Is Your Hand Sanitizer Disappearing at Home?

Published on May 18, 2012 in Parenting, Prevention, Safety, Teens and Uncategorized. 0 Comments

It always amazes me how children will try just about anything to get a high. This is nothing new. Some kids have just gotten more sophisticated these days. Years ago, I had heard about teenagers drinking hand sanitizer to get drunk. The new thing is to distill the alcohol, turning the gel into a 120 proof shot. I have not encountered a teen who admits to doing this yet, but I would be surprised if there are not some out there.

Hand sanitizer is a helpful way to maintain good hygiene, but when ingested, it is very potent alcohol. Kids who do so can get highly intoxicated, potentially leading to trips to the emergency room. I came across this news story that has some quotes from a toxicologist—a friend who I did residency with—that discusses this trend and the related dangers.

So, if you notice that your hand sanitizer bottles are disappearing at an alarming rate, it’s time to have a serious conversation with your children.

Happy Mother’s Day

Published on May 12, 2012 in Uncategorized. 0 Comments

I wanted to give a quick shout out to all the moms out there, including one special lady in the Nohle household who brought two incredible children into this world.  Being a mom is not easy, as any parent knows. I know there are days when many moms jokingly want to say “I quit”  because of fighting, arguing, or constant whining, but moms keep coming back for more.

A big thanks to all the moms out there including my wife.

Have a great Mother’s Day this weekend.

Do You Like Green Eggs and Ham?

Published on May 8, 2012 in Babies, Parenting, school and Uncategorized. 0 Comments

I do not like them Sam-I-am …

And so it goes nearly every evening in the Nohle household. It doesn’t matter how many times I read those words, my son can’t hear them enough. Green Eggs and Ham is his favorite book for read-aloud time at the moment. My daughter had her own favorite when she was younger: Andiamo Weasel. Now she reads her chapter books.

I must have read Andiamo Weasel a thousand times, partly because it was a mainstay of the bedtime routine, and partly because I just loved the story, not to mention all things Italian. It was just one of those books that I did not get tired of reading again and again. With Dr. Seuss, I tell my son that he was the last good doctor out there. The silliness of the book just makes me laugh. I try to read it from cover to cover without making a mistake, which is quite a challenge if you have not tried.

In clinic, I often talk about the many benefits of reading aloud to kids. When you read to your kids, you’re helping to orient them to language—teaching them basic speech skills and vocabulary. Behind the language, you’re helping them to learn logical thinking skills such as cause and effect. Studies show that children who are exposed to reading before preschool do better academically when they enter school. This is why many of our clinics are part of the Reach Out and Read program which gives away books to young children at their well visit.

Read-aloud time can be an important part of a child’s daily life. I sometimes wonder why my kids can tolerate hearing the same story every evening for weeks at a time, but I realize it’s one of many facets of their daily routine that helps them feel secure and comforted.

Maybe even more importantly, when you spend time reading aloud to your kids you’re building a loving relationship with them. Sharing uninterrupted time, and a story you both enjoy, can be nurturing for both parent and child. My kids love to have this special time I spend just with them, and I also look forward to a chance to slow down and have a quiet segment of the day with my kids.

Group Health Pediatrician on the Local News Tonight

Published on May 4, 2012 in Uncategorized. 0 Comments

Whooping cough, otherwise known as pertussis is making its rounds in WashingtonState. This evening at 5 PM, one of our star pediatricians, Dr Emily Chao at the Burien Group Health Clinic will be on King 5 news talking about this important topic. Check it out.

A reminder to everyone out there to make sure that you are up to date on your tetanus pertussis vaccine (Tdap).

Building Strong Bones Now and for the Future

Published on April 25, 2012 in Vitamins. 0 Comments

Those of you who have seen me over the years in clinic have heard me say that my advice on the need for vitamins has changed over time. This is especially true when it comes to vitamin D, which I’ve learned can make a significant difference in building bone strength for both kids and adults.

Those of us living in the Northwest do not see the sun often enough to make enough vitamin D, and thus need to supplement. The problem here is that although the sun helps our bodies make vitamin D, we just don’t see that yellow ball in the sky for nine months of the year. When it is out in the summer, you should be applying sunscreen, which protects you from the sun but unfortunately decreases your natural vitamin D production at the same time.

Most children and adults with a typical healthy diet will take in adequate amounts of the other nutrients, but with vitamin D, it’s challenging. In 2010, the Institute of Medicine increased the recommended dose of vitamin D to 600 IU for all people who are more than 12 months in age. This is up from the prior recommended dose of 200 IU. A glass of milk or fortified orange juice has about 100 IU per serving. We typically do not recommend children drink more than 2 glasses of milk a day. Cheese does not have vitamin D. Things like yogurt contain only about 40 IU per serving. Herring has about 1300 units for a small serving, but I doubt you will get your child to eat it on a regular basis. Salmon and Halibut are fantastic sources with a small serving getting us very close to our daily need but it is too costly for most households to eat on a regular basis. That leaves us with the need to supplement.

Vitamin D is important for healthy bone strength as it plays a role in calcium and phosphate regulation. This is where there is the best evidence for its benefits. It’s a fat-soluble vitamin, which means that your body stores it and thus it’s possible to get too much if excess doses are taken for a prolonged period of time, causing symptoms such as irritability, muscle weakness, elevated blood pressure or kidney stones. It’s the in-vogue vitamin these days and gets mentioned for other indications such as prevention of multiple sclerosis, cancer, and heart disease, but the evidence thus far is not as strong. More studies are necessary to really tease this out. Time will tell if it lives up to the hype, but at least we can encourage strong bones in future by getting an adequate amount now.

To Pedal or Not to Pedal, that is the Question

Published on April 13, 2012 in Uncategorized. 0 Comments

The weather is finally changing and I am seeing more children outside playing which is a very good thing. My own children have been out riding their bicycles, as well. My eight year old is a pro on two wheels. My son, age 4, alternates between his balance bike, without pedals, and his Transformers-theme bicycle with pedals and training wheels, depending on his mood. The Transformers ride seems to be winning out thus far.

Parents often ask me what I think is the best way for kids to learn to ride a bike. They wonder if it is better to start kids off with the newer pedaless bikes, scooting along with their feet on the ground for locomotion. The short answer is that I don’t know. I’ve reviewed the medical literature to see if there was anything studied on this topic and found nothing.

Balance is a skill that children learn over time and one that requires practice, whether it be riding a bike or walking the balance beam on the playground. Let’s face it, some children are more coordinated than others, but practice is critical. This can be done by encouraging fun activities like setting up an obstacle course, balancing on objects on the playground, playing games like hopscotch, or even yoga.

Circling back to the balance-bike question, there is no right answer. Every child is different. One would think that by allowing a child to focus on the balance part of learning to ride, instead of pedaling, it would speed up the process, but this hasn’t been the case for our family thus far. The most important thing is that your child is active and having a great time riding no matter what type of bike they are using.

Don’t forget the helmet please.

Vaccine Studies Reinforce Our Decisions

Published on April 6, 2012 in Uncategorized. 0 Comments

An article in the current issue of Pediatrics is making the rounds online and is a good example of the information that physicians use to make decisions when it comes to using combination vaccines versus separate vaccines. The article is an expansion on the use of the MMRV (combined mumps, measles, and rubella vaccine and varicella vaccine) and any associations with a febrile seizure. A prior study in 2010 showed that use of the combined vaccine as compared to separate MMR and varicella vaccines was associated with a greater likelihood of a febrile seizure. Because of this, the CDC recommendation from May 2010 stated basically to use separate MMR and varicella for the first dose and the combined vaccine for the second dose which is typically given around four years of age. The new large scale study showed that this slight increased risk of a febrile seizure did not exist in children of ages four to six years old receiving the MMRV vaccine reinforcing the strategy we use at Group Health when it comes to this vaccine series. For those who wonder about the benefits of the combination vaccine–this means less shots for your child in the long run, which is always a good thing.

As any parent who has witnessed a febrile seizure knows, they are frightening. Even we pediatricians do not like to see them. As frightening as they are, it’s important for parents to know that they do not cause a subsequent seizure disorder or lead to epilepsy. The typical age for febrile seizures is between 6 months and 6 years of age with the peak incidence being around 18 months. Any illness causing a fever can cause this and to put things into perspective, the majority of children that have a febrile seizure will have them due to a viral illness.

I do not see this as any big controversy or anything groundbreaking but as an example of how we try to use evidence-based data to make better decisions when it comes to vaccines or for that matter, other aspects of how we practice medicine.

Allergies? Consider Typical Treatments before Testing

Published on March 27, 2012 in Allergies and Uncategorized. 0 Comments Tags: .

The flowers are beginning to bloom, which means we’re heading into spring allergy season. I see children with suspected allergies all year, but spring is a hot time for symptoms, even if the Pacific Northwest weather is still on the chilly side. My own allergies have certainly kicked in already.

At least a few times a week, I have a conversation with parents about allergy testing for seasonal allergies. The conversation predictably goes something like this: the child is having allergy symptoms this time of year due to something in the air and the parents are interested in testing for that allergy but have not tried any typical treatments first. I’m not sure why parents can be so willing to subject their kids to skin prick tests, which can involve upwards of 20-plus pinpricks.

When it comes to most allergies, I prefer a try-and-see, broad-spectrum approach before going for testing that can be uncomfortable for the child, and expensive depending on your coverage. Don’t get me wrong, there is clearly a role for allergy testing, but I like to have parents try medications containing cetirazine or loratadine first prior to testing, to see if they bring some relief. Even if the testing does show results, the treatment still might be over-the-counter medications. For most of us, it matters less what we are allergic to and more how we can alleviate our symptoms.

I do recommend allergy testing when medical therapy isn’t doing the job or allergy shots are the preferred mode of treatment because the parent or child simply does not want to use a medication. Food allergies are a different topic for another day.

How Medicine Differs in the Pediatric World

Published on March 16, 2012 in Uncategorized. 0 Comments

I read an interesting article in The New York Times this week: “Things Adult Medicine Could Learn from Pediatrics.”  The article discusses differences in how we care for patients depending on their age. For example, in the pediatric world, we clearly acknowledge the fear involved when a child is hospitalized and try to take measures to mitigate that fear such as parents being able to room in with their child. I have always known that many things that we do in the pediatric world are different than with adult medicine and that kids aren’t mini adults.

As examples, I’m much less inclined to do a test that involves pain such as a blood draw or allergy test unless it’s really necessary. When it is necessary, I don’t think twice about it.

I can think of countless other examples where I think we show a sensitivity in the pediatric arena that you sometimes don’t see in adult medicine.  Pain with urination comes to mind. We would never make a child wait until tomorrow to get a urine sample to evaluate for a bladder infection, yet I can recall times in the past when the adult would be told “we can get you in tomorrow.” That just wouldn’t fly in my world. As many parents can relate, that mommy- or daddy-bear instinct just kicks in when it comes to our children and we expect more and thus we as pediatricians also want to deliver more. Ultimately we all deserve to be treated with care, compassion, and dignity.

Can Families and Pediatricians Still Build Close Bonds?

Published on March 1, 2012 in Parenting. 0 Comments Tags: .

Recently, a reader asked an excellent question that really got me thinking and reflecting. As a new parent, she wondered, what should she expect from a pediatrician in terms of partnership and engagement in the well being of her child? She was thinking of her own special relationship with her pediatrician as a child. She asked me if that’s too much to expect with today’s health care environment and hectic pace of life.

I also had a great relationship with my pediatrician growing up and it definitely shaped why I chose to go into the field. He is still in practice in the Tacoma region.

The short answer to this reader’s question is no, you’re not expecting too much and you shouldn’t settle for less. Most of us who choose pediatrics do so because of our love for children and want a career where we can watch children grow up over time. This is the most rewarding part of the job. This is the person who’s going to be caring for your child and you need to be able to have trust in this relationship. This does not always mean you will see things eye-to-eye, but there should be mutual respect for each others’ opinions. I really do see myself as part of the family for the first 21 years of your child’s life.

It’s true that it can be harder for physicians at this time to deliver on this kind of relationship looking at the medical field as a whole. Medicine has evolved and it is clearly a business. The majority of the country is still in the fee-for-service world. Basically, this is an antiquated system based on the premise that the more visits and procedures providers do, the more money they make. It’s a broken system that ignores quality in the equation. As reimbursements from various payers have declined, many physicians need to see much larger numbers of patients in a day in order to survive and cover their overhead. This clearly can make it challenging to deliver on a meaningful positive experience in a short time period. The bright spot is that there are systems that are finding ways to buck this no-win cycle and improve both the patient-physician relationship and the quality of care. I’m proud to say this recent show on PBS cites Group Health among these breakout systems. It’s not impossible, but it takes work.

Ultimately, you should seek out a pediatrician that both you and your child feel comfortable with and one that embodies the traits of good medical knowledge, excellent listening skills, and compassion. There are a lot of these fine doctors out there. Sometimes you find the right fit from the start, and sometimes you have to try a few doctors to find that relationship that will last.

Here’s a post I wrote a while ago that talks about what I look for when I’m hiring doctors at Group Health.