antibodies that are made to fight any infection. Breast milk also contains digestive enzymes that help the infant digest it so easily and some researchers have hypothesized that these enzymes help open the duct and thus help resolve the blockage. Most of the time, the blocked tear duct will resolve on its own by 4-6 months of life and can be addressed at a routine well child check as long as there aren’t any signs of an eye infection as noted above.
5. Jaundice: Most newborns have jaundice – a yellow coloring to their skin due to a substance called bilirubin. Bilirubin is an antioxidant and experts believe it serves some protective critical function in the vulnerable newborn period. However, if the bilirubin level gets to high in the first 48-72 hours, there can be complications such as hearing loss and seizures. In 2018, most newborns will have a bilirubin level drawn prior to leaving the hospital. The doctors and nurses should explain the significance of the level and let families know if it is worrisome or not. They should also give clear follow up instructions if the level is borderline or high. The bilirubin level usually peaks at 3-4 days of age so it may get worse once you leave the hospital. Therefore, it is very important to follow the instructions of the hospital team at discharge regarding bilirubin levels. Once home, try to place your infant in a sunny window. Indirect sunlight can help lower the bilirubin level and your infant will not be negatively affected by sun received through a glass window or door. Infants also excrete the bilirubin through the urinary and GI tracts, so the more an infant eats, pees and poops, the better. However, elevated jaundice can cause a newborn to get sleepy which can negatively impact feeding. If your newborn seems excessively sleepy (not awakening to eat or feeding for less than 10 minutes at a time) and more yellow than when she left the hospital, I recommend calling your pediatrician. ‘
Please visit us next week for part two of this blog that will have concerns six through ten.
Written by Dr. Kathleen Parker-Lundgren
ALL Pediatrics is sad to announce that our beloved Dr. Shanti Chang, RN, FNP, Doctor of Nursing Practice, is resigning from ALL Pediatrics, effective September 15th. We are sad to see Shanti go, but are proud that she will be taking her skills onward to George Mason University where she will be teaching nurse practitioner students and helping to manage a clinic for underserved children.
For the immediate future, Dr. Brittany Taylor will be seeing patients until 8 PM in Lorton on Wednesdays. We ask for patience as we work through the hiring process; please stay tuned for further information about Lorton hours!
Although this represents a decrease in Lorton evening hours, we are pleased to announce that Lara Griffy, an experience nurse practitioner with ? years’ experience, will be joining the Lake Ridge staff where we will be holding evening hours beginning…………?”
Stay tuned for further information about Lorton hours!
At ALLPediatrics we strive to provide patient-centered and family-friendly care ALL the time and we thank you for being loyal families to our practice!
Please contact the office for any questions/concerns that you may have.
We are excited to announce that the Lakeridge location will have evening hours Monday through Thursday beginning in September 10th.
Part two: Urgent Care Centers Versus Our Office
What if your child is ill, and you want him to be seen quickly, and you know he does not need an ER visit? Your choices are between us and an urgent care center.
We have been working hard to make our office more parent-friendly. Thus, all our locations have walk-in hours from 8-12 and 2-4 each day, if you want to just come in with an acute mild illness (e.g. coughs and colds, fever, mild injuries), and wait for the next available opening. We tend to process these quickly although there are times – for example, during flu season – when there can be back-ups. As always, we continue to offer sick appointments as well if you want to be more likely to have your child seen on time, or have a more complicated problem (e.g. headaches, ongoing abdominal pain). We also offer evening hours and weekend (Saturday and Sunday) appointments.
The undeniable advantage of going to an Urgent Care instead of us is that it is usually right near-by, with a short drive, and can be quicker than seeing us. What could be simpler than going in for a quick strep test to see if your child needs medicine?
The answer has to do with the quality of care you might receive. Most Urgent Care Centers are staffed by practitioners who have trained primarily in adult medicine. (There ae some exceptions to this. KidMed in Stafford uses providers with pediatric backgrounds, and the Inova Urgent Care locations in Manassas and Springfield do as well, at least for part of the day). They are less comfortable taking care of children, and as such often practice ‘defensive medicine’ to make sure they are not missing something, as they have less confidence in their clinical skills.
As an example, I will describe a very common scenario. You take your child to an Urgent Care for a sore throat. There, a rapid strep test is done (perhaps reasonable, but not all sore throats require testing, if the doctor can be pretty sure it is not strep). Then because of a bad cough (which, by the way, makes strep much less likely), a chest-X-ray is ordered to see if there is pneumonia. Now, pneumonia which can only be seen on X-ray, and is not suspected on a physical examination, is almost always viral, and will not respond to antibiotics, so the x-ray, even if positive, should not change treatment. We therefore almost never order X-rays on patients we see in the office. When both of those come back negative at the Urgent Care, indicating a viral illness, an unnecessary antibiotic is often prescribed anyway, ‘just in case.’ Many times, the antibiotic is Zithromax, rather than the less expensive but otherwise identical generic azithromycin. I will also point out that, while azithromycin can be useful in adults, in pediatrics there are almost no common conditions for which it would be the first choice, even if an antibiotic were indicated.
Thus, if you do go to an Urgent Care, and they want to order an X-ray or blood test, I recommend you at least ask what they hope to find that would affect treatment. And, if they do order an antibiotic, ask them what they think they are treating. In our office, in the case described above, your child would be seen, diagnosed as having a virus without unnecessary testing, and sent home without an antibiotic but with information about what to do while you wait for your child to improve naturally on their own over the next few days.
Bottom line, although urgent care centers have their place, I advise that, when possible, you bring your child to our office to be seen instead. You will be seen by someone who has access to your child’s medical history and knows pediatrics. While it may not be quite as convenient as an urgent care center, I strongly believe that it is in your child’s best interests as well, and that is why I recommend it.
Author: Dr. Jon Farber
There are different places you can take your child to for health care, and in this two-part article I will explore them in greater detail.
Part one: The ER
I will start with the ER first. Hopefully, your child will never need one. However, I understand that there is nothing as worrisome to a parent as having a sick or injured child, and the temptation to use one in these circumstances can be great. How do you decide whether or not your child needs an ER? I have a simple rule to help you decide:
IF YOU DON’T FEEL YOU NEED TO CALL 911, YOU DON’T NEED TO RUSH TO THE ER.
Of course, no rule is 100%, and you still need to use your judgment, but this is highly reliable. This does not mean your child can avoid going to the ER; what it means is that you have time to look into the question further before making a decision. To help you decide, I suggest that you call our office. We have triage nurses available 24/7 who work under the supervision of the doctors, and who are trained to answer these questions, with set protocols. A doctor from the practice is always available (again, 24/7) as back-up if they feel we are needed. If the recommendation, following talking with us, is to go to the ER, you can feel comfortable that that’s the way to go.
Another source of reliable information is our webpage, which has useful links on pediatric conditions. Lastly, for those of you who have smart phones (which seems to be everybody but me), the app Pediatric SymptomMD ($2.99) is a very reliable resource on pediatric care that is meant specifically for parents.
There is a surprisingly long list of things which do not usually require ER visits, even after discussion. This includes: fevers, even if high; lacerations which stop bleeding on their own; head injuries where a child is not unconscious, even if there is large swelling; finger and toe injuries even if they look broken; vomiting if not yellow-green, even with abdominal pain; and croup. Call us; if we feel you should take your child to the ER, we will tell you so, but otherwise we can make arrangements to be seen in our office, if needed, in a more efficient manner.
Why do we try to avoid the ER? For one thing, we feel that it should really be just for emergencies. Every patient who shows up in an ER who does not need to be there is potentially taking time away from someone who truly does have an emergency. A second factor, quite honestly, is the cost. If you have a plan with co-pays, you will pay significantly more for the ER visit than being seen elsewhere. And for those of you with high deductibles, the average cost of an ER visit starts at around $1000 and can go much higher.
Author: Dr. Jon Farber
“Primum non nocere”, Latin translation from the original Greek “do no harm” as in the Hippocratic Oath as recited by all medical students.
Perhaps while you were growing up (much as I did) you heard statements such as:
In essence, taking an antibiotic meant getting healthy.
However, in my quest to provide quality care, more often than not I have learned that NOT prescribing antibiotics is the only way to truly follow the Hippocratic oath and do no harm!
Why not prescribe antibiotics just in case?
Antibiotic resistance – the CDC sees antibiotic resistance as amongst the greatest public health threats today, leading to an estimated 2 million infections and 23,000 deaths per year in the United States (1). Taking an antibiotic when it is not needed, the wrong antibiotic, the wrong dose, and/or the wrong duration can all increase the likelihood of bacteria developing resistance and becoming ineffective.
Antibiotics upset the balance of good and bad bacteria in your intestinal tract. Antibiotic associated diarrhea is its mildest of forms. Clostridium difficile is its most severe (profuse, often bloody diarrhea with abdominal cramping).
There also is the potential to develop an allergic reaction to your prescribed antibiotic, hives being the mildest form. However, these reactions can progress to a more severe allergic reaction leading to an emergency room visit or even hospitalization.
There are ongoing studies being done on antibiotics and their effects on our microbiome (the genes in the trillion or so symbiotic helpful microbial cells harbored by each person ) and ultimately our overall health
Based on this, I challenge you not to ask your physician why is my child not getting an antibiotic, but why ARE they getting an antibiotic. Don’t get me wrong – there are often times where the benefit outweighs the risk. The development of antibiotics by Alexander Fleming in 1928 was nothing short of a miracle. Having a treatment for Group A strep throat and thus preventing rheumatic fever, treatment for bacterial pneumonia, severe ear infections ( notice the use of severe, as often mild ear infections will resolve on own ), persistent or severe sinus infections ( again, mild ones often will resolve on their own ) has prevented significant morbidity and mortality.
To this end, All Pediatrics has undertaken a quality improvement project with the Virginia AAP and the CDC to improve antibiotic prescribing practices.
There is compelling evidence, as stated above, that often there is no benefit to the use of antibiotics and there are real risks. I sure do wish there was more I can offer as a pediatrician to ease the symptoms of a troubling cough that keeps your child up at night. It would be very rewarding. However, I will take peace in knowing that I have given sound advice that will keep your child from being harmed.
Author: Dr. Michael Caplan
Along with holiday cheer, snow and cold weather comes Influenza (flu) and Respiratory Syncytial Virus (RSV), two common winter illnesses that can be very serious for children. Below is Part II of my primer on winter illnesses.
Influenza (flu): This illness presents with the sudden onset of fever (often with chills), headache, diffuse body aches, lethargy and non-productive cough. During the course of the first few days, upper respiratory symptoms worsen and evolve into lots of congestion, productive cough and sore throat. Think of flu as a common cold magnified 100%. Symptoms such as conjunctivitis (pink eye), abdominal pain, nausea, vomiting and diarrhea are uncommon with influenza. The illness is highly contagious and primarily spread by respiratory secretions….infected people sneezing and coughing. Annually, 10-40% of healthy children getting flu. The peak incidence in the United States is anytime between November to March but most commonly between January and March. Influenza is largely diagnosed clinically. The tests commercially available are not reliable and I would trust a pediatrician’s exam and clinical opinion much more than a test in most cases. Children less than 24 months have a higher risk for complications from influenza including hospitalization and death. The CDC data from the 2016-17 season note a total of 101 flu associated deaths in children with the majority of those occurring in unvaccinated children. Treatment of flu is usually symptomatic only. Tamiflu, an antiviral medication which decreases the replication of the influenza virus is not a cure but has been shown to decrease the duration of the illness by several days. It is not recommended for the healthy pediatric patient older than 2 years old and side effects such as nausea and vomiting are very common.
After years of seeing lots of children with influenza, there are a few symptoms that I have found to be most concerning to parents of children of all ages.
#1 fever – it is high! The highest fever I have ever seen with any infectious disease is with influenza. It was 106.3 and I was more affected by the number than the 3 year old sitting on the exam table. While the child surprisingly didn’t look that ill with the fever, she definitely seemed like she felt better when it was brought down. Parents should be prepared for high fever of 103+ that can persist for 3-6 days and remember that most children do look listless with fever. The child may also have a pounding heart rate and they are often breathing fast which are normal body responses to higher temperatures. Hallucinations can also sometimes occur. The important thing to do immediately is get the fever down, not rush to the ER or call 911. Fever in and of itself is not a medical emergency. Take off some clothes or blankets, apply cool compresses, give fever reducer and monitor closely for the child to seem overall more comfortable when the fever lowers. I recommend parents call their pediatrician if the fever is greater than 104, persists longer than 72 hours or if the child is ill appearing regardless of fever. As long as the fever comes down and the child seems happier or states they feel better, this can be done during regular business hours.
#2 Markedly decreased activity – Children ill with the flu literally just want to do nothing for 7-10 days. This is understandably very disturbing to parents of children of all ages, especially because most children are innately very active. Many parents use the word “lethargic” which is defined medically as an “abnormal state of drowsiness due to disease or drugs”. A lethargic child is somewhat unarousable, much sicker appearing and most likely not able to use or even be interested in a smart phone or I-pad ( I suppose a good crude way to test degree of illness in 2018). I try to frame this concerning behavior in a positive light when I counsel parents. It is good the child is comfortable enough to rest as this is what is needed to improve and fight off the illness. Regardless of the amount of daytime sleep/rest, parents should see periodic episodes during the course of the day when a child perks up, asks for Elmo or checks Instagram and generally seems more like him/herself, even if 20 minutes later they are back on the couch asleep.
#3 Body aches and pains – When I examine a child and I feel like they are uncomfortable with me even laying my stethoscope on their chests, I always worry about flu. Children with flu often seem like every ounce of their body hurts …maybe another reason why activity is so diminished. In addition to diffuse generalized body aches, increased muscle breakdown due to the virus can occur in large muscles such as the thighs and calves and affect a child’s desire to walk. (think of how you might feel after an intense leg work-out). In this case, increased intake of fluids is essential to help.
With regard to influenza, here are my top pieces of advice:
Respiratory Syncytial Virus (RSV): This is one of the most common diseases of early childhood. Most children are infected in the first year of life and nearly all are infected by the second year of life. Again, a very bad common cold with lower respiratory tract or wheezing 20-30% of the time. The lower tract symptoms are called bronchiolitis – inflammation of the bronchioles or small airways in the lungs. RSV is one of many viruses that can cause bronchiolitis. This inflammation results in wheezing as well as what parents sometimes describe as “rattling” in the chest or “chest congestion”. If your hand is on your child’s chest, you can feel a vibration like sensation when they breathe. This usually clears with coughing or crying. It is also usually causes increased respiratory rate or very fast breathing almost like panting. Other symptoms include fever and copious amounts of congestion. Infection is spread by contact with this congestion – sneezing, coughing, contaminated surfaces such as hands or daycare toys. Secondary complications such as ear infections can occur and the cough/wheezing associated with RSV can take 4-6 weeks to completely resolve.
The most frustrating aspect of these diseases for both pediatricians and parents is the lack of treatment other than time and close monitoring. Even in situations where patients are in respiratory distress requiring hospitalization and supplemental oxygen, they are provided symptomatic care only in a safe controlled setting and VERY closely monitored. There are no medications to make this virus go away. In the past, doctors prescribed Albuterol – a medicine that opens the airways that is used for people with asthma. Many studies have now shown this does not help with viral induced wheezing/bronchiolitis and it is not currently recommended. Given this often unsettling and nerve-racking watch and wait approach, my top pieces of advice for RSV are as follows:
I hope the information provided was both interesting and helpful for those families reading. Please remember to teach your child to cover your cough and practice lots of hand washing. Wishing all a Happy New Year and a healthy 2018!
