The Importance of Well Checks – PediaCast 465
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- Well child checkups are important… even during a pandemic! Our Plain Language Panel returns for an insider’s look at these visits. We explore immunizations, growth and development and guidance offered for each age group. Also: tips for a safe visit with your child’s medical provider. We hope you can join us!
Announcer 1: This is PediaCast.
Announcer 1: Welcome to PediaCast, a pediatric podcast for parents. And now, direct from the campus of Nationwide Children's, here is your host, Dr. Mike.
Dr. Mike Patrick: Hello, everyone. And welcome once again to PediaCast. It is a pediatric podcast for moms and dads. This is Dr. Mike coming to you from Nationwide Children's Hospital. We are in Columbus, Ohio.
It's Episode 465 for July 8th, 2020. We're calling this one "The Importance of Well Checks". I want to welcome all of you to the program.
So my big question for you, before we get started talking about well child checkups is, what has your summer been like? We, of course, like most of you are staying home for the most part. And we're creating an outdoor oasis in our small suburban lot. Our previous owners of our house went pretty crazy with the landscaping which has matured quite a bit. So we had large fir trees and really some natural shaded areas and natural screens with arborvitae.
Honestly, I'm not that much of a green thumb and, probably, if I have been putting our lot together when it was very first built probably would not have number of plants and trees that we have. And through the years, we've looked at it as we kind of come and go. And yeah, it's pretty and it gets pruned back and the lawn gets mowed and whatnot, but very little really has been done to it in these years.
But now that we're home, like many of you, you start looking around and seeing projects that need to be done. And our big project this summer so far has just been to create an outdoor oasis for the birds and primarily the birds and to some degree, the squirrels as well. And we've gone pretty crazy feeding them.
And it's been interesting researching what birds are coming and identifying which birds are there, so that's been kind of a fun family project to see who your visitors are and then what sort of feeders is best suited for the birds that tend to be in your area. So we've got a couple of hopper feeders, a finch feeder, a suet feeder, a hummingbird feeder, peanut feeders, some ground trays and we've been providing seeds and suet, bark butter bits, Jim's Birdacious Bark which you can smear on trees. The woodpeckers love that stuff. And then, mealworms. And we provided a bird bath complete with a running fountain.
So it's quite the sight. I do have some pictures on Instagram. I will say it's not been cheap. The stuff, especially if you buy quality bird feeders that are going to last more than a season or two. They can get a little expensive, but we'd have to cancel two vacations so far. One over spring and then another that was going to happen in late summer, early Fall. So we've not had much to spend our summer activity budget on, so we've taken the opportunity to create our own little backyard habitat.
And identifying and watching the visitors has been a whole lot of fun. Our kitties also like to watch from inside the house. We've seen cardinals, and robins, and finches, and hummingbirds, sparrows, wrens, red-winged blackbirds, blue jays, crackles, mourning doves, starlings, cowbirds, downy woodpeckers, hairy woodpeckers, ducks, and the Cooper's hawks, which caused a tense moment for all.
And this is all in our suburban small lot that we've seen all of these different birds. So regardless of where you live, bird watching with your kids is really a lot of fun.
We've also had some mammals visit our retreat including squirrels which we've been providing some peanuts for them. Also bunnies and the occasional raccoon.
We watched parents feeding babies, young birds taking their first bath. And we've seen some confrontations including mama robins chasing squirrels through the trees.
So lots of fun in the backyard this year. How about your summer? What has your family been doing in 2020? We'd love to share some reports from listeners and you can easily comment by visiting our contact page over at pediacast.org and sharing your summer story with us. Or share it with the group on social media. We're on Facebook, Twitter, LinkedIn and Instagram, simply search for PediaCast.
All right, what are we talking about today? Well child checkups, what are they? I think you have a general idea of what they are. If you're a parent, you've been to one. Are they really necessary? The short answer is yes, but then we'll spend some time explaining exactly why that is, and even in the midst of the pandemic and stay at home as much as possible, getting those well checkups are still recommended.
How often are they recommended? And are they merely a mechanism to update kids on immunization or is there something more? What can you expect for the various age groups? What topics are we likely to cover? How can parents best prepare before the visit? And what questions should you consider asking while your child's provider is in the room?
We'll answer all these questions today along with countless others as we are joined by our popular Pediatrics in Plain Language panel, Dr. Mary Ann Abrams and Dr. Alex Rakowsky, both with Primary Care Pediatrics at Nationwide Children's Hospital. They will be joining us shortly.
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Before we get started with our guests, and they are on the line and ready to join us, just want to remind you very quickly that the information presented in every episode of our program is for general educational purposes only. We do not diagnose medical conditions or formulate treatment plans for specific individuals. If you have a concern about your child's health, be sure to consult his or her pediatrician or other healthcare provider.
So, let's take a quick break. We'll get our Alex and Mary Ann connected to the studio and then we will be back to talk more about the well child checkups. That's coming up right after this.
Dr. Mike Patrick: Our Pediatrics in Plain Language Panel joins us again this week. You will recall that Dr. Mary Ann Abrams is an assistant professor of Pediatrics at the Ohio State University College of Medicine and a pediatrician with Primary Care Pediatrics at Nationwide Children's Hospital. And Dr. Alex Rakowsky, also an assistant professor of Pediatrics at the Ohio State and a pediatrician at Olentangy Primary Care at Nationwide Children's. Really appreciate both of you joining us again this week.
Dr. Alex Rakowsky: Thank you, Mike.
Dr. Mary Ann Abrams: Great to be here, Mike.
Dr. Mike Patrick: So Mary Ann, remind us again what we mean by plain language and why is that such an important thing.
Dr. Mary Ann Abrams: Well, as we know, plain language is always important. And I think we can make the case that it's even more important right now in the times that we are living. But basically, by definition, plain language is using clear words to convey meaning in a way that makes it easy for anyone to understand.
And a couple of ways we like to think about it and talk about it is sort of living room language, the kind of wording words and talking you would do at home when you're just talking to your family or friends, words that your grandmother would understand.
So someone who maybe doesn't speak a lot of health language, and maybe isn't plugged in to a lot of things, so speaking in a way that's understandable and useable for everyday people. And it's always important as we've said that I think at this time, especially with the coronavirus outbreak and pandemic, it even gives us more reason to be sure we use plain language.
There's so much information that's changing and it's so important. It's really incumbent, meaning really important that we, as healthcare providers really make sure that everyone understands. So I can give you a couple of examples if that would be helpful.
Dr. Mike Patrick: Yeah, absolutely.
Dr. Mary Ann Abrams: So one example is we forget what words are not commonly understood, because we hear them on the news and we use them all the time, but to some people, words like PPE, personal protective equipment, are not everyday words. So don't forget about the jargon and the technical terms that we use. We have to make sure people understand.
As most people know, they use a telehealth, whether it's a video or a telephone call, it's being used so much more which has advantages, but it also creates opportunities for miscommunication and maybe a hard time realizing when somebody doesn't understand. So it's really very important again as the healthcare team, we make sure people understand using plain language, plain language terms and then making sure people really understand that when we talk with them.
And I heard one very unfortunate story on the news, which could possibly be related to this kind of lack of understanding. There's a gentleman who had COVID and had been talking with his healthcare provider and was doing okay. So he was at home, but as he started to get worse and worse symptoms, his family kept telling him to call his doctor or go back.
And the message that he understood from that initial encounter was that he didn't need to do that, and he shouldn't call back or go to the emergency room or whatever it was that he was told. And eventually, he got very very ill. And eventually, he actually passed away from COVID.
So we don't know with 100% certainty but it's very possible that the message that he took away from that initial discussion was one that you don't need to come back, or you don't need to call, or it's dangerous to come into the emergency room if you're getting sicker. And that's certainly not what we want to convey.
Dr. Mike Patrick: So it's not only medical jargon, it's even just clear instructions for someone's understanding. It may even be that you're really doing a good job of using plain language. But if you are not communicating that in a way that's clear and maybe one idea is to have the teach-back moment where you just ask someone, "Hey, what did you get out of this?" And let them teach it back to you just to kind of verify that they understand what you're talking about.
The other thing that came to me was this was great advice for us medical providers, but parents can also take something from this in that if you do have a question in your mind, it is absolutely okay to stop the conversation right at that moment, and say, "Hey, help me understand. I'm not understanding what you're saying."
And it's not really a waste of our time. Sometimes, you think, "Oh, I'm going to interrupt the doctor and that's going to take up more time." Or, "They're busy person, they've got other patients to see." But we would rather you understand and interrupt us, right?
Dr. Mary Ann Abrams: Absolutely. Because at the end of the day, we want to make sure you have the information you need to take care of yourself or your family. And absolutely, please feel free to let us know.
Or think about it in terms of, well, what am I going to tell the rest of my family about this later? You want to be able to understand it well enough to put it in your own words, so you can explain it to someone else. Think of it that way.
Dr. Mike Patrick: Absolutely. So today, we're going to focus on well child checkups, and of course, this is a terrific opportunity to practice plain language and to talk very clearly.
What exactly is well child checkup, Mary Ann, and why are they important?
Dr. Mary Ann Abrams: I really like to think about, I guess we take well child checkups for granted, but there's a lot of science behind them. They're periodic, a very so often visits between their child and family and the healthcare provider.
And the timing of those is really purposely. It's tied to the age and the developmental status and the growth and how babies and teenagers grow and evolve over time. So there's a lot of that that goes into how frequently we see people, children, at different ages. And we want to be able to focus on things that are very important at each of those critical points in time.
And we sort of think of well child visits as looking at checking in with the family, how are things going, are there questions you have, any problems with concerns? And then we talk about we want to make sure we do screening, which is a way to check for problems that might be evolving or showing up or starting to show up that we can do something about early, and catch them early, and help prevent them or keep them from getting worse.
And that also depends on the age of the child, too. So whether it be checking for lead poisoning or developmental delays, things like problems with speech or hearing or vision, or behavior problems, or autism, depression in older children, blood tests for anemia, all those sorts of things, so we like to do these screenings, again, based on the age of the child. And then, of course, vaccinations, which are so important to prevent other very serious infections and illnesses, and for some vaccines, even cancer.
So it gives us a chance to check in with the family over time, reinforce all the good things that are happening, and pointing out the good things that are coming down the pipe, and also to catch things early and prevent problems down the road.
Dr. Mike Patrick: Really just an opportunity to sort of have a living room chat with you and your child's doctor and talk about whatever it is that is on your mind and what's on your doctor's mind. And I do want to point out that this is separate from what would be for student athletes, a sports physical. So we'd really like to see kids, especially for student athletes for your well child exam, but then also for sports visit, because there's so many additional things that you want to talk about that that can fill out a whole another visit. And so, those really ought to be two separate things for student athletes.
And we did an episode, Episode number 424, on sports physicals that I want encourage folks to check out, and I'll put a link to that in the show notes for this episode over at pediacast.org.
So obviously, these well checkups, they occur more often the younger the kids are, right, Mary Ann? So like in infants, you see them every couple of months, but then as you get to be two to three years, then once a year is really adequate, right?
Dr. Mary Ann Abrams: Pretty much, yeah. And that's because so much is changing so quickly the first year, especially, and then even the first two years, and then we start to spread those out. And then, that first year, first year and a half, we do see them very frequently to check on all those things I've talked about, to screen for things we've talked about, and to make sure they're protected with vaccines as soon as possible.
But we also want to keep seeing them once a year as they get older, because things change then. And the world becomes a bigger place, so we want to make sure that things like school and friends and socialization and family problems or depression that we don't let those go by, that we can check on those and see if we can be of help, if those were problems for the child or the teenager.
Dr. Mike Patrick: We want to talk about sex, drugs, and rock and roll.
Dr. Mary Ann Abrams: There you go.
Dr. Mike Patrick: Some resources that I'm going to also put in the show notes for folks. One is the Bright Futures Website and its great information source to help you prepare for a well checkup visit. As a parent, you can anticipate topics that may be talked about in a particular visit, and that may help to get you thinking about questions that you have. So I'll put a link to that in the show notes.
Also, the recommended immunization schedule from the Centers for Disease Control and Prevention. I'll put a link to that. It includes all the recommended timing and links to the different vaccines and the safety concerns and the diseases that they protect against.
And then, there's a couple of episodes that I did with Dr. Mike Brady, who's an infectious disease expert and immunization expert also. It was PediaCast episode 351 and 352, both of those on childhood immunizations. We basically just look at every single one of them and what they do and why we give them. So I encourage folks to check those out for sure.
Alex, how has the pandemic affected well child checkups?
Dr. Alex Rakowsky: Actually, in a few ways. I think the most important is a lot of parents were afraid to come in for a well child visit. So we had decreased volumes, one, because of parental concerns about catching COVID in the waiting rooms or in the actual clinics.
The second main way is the fact that a lot of our clinics then sort of limiting the number of patients we're seeing, one, per session, and two, the age ranges that we're seeing, really focusing more in the ages where vaccines are given.
So that was the second main change, and then a third, at least one I've noticed when seeing patients in clinic is that parental concerns do change some. There's more concern about where I can get food now because I lost my job? Or what am I going to do about schooling? Or, are there any resources I can use to help schools, since they're not going to school physically?
So those are the types of questions that actually started to change. I want to mention one more is that I felt like a lot of parents sort of lost some of their confidence in their ability to parent. And I actually wrote a blog about this where a lot of the people that were fairly competent parents all of a sudden, with all the uncertainty, just seem a little less certain about their ability to parent in this sort of fluctuating time. So both volume and then changes in the parents per se.
Dr. Mike Patrick: One of the things I hear from a lot of parents is, is it safe to take my kids in for the well checkups? We were told at the beginning of the pandemic, just hold off on the well checkups for right now. And as the cases started to come down, now they're creeping back up, is it safe for families to take their kids and to see the pediatricians especially when they're well?
Dr. Alex Rakowsky: Yeah, so our system for example, I think this kind of hold for almost every system in the country, have made a concerted effort to keep the waiting rooms sort of emptier or as empty as possible. And then to have six feet of separation and mask in every child and parent in the waiting room. So we've really tried to either limit, if you're in a clinic just by yourself, limit the number of patients you're going to see so you can actually move them in and out.
And in the summertime, we've asked a few families just to wait in the car, which would be hard to do in the winter. And with the resident clinics, we tend to be almost twice as busy. We struggle to keep the waiting room open or at least as open as possible. We've utilized the car fairly often just as a waiting room. And then security comes out or we give them a text that, "We're ready to see you now." Because otherwise, it's really hard to kind of see the huge volume that we see in resident clinics.
Dr. Mike Patrick: Yeah, and this is something we hadn't really imagined.
Dr. Alex Rakowsky: Not at all.
Dr. Mike Patrick: That we would try to figure out. But there's really been a lot of ingenuity and each place is going to be different. So if you have any questions about what your pediatrician or your child's other medical providers are doing to keep your family safe, absolutely call their office and ask, "What are you doing? What can I expect when I bring my kid in?" So they know exactly what's going to happen.
Dr. Alex Rakowsky: And actually, a lot of our colleagues, for example, the clinic I'm at is usually two-attending clinics or it'd be one attending with the residents in, one attending just kind of work on their own. The second attending is now working on telehealth, so they're doing a lot of things by phone or by sort Zoom meetings with telehealth meetings, compared to where we would both physically be there.
And that's actually the case with some of our sort of community physicians as well, where they've relied on some of the telehealth resources just to kind of see some things by phone or by video.
Dr. Mary Ann Abrams: Alex, do you want to just clarify for our listener who may not know what an attending refers to?
Dr. Alex Rakowsky: Yeah, so an attending is actually sort of a senior faculty member. Or somebody who's actually finish all their training and now, they're actually working by themselves in clinic or teaching residents in clinic.
Dr. Mike Patrick: Yeah, great. I kind of envisioned the rest of this episode just kind of going through each age group and giving listeners a taste for what they can expect at a particular well checkup. So we're going to talk about babies and then toddlers moving to school-aged kids, and then teenagers. Just really emphasize the importance of these visits and the wide variety of topics that we talked about.
So Mary Ann, I'd ask you to say a few words on infants. Why are these frequent visits that we do so important and what can parents expect to learn during this?
Dr. Mary Ann Abrams: Yeah, we've talked about this a little bit earlier, but it's just really important because babies are changing and growing so rapidly. And there's so much going on in their bodies and in their brains and the fact that they're developing, basically learning growing just little baby doll type who's really just lazing and maybe wiggles a little to about by the end of that first year, they're able to walk and get around and get into things.
So their bodies are changing, their brains are growing, and their needs change over time, what they eat, and what they have engaged with their family and other people. So it's just so important to see them regularly again to encourage parents and tell them what a great job they're doing and to kind of point out what the next little things to look forward to are. Because that's always exciting to parents, especially for a first child to say, "Oh, it's not going to be too long before they're going to be able to start sitting up on their own."
We've said we're going to be able to catch problems that might be emerging early. And then, again, parents often have a lot of questions during that first year. As Alex referred too, some parents have questions about a lot of things, others may not. But if a question comes up, we want to be able to have a way to ask that.
Dr. Mike Patrick: Yeah, because babies don't come with instruction booklets. And there are volumes of instruction books that you can buy in bookstores and websites that you can find. And sometimes you get conflicting information. And you don't know, "Which do I believe? Do I believe what Aunt Suzy's telling me? What about my grandma? She did it this way, but someone else is telling me that?"
So you really need kind of a quarterback, or maybe it's really the coach to help you discern, well, which one I'm going to listen to, and which one am I not and what's the tiebreaking vote here?
And the person who really has dedicated their life to the health and wellbeing of children would be a good person to choose for that, especially when that medical provider is seeing lots of kids day in and day out and seeing the same kinds of questions and seeing all the different advice that parents get can kind of walk you through maybe what the best thing to do is.
So it's really having a real living resource right there in front of you and who doesn't want that when you really want to help your kids to grow up to be well and healthy.
Dr. Alex Rakowsky: And you give more instructions with your microwave or cellphone than you do for the hospital when you go home. And also, I like the fact that we have so many visits because we do encourage your parents to come in with holistic questions. And I'd like to encourage every parent out there, list the questions. But there is always a time limitation or parents will forget, or if you get to address something that the parents asked.
So you can always say, "I'll see you back in six weeks or see you back in eight weeks." So a lot of times, parents have a certain concern and then they'll see you back in two months. And they've taken care of that concern.
I think you've both conferenced with the parents as well that all of a sudden, "Oh, I have a concern about the feeding," and all of a sudden, "I've done a better job." Or. "I've done a good job." So I think the really often visits helps out of that a lot.
Dr. Mary Ann Abrams: And I think to your point, too, that there are just so many more sources of information now, many of which are not expert, but pretend to be experts, so all those things on the Internet and all those social media groups. And then, add to that, the comparing your life and your baby to everyone else's and people who have picture perfect pictures, well, it's never perfect, and that leads to second guessing.
And then getting conflicting information from well-meaning relatives and friends about how to feed your baby, you ask what common topics from that, feeding, feeding, feeding, sleep, safe activity, safety in general, and some of those developmental topics as well.
Dr. Mike Patrick: And immunizations really are at the forefront of a lot of parents' mind because there's so many of them and babies are getting them pretty much with each visit that they come in, maybe a little break there at the ninth-month visit. But what do you say to parents, Mary Ann, who say is this too many? Are we giving kids too many vaccines?
Dr. Mary Ann Abrams: I think that it's really important and I think we're going to find out how really important this is. And then, next year, so because of just the unfortunate side effects of the pandemic that a lot of kids are going to falling behind on vaccinations. And we're going to do what we can to catch them up because of them not coming in and cancellations and rescheduling, people are going to get behind.
But why is that such a big deal? We have such a really well-designed vaccination system. But the vaccines themselves are incredibly well researched to make sure that they are safe and effective. But on top of that, the schedule is designed so that we can protect those babies at the earliest point in their life as possible.
So each vaccine is carefully studied to know that starting at two months of age, the baby's body can start to respond to that vaccine and it's protecting against a serious or life-threatening disease that affects babies of that age.
Now, some vaccines may not start to work well for the baby till they're a year. And sometimes, that's just the product of baby's immune system and the way the vaccine works, or it may be because they still have some protection from their during mom depending on which infection we're talking about.
But it's a very careful well thought of schedule that it's time to protect babies as soon as possible. So that's why we give the diphtheria, pertussis, and tetanus or whooping cough vaccine as early as we do because it takes three doses at least, and that fourth one a little bit later, to really get that baby's immune system as protected as possible against whooping cough, which is a terrible, terrible life-threatening disease for infants, especially.
So that's one example. And what we do know too is that babies' immune system and all our immune system are able to manage multiple vaccinations at one time. And just like you go out the door, your body is affected by hundreds and thousands of different potentially infectious things. So these are relatively a small number and that they're carefully well-designed.
Dr. Alex Rakowsky: And I think it's important and you physically see more shots being given now. So if a grandparent comes in or even an older parent comes in, they'll remember getting one or two shots for them or for their child. And now, we're giving at some visits up to six shots. So at least what we try to do in our clinic is to kind of spin it around not so much the actual needles, but what's inside those needles.
And I think a big concern a lot of parents have is that, "My child is this almost like sterile, clean baby and you're injecting infections into them." But you'll actually get such a cleaned-out vaccine that you're injecting in very small amounts, what we call antigens which are these sorts of like small particles that your immune systems respond to.
I'd like to remind parents that having some bacteria in your body is normal. Your immune system's actually built to kind of recognize them. And you actually get more antigens or sort of little proteins into your bloodstream by just falling and scraping your knee than you get by your entire vaccine series.
And I think it's a legitimate concern, parents are concerned because they see such a large volume of needles coming the child's way? And they scream and they yell, and none of us like seeing your child screaming and yelling. So, you have to acknowledge that but also kind of reassure them that you're not giving huge amount of unsafe things, that we're designed to get those things.
Dr. Mike Patrick: And as pediatricians, we care about kids and we certainly would not be injecting them with something that we felt was dangerous. That by far and away, the benefits outweigh any minuscule risk that's associated with them. And I like what you said about all of the bacteria and viruses that we're exposed to in a daily basis.
And in fact, more of our cells in our body are microorganisms than they are us. And we talked about that a few episodes back on how our immune system works. And that always just, you start to think about that, the fact that there's actually more bacteria on me and in me right now that there is of me.
Dr. Alex Rakowsky: So when I make a mistake, I blame my bacteria for it.
Dr. Mary Ann Abrams: The bacteria that's at fault.
Dr. Mike Patrick: Yeah. Let's move on to toddlers and preschoolers. Alex, what topics are important during well checkups, during the terrible two's and beyond up until school.
Dr. Alex Rakowsky: I guess I don't really like to term terrible two because it's part of who you are. And it's essentially the big change in toddlers is, they want independence. And we're all designed to have a bit of an independent streak. So how do you actually channel that child's desire to be more on their own and do things on their own and yet not hurt themselves. Or how do you it in a constructive way?
So a lot of the focus of the 12-month visit, 15, 18-month, and the 24-month visits really tend to be on behavioral changes. Sleep, I think is by far the number one thing that's discussed in a lot of the toddler visits just because they'll fight the sleep. And then, it's sort of like how do I make sure that they sort of get to help pick out what they're going to eat but still get a healthy diet.
So sort of that balance to kind of help parents out. And there really is no easy answer, it's a whole topic on its own, but just kind of encouraging parents and kind of giving them some tricks that we've all learned through the years.
And then, the second thing is it's the time where children really develop, and we already talked in the past about health literacy. We've talked about developing language and the impact that it has on your life trajectory as far as school. So we really push the fact that the toddler brains are like sponge. They can learn a new language literally in two months and it will take me literally two decades to learn the same thing.
And they're designed to soak information. So how do you actually, as part of play which is how they learn, do you encourage them to learn new words, to run, to throw, to draw, to sing, etc? And making parents sort of proud of the fact that their child is developing and really an active part of their child's development.
I think it's a mindset change because virtually 15 years ago, where we kind of show where the child was and then we'll go, "Oh, this is bad," compared to now, we'll say, "This is where I like to see your child go in the next three months. And here are some things you can do at home to help encourage that part of development."
So I love to talk early years. I actually find those kids fascinating. They're little two-foot independent beings, so they can just do a lot of things, and they think they can do everything.
Dr. Mary Ann Abrams: It's the terrific two's, not the terrible two's, terrific two.
Dr. Mike Patrick: And in fact, sometimes, threes are actually a little, I will say worse than twos, but their independence just continues to grow. And then, they figure out ways to get what they want and it's not always pleasant.
Dr. Alex Rakowsky: And I think it's always important that we always talk about things like autism which is very important, that we talk about some of the more severe developmental issues. But a baseline or like just naturally, 8% to 10% of all kids are going to have a reading problem or a speech problem. And one of every ten kids are going to have a problem with speech.
So it's a common thing, but if you can actually catch it early and do some things at home and potentially go to speech therapy, from nine out ten of those children aren't going to have problems down the road. But if you don't catch them, then they're going to struggle in school. And some of the worst outcome had been in kids who go to school and get pegged as the slow kid, or the kid with a lisp, or the kid who can't read.
So I think it's vital as pediatricians to really notice these small problems, work on them, and have the parents really engaged in trying to get that child to develop as best as possible. Because a lot of these things respond to physical therapy or speech therapy remarkably well.
Dr. Mike Patrick: Yeah, very important. And again, if you're not going in on a regular basis to see your child's medical provider for these well checkups, these are the kind of things that might get missed. And I love all the questions, right, during the preschool years. All the questions, why, why, why, why? But it could really fun to answer those, right? I mean, that's really an opportunity. I mean, you're growing and engaging with your kids together, so important.
And then, in addition to language and reading, and development, and talking about screen time, and sleep and eating, and all these things, we also want to keep our toddlers and preschooler safe. And so, home safety also becomes a really important part of these visits, right?
Dr. Alex Rakowsky: We have some great episodes about the Safe at Home Program here at Nationwide, and then there's a lot of great resources out there. But toddlers are not suicidal, but they don't think about consequences. If there's something interesting in the toilet, they'll put their head in. Why not put a fork in the socket? Why not run into the street?
They just don't think about consequences. So I'm shocked that many kids survived, as urgent care doc and you do a lot of ER, as many kids survive toddler years as they do. Because most animals, usually by the time they hit toddler years, they're very good at knowing what not to do. I think toddlers are very good at realizing what's the most dangerous thing I can do and actually go and do it.
So part of it is just to kind of think like the toddler. And I usually recommend to families, just get down on their level, and if you can reach the screen door that goes outside at their level, they will open it. I mean, it's just their curiosity, it's their independence.
Dr. Mary Ann Abrams: Yeah, I would just add to that, that the infants and toddlers, their bodies and their growth and development are changing so quickly that parents may have everything perfectly childproofed and safety-proofed but in the blink of an eye, they've reached a new developmental stage. They've learned how to climb. They can reach something they couldn't reach. They can pull something that before they didn't have the strength to and now comes on top of them, all those things.
So that's part of that role of what we call anticipatory guidance, letting parents know to look for these things or coming down the pipe, get ahead of it. Put breakable things out of reach, make sure things are anchored to the wall. Make sure objects or grandma's or visitor's purses are up high, things that have medications in them because invariably kids explore, which is healthy and part of their normal development. But one of the ways they explore is by putting things in their mouth and present a poisoning hazard or a choking hazard, and all kinds of things.
So this concept again, anticipatory guidance. We provide guidance to anticipate or look ahead to see what is coming down the road and promote the good things, their stronger language skills, their interest in newer kind of books that actually tell a story not to show pictures, and also things that could be a hazard to the children.
Dr. Mike Patrick: And Alex, you'd mentioned we've done a lot of episodes on safety in the past. The good jumping off point would be Keeping Kids Safe, which was an episode that the three of us did last summer, when the world was quite a different place. That was Episode 436 and I'll put a link in the show notes for this episode, 465, over at pediacast.org.
Let's move on to school-aged kids. Mary Ann, what are some of the topics that we like to talk about during well checkups when these kids, kindergarten through middle school, kind of come in.
Dr. Mary Ann Abrams: Yeah, in addition to those kids still growing and developing, and their brains are rebounding in their ability to think and ask questions, all of that is continuing to grow in a positive way. But their world is also getting bigger. So now, they're starting to, they're going to kindergarten, they're going to school, so that whole world of new people, new friends, new relationships is in front of them.
School itself is a big opportunity and a big challenge. They may be on middle sports team where they have to learn how to take turns and take coaching and work as a team over time. So their world is getting bigger. They're exposed to more things. And our job at that point is to help the parents and the child navigate that well.
So in addition to healthy nutrition, healthy activity and safety, we really want to look at things like school, kindergarten readiness, which is something that we've worked with them from early days, looking and sharing books together, looking at books together, telling stories, reading together to help them reach school, ready to loving books and then ready to learn.
And then navigating through school to see if they have any problems with learning disabilities or language issues or reading problems. Because we really want them, by the time first grade comes around to be able to shift effectively from learning to read to reading to learn. And if they're still struggling with reading at that age, then it's going to be even tougher. So again, all that time, we'll be looking at those pieces as well.
And they're going to start to be making more of their own decisions and start to be able to manage more of their healthcare. They should be able to brush their teeth couple times a day and to start answering simple questions from the doctor.
So not just mom or dad answering all the health questions, but we should start to talk to them as they get their second, third, fourth grade. "Tell me what you eat for lunch at school. Tell me what you like to do after school. Tell me what your favorite class is." All those things are a part of how we learn how they're doing.
And then, because the world is getting bigger, we do get some vaccines as they enter school. Boost their doses to make sure they don't get whooping cough and bring it home through a younger sibling or get it themselves. Measles dose to make sure that they're really, really protected from measles and mumps and rubella and chicken pox, too. So there's a whole lot of topics that are important and remain important through their school years.
Dr. Mike Patrick: And who knows what questions any of us are going to have when the new school year get started as it relates to our school aged kids. Because we don't really know for sure what the school year is going to look like and it may be different from one region of the country of even one suburb to another suburb within the same city. There may be quite a bit of differences on what school looks like this year.
And sometimes, in these visits, there's not always a right or wrong answer to many topics, right? I mean, you're really, as pediatrician, helping parents navigate in thinking about risks versus benefits of any decision because things aren't always clear cut. And sometimes our job is just to sort of be there to support parents and say, well, let's think about what are the good things about doing something a certain way? What are the bad points? What is your family's tolerance for risk?
Just an example, parent may ask their pediatrician, is it safe for my kid to be in daycare right now? It's not the same answer for every single family that's nuance and our job as pediatrician is just hoping parents kind of walk that path of making that decisions. What do you think of that, Alex?
Dr. Alex Rakowsky: I actually want to sort of expand on that because it's not only the answers are not going to change but also the questions that we get. So there is, like Mary Ann mentioned, a series of questions that we should be asking every family. What do they eat? How do they sleep? How's school, etc?
But then, every family by this time is going to start to having a different approach or a different life. And the questions then may veer a certain way. So we have family that does a lot of activity, so they do like the athletic school, they play hockey. So the question is really spent on how do I get a healthy meal on the travel hockey team?
Or is it okay for my child to be speaking three languages? Is that going to hurt his development or help his development?
And I may not go to get that question at all from another family that may be more focused on "My son's struggles because he's an introvert. And my daughter's an introvert. And they actually enjoy being home. How do I actually make sure that they don't enjoy it too much because when school does eventually reopen in 2025, we may need to sort of make sure they have social skills?"
So I think there's a series of questions. Again, I think this is why school age visits are so important. And you really want to have the parents kind of think, well, what's specific to you? Something that they try to teach the residents is go through the questions that you see there because you got to leave some time behind for both the child and the parent to kind of start asking you questions.
And I agree, a lot of the answers will, there are some answers that are always correct for everybody. Don't go drink and drive. Get your vaccines. But then, there are some things that really vary depending on what the family circumstances are.
Dr. Mary Ann Abrams: And sometimes, just providing some guided questions to help them solve the problem themselves because there may be a question and we would answer it one way. But we don't know the circumstances. We don't know what they have at hand. We can't make those direct recommendations. But helping them recognize the assets they have in their own life or ways that they can deploy things, circumstances to help their child or their family.
An example might just be, "Well, how can I get my child to be more active when it's either cold or bad weather or unsafe or whatever?" And just sometimes shifting the perspective like with dance. Dancing is great exercise and everybody's got some source of music. And how can you use dancing whether your kid likes to do it on their own or have a little family dance party or TikTok whatever to use that as a bonding as well as physical activity, that working in partnership, not just putting a list of to-do's.
Dr. Alex Rakowsky: And I think it's also important because we're sort of spoiled with well child visits being so often the first two years of life, that if a parent has questions, we will see you back in two, three, max six months. Compared to well child visits in school where some insurance companies are covering every other year. And it's really, the one main regret I have as a general pediatrician, I love general pediatrics, is you always feel a rush with the seven-year-old visit or the nine-year-old visit because you can literally spend an hour just sitting down with family just discussing things.
So I've become a big sort of believer in having like we have something called MyChart here, but something similar where if I could just email you. Yes, you have to do it after your session is over, but I love getting those questions back as they go, "I want to bring this up but we only had 20 minutes together, but he strains every so often if he's pooped." Or, "How much salt is a good amount?"
Again, something to kind of encourage parents, come in with list of questions. We may have to sort of prioritize them, but feel free to reach back out and we can always set up another appointment. But I wish we have more time for these visits because there's so much to cover in the school-aged kids. I think we just tend to say, "Oh, you're a healthy fifth grader, see you later." It's just fascinating ages.
Dr. Mary Ann Abrams: And if people have the ability to a quiet relatively private encounter, that's where sometimes telehealth, telephone, but preferably a video visit can be so helpful. It's a less of a need lay hands on... We'd like to do a physical checkup at the well child visit if there's a follow up like Alex just referred to, sometimes we could have a quick conversation over the phone, help put parents' concern to rest, and then sometimes it helps them identify a solution. That's a great way that telehealth could be added.
Dr. Alex Rakowsky: But parents really should feel empowered to help us out through some magic list of questions I have to get through. Now, I'm going to ask you some basic questions but I'm really, for those visits here, to answer your questions. I love when parents come up with list of questions. And you have to be honest with what you can answer and how many, but I think it's important for parents now, "This has really been bothering me. I don't want to see you maybe the one time this academic year or this calendar year."
Dr. Mike Patrick: So yeah, really, really great information. And one of the things that you said, Alex, that really struck a chord with me was just the whole in-between those well checkups, especially when they're a year apart, to utilize MyChart when you have questions. And from a patient standpoint, I was very hesitant to do that with my own doctor because I think just the natural inclination that all of us have, not as medical providers but as patients, on the patient side of it, is that our doctors are busy. And they're seeing so many people and they're sick enough to be in the hospital and my little question isn't important enough.
But then, my provider said reaching out to me through MyChart as the patient when I had lab results come back and make a little comment about it, or she may say, "Hey, how's your blood pressure's doing?" Just out of the blue and through MyChart.
And so, that started to give me more permission to, if I did a question and my wife has been the same way, to reach out and ask a question, knowing it may take a couple of days before you get a response back if it's not an emergency. But it really is a great way to keep in touch. Do you find that that there are too many of those, Alex?
Dr. Alex Rakowsky: This time, no. I have family medicine colleagues who will say that getting 100 MyChart messages can be a little overwhelming. But there are some practices that will actually have some release time to kind of get to those messages. I think in pediatrics, parents tend to be pretty open about not asking many questions.
But I'd much rather get a question, I'd probably spend 15 minutes in a full day on MyChart. And in my head, I can easily spend maybe half an hour on MyChart. And that's answering probably up to ten questions. I'd rather answer those and have somebody go on the Internet. If somebody once said, I'm not a real doctor but I play one on the Internet. So the parents are going to get bad information potentially, so I'd rather be the person that kind of helps. Plus, it builds the relationship.
And a lot of times, once you know a family, they may be in there for flu-like illness. Now, they trust you enough that they say, oh yeah, we talked about the constipation three months ago, waiting for the flu swab. Can I ask you a follow-up question on that? And it builds relationships, and there's a lot to be said for some relationship building between the families and the doctors, which I think we've really lost as a medical system in general.
Dr. Mike Patrick: Let's move on to teenagers and young adults. Alex, what's important at these visits? I think these are the ones sometimes that really fall through the cracks. You get kids to high school especially if they're healthy, if they don't have any chronic underlying illnesses, it's easy to let the yearly well checkup slide. Or if they're involved in sports, you say, "Well, they have their sports physical, that's good enough." But no, these are really important times for us to keep in touch and help these kids out, right?
Dr. Alex Rakowsky: Yeah, and this is one I got both of the independent age groups, the toddlers and the teens. But this is a time where kids become adults. And they will be doing some things that the parents and the teens really need guidance upon. For example, driving, alcohol, drug use. For example, right now, we have teenagers in clinics say marijuana say is completely fine to take. And we know better that there are some potential long-term consequences.
Also, a lot of behaviors just come up. And there have been a couple very well-done studies that about one in four teenagers are going to have some sort of anxiety at some point during high school. And that's a staggering number. But if you actually look at that data, nine out of ten of those kids with proper management, most likely at home, or if you're counseling at school, do fine. But if you don't catch then, they may become that 10% that will struggle with anxiety forever.
So it's important to kind of really dig down besides just sex, drugs and rock and roll to "Who are you?" "Tell me your struggles," "How are you doing in school?" "What do you plan to do with your life?" And kind of help guide the teen, but when you're out with the parents, you're also having the parents involved to help guide the teen as well.
Because I think a lot of times, the parents either tend to be too sort of like "He's a teen, they can do whatever they want." Or they're too strict. And you almost have to help set that line between, "This is going to be an adult in the next couple of years. Let's work on this together." So these are really important visits, especially for mental health reasons. And you see tons of it.
Dr. Mary Ann Abrams: As I have said earlier in those school years, it's important to start asking kids sort of general questions about their health so that they can become their own spokesperson and advocate for their own health, as they enter those teen years and become adult. So all those things that Alex just talked about, it's important that during those teen visits, we ask the parent to step out so that we can talk privately with the teens themselves.
And to reassure the parents that this is part of their child growing up and helping them be a responsible grown up person for their health, it's not that you're having some big secret conversation. And reassuring both of them that if there's something very serious, reassure they'll encourage the teen to share as well and get the help they need.
Dr. Alex Rakowsky: And we tend to think of teens as being healthy, but if you look at the numbers, 5% to 7% have asthma, 3% to 5% still have ADHD symptoms and need medication. Three to 5% percent have some kind of chronic joint or muscle problem, 10% to 12%, 15%, 20% have behavioral issue.
So this is also a good time to start talking to the teenager about what do you want your health to look like. And I much rather have an additional five minutes with the teenager kind of trying to discuss how they feel about your asthma and taking a controller med and how to not seem like they're chronically ill and give it up on them, but this is why we're trying to keep you from getting a flare, than seeing them, Mike's an urgent care doc also, in urgent care for really bad attack and potentially having to get it admitted.
So I think another big important thing of the teen visits is to sort of try to figure out what the teenager views their future medical health and help guide it. And literally, every second or third teenager we see in clinic has some chronic issue, one sort of another. And they will be the ones responsible for it in the next year or two or three. So you almost have to start opening their eyes to the fact that if you don't take their controller med in college, you will get in trouble. And this is why you worry about it. And then some kind of acknowledgement on their part.
Dr. Mary Ann Abrams: And then, that help prepare them as they do eventually seek out an adult physician who would care for them as an adult to help them make that transition, especially if they have one of these conditions like asthma or heart problems or kidney problems to help smooth that transition. Because the adult healthcare system is often quite different.
And helping those kids and their families understand how to be stronger advocates for themselves in that setting and how it works, what to expect, what to look for, and things like health insurance, all those things are roles that we want to play as the kids reach late teens and young adult ages.
Dr. Alex Rakowsky: And it's also the issue of transition, like you mentioned, Mary Ann, to adult care. So one of our residents who's a MedPed, so she's training both the pediatrics and adult medicine, she's doing a whole project just looking at the transition period and how can she train her fellow residents on discussing this topic of teenagers. Because I think it's so easy to kind of see, I've always seen my asthma specialist for my pediatrician as a kid, how do I navigate a big adult hospital or a big many more options?
And let's face it, pediatrics is like 10% of the workforce, so the number of pediatric options in the town are going to be much smaller than adult docs. So how do I actually figure that out? How do we go to somebody I'm comfortable with?
And the topics she's looking at had been helping her a little bit and it's amazingly complex what, again, as pediatricians we tend not to think about, but somebody who has feet in both worlds sees that. And how many kids fell through the cracks and then she'll see him as an adult doc. And I think that's part of our job also, is to kind of let teens realize that soon, you're going to be on your own, so let's start discussing things.
Dr. Mike Patrick: And for those who want to hear more about transitioning your teenager to young adult...
Dr. Alex Rakowsky: You have a great one.
Dr. Mike Patrick: Yeah, Episode 402 is the one where we talked all about that, and I'll put a link to that in the show notes.
Dr. Alex Rakowsky: It's a must listen trust me.
Dr. Mike Patrick: It is definitely an important thing. And the thing is there are little things that you can do at a very young age to start getting kids involved in the care of their own health. And we talked about some of those things in that particular episode.
Well, we have a really fantastic Primary Care Pediatrics network at Nationwide Children's. Alex, tell us a little bit more about what you guys do and how many offices? I mean, I don't need an exact number, but you guys are all over the place.
Dr. Alex Rakowsky: So I have to tell you about our offices. So we have actually 13 offices, 6 of which train residents, 3 which train medical students. So we have 13 physical offices and then we have a mobile unit, and we have school health clinics. And then, we have some other clinics. And we have a clinic dash, we'll go to shelters to kind of help out as well.
So we upwards of 200,000 individual patient visits. So it's about 80,000 to 100,000 kids that we follow on. I'm going to get yelled at my division for not knowing the exact number, but it's-
Dr. Mike Patrick: It's a lot.
Dr. Alex Rakowsky: It's all over. It's almost a quarter million visits that we see in our system, so it's a large amount. And there's about 100 of us that work in the division of Primary Care, so it's the biggest division here in Nationwide Children's. And it's an honor because we're working with some kids who had a tough life and we see plenty of it. And we also see a lot, the clinic I'm at is 50% immigrant and there are days where I speak English maybe twice and everything else is with an interpreter. So it's a very unique kind of clinic system here.
Dr. Mike Patrick: And we'll put a link to Primary Care Pediatrics at Nationwide Children's so folks can learn more. We also have our Primary Care referral line. If you are in Central Ohio and you do not have a regular doctor for your kids, 614-722-KIDS is the number to call to get linked up with one of our pediatricians. And I'll put that phone number in the show notes for folks again over at pediacast.org.
Dr. Mary Ann Abrams: Since we're winding up or down, as the case may be, and I just wanted to add a few points because we really did talk a lot about the well child visits and vaccines today. And just a few tips for parents who may be concerned about their children being behind on their vaccines. First, we at Children's and other pediatric providers are really trying to reach out to kids who missed those vaccines and missed their well child visit.
But don't wait to be called. Feel free to call in and ask there if there are catchup vaccine schedules that kind of accelerate or move that doses a little closer together in a safe way that helps your child get caught up. So don't hesitate to check, you want to protect your children.
And if you've lost your health insurance, for some reason, maybe because of job circumstances in this time, there are programs that pay for vaccines or the vaccines for children program. So that you don't let the cost of the vaccine or the fear of the cost of vaccine prevent you from seeking those out.
And finally, flu season is right around the corner as well. And we know that it's going to be tough Fall because of flu, because of COVID, because of COVID and flu. So don't forget about flu vaccine and don't be surprised if it's recommended in the middle of August, and just keep your ears and eyes open to that. And at the end of the day, feel free to ask questions and make sure that you understand what we're telling you.
Dr. Alex Rakowsky: I'm glad you brought that up because I think a lot of parents, speaking as a parents, you use the beginning of the schoolyear as you're sort of "Oh, I should go to the pediatrician now." It's almost that mental tickler. Most parents will have a big sticky on their calendar saying, "Call Dr. Mike, set up an appointment."
So if we end up having a situation like we have in the Spring where kids are not going back to school, it won't get into a lot of parents' sort of like radar that I should call my pediatrician. And yes, we've been reaching out but, again, a plug to every parent listening is, follow your usual routine of getting a school health form or getting the vaccines caught up to date.
I'm good friend with somebody I trained back in Pennsylvania, where they're actually probably going to close the school district where she practices. And she's already saying that a lot of parents are, "Well, we don't have to go back to school so I don't plan to visit for a well child visit." It's almost like school mandates this. But there's so much more to the well child visit than just being mandated by school. Just to remind parents that if you don't go back to school, you'll still got a lot out of it.
Dr. Mike Patrick: Yeah, absolutely. And I'll put a plug one more time in for the immunizations because there are so many diseases. Like some of the diseases, you think about diphtheria. We don't see much tetanus here, things that are more distant from us today. But it wasn't that long ago when kids had a much higher rate of meningitis just from things like a Haemophilus influenzae and pneumococcus. And so bacterial infections that cause blood infections and meningitis and killed lots of kids that are very easy to prevent today with vaccines.
And so, there's a lot of kids living today who would have died a generation ago with many of these diseases. So it's not just illnesses that you read about in the history books. There are some real things that weren't that long ago that we still need to protect kids from.
Dr. Alex Rakowsky: I'm not that old, but I remember and we're all about the same age, I guess I'm the oldest. But when I was training as a resident, it's literally every time you're on call, every third or fourth night, you're admitting a child with meningitis, just considered part of pediatrics. And nowadays, we have a resident where he saw a meningitis case couple of months ago, and the resident was like "Oh, my gosh, we saw a meningitis case."
It was like we saw a zero for purple head. And it was like something so unique. And we were like whatever because we were seeing this literally three to four times a week. So it was huge change. And I think people tend to forget that it's not that long ago, or maybe it is.
Dr. Mary Ann Abrams: Well, those vaccines are the ones that are given to infants and early toddlerhood. So we're not talking about something that all, obviously, older kids can get that meningitis as well, there are meningitis vaccines for older kids. But as Mike mentioned Haemophilus influenzae and pneumococcus, those are out there and if the kids are falling behind because of missed well visits, it's really, really important to get those caught up.
Dr. Mike Patrick: Yeah, absolutely. You're right, that's not even the meningitis vaccine that we're talking. When we say meningitis vaccine, we're not talking about those, those are also meningitis vaccines.
Dr. Mary Ann Abrams: And they're scary in that.
Dr. Mike Patrick: So, Alex, you are the oldest. I'll let you clean up.
Dr. Alex Rakowsky: No, thanks. At least I remember it, so yeah.
Dr. Mike Patrick: All right, well, it is always a pleasure and a joy when our Pediatrics in Plain Language panel joins us. So Dr. Mary Ann Abrams and Dr. Alex Rakowsky both with Primary Care Pediatrics at Nationwide Children's Hospital. Once again, thank you so much for stopping by.
Dr. Alex Rakowsky: Thanks, Mike.
Dr. Mary Ann Abrams: Great to be here. Thanks.
Dr. Mike Patrick: We are back with just enough time to say thanks once again to all of you for taking time out of your day and making PediaCast a part of it. Really do appreciate that.
Also, thanks to our guests this week, our Pediatrics in Plain Language panel, Dr. Mary Ann Abrams and Dr. Alex Rakowsky, both with Primary Care Pediatrics at Nationwide Children's Hospital.
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