17 thoughts on pediatric practices

January 1, 2019

Here are some various observations that have guided my own pediatric practice over the years. Perhaps they will help you with yours.

1. Heat can affect newborn metabolic screening tests, especially galactosemia,1 which would go along with my impression that false-positive tests are more common in the summer.

2. Would “head-to-head” really be the correct description of a study comparing diaper creams?

3. Parents often do not distinguish between the flu and “stomach flu.” This is not just of academic interest. For example, parents often assume that flu vaccines do not work because their child later had an intestinal virus. Please do not use the phrase “stomach flu,” and when you hear parents use it, gently educate them about it.

4. I believe the first shot hurts the most, so from a pain point of view alone, it is better to get 3 shots in 1 visit rather than spacing them out (which would mean 3 “first” shots instead of 1).

5. If I were to try to compare unpleasant sensations, I would consider nausea much worse than pain.

6. Along those lines, there have been, of course, many advances in outpatient pediatrics in my 40 years. Of these, my favorite, even more than vaccines and ceftriaxone, is perhaps ondansetron, particularly the oral-dissolving form. This works so much better, with fewer adverse effects, than the rectal phenothiazines we used to use. Besides relieving suffering, it helps keep children out of the emergency department (ED) and inpatient ward. I have a low threshold for prescribing it.

7. Physicians do not always understand how discount coupons work. For example, suppose you have to choose between a generic epinephrine with a $20 co-pay that costs the insurance company $500, and one with a coupon where the manufacturer pays the $50 co-pay but the insurer is charged $2000. The parent saves money with the coupon, but the insurance company and ultimately all the subscribers pay more. Remember this the next time you are tempted to use a coupon for what might otherwise not be your preferred medicine.

8. For many illnesses, before I examine a child, after the history, I will tell parents I have whittled the diagnosis down to 2 choices, which I will then narrow down to 1 before they leave the office. I also indicate what the treatment and expected course will be, depending on the outcome. For example, I will tell the parents that either their child has strep, or they don’t. Then, when the test is negative, they already have been informed that no antibiotic will be needed.

9. Possible thrush, which looks like a dusting of powdered sugar on the tongue, does not need to be treated. I wait until it looks more like cream cheese or spreads beyond the tongue.

10. For most diarrheal diseases, one can rehydrate with the child’s preferred beverage and not a more expensive, less tasty electrolyte solution (even apple juice).2

11. Does everybody with a nonanaphylactic food allergy need to carry epinephrine around? It would be great if there were a way to determine who does and does not require one.

12. A good guideline for parents about deciding to go to the ED is the following: If they do not feel the need to call 911, they probably have time to call their pediatrician first to help decide.

13. Having recently seen yet another child who was rushed to the ED for a fever of 104°F, despite my having educated the parents otherwise, I think families would be better served by having a thermometer that only went up to 102°F as the highest reading, and one would need a medical license to use one for recording above this cut-off.

14. Concerta capsules do not dissolve; they work on a piston-like mechanism, squeezing the medicine through a hole in the capsule. Parents will sometimes see the capsule in the stool. This is normal.

15. Unless you are sorely pressed for space, let mothers breastfeed their babies in the examining room after a visit. This will make for a happier baby, and thus mother, on the ride home.

16. Experts are vague about how long to quarantine a child with hand-foot-and-mouth syndrome, but a general rule they give is that a child can go back to daycare when afebrile and behaving well. Since the disease is generally benign, that is the guideline I follow, rather than waiting for the rash to be gone.

 

17. Often we “do nothing” when we see a child, in the expectation that a condition will resolve on its own. This is more palatable to a parent if we attach a plan to it. For example, if a well-looking child presents with a 5-day fever that I think is viral, besides explaining that to the family I tell them to give it 3 more days, and if not improving, they can call back and we will probably order some lab work then.

References:

1. Adam BW, Flores SR, Hou Y, Allen TW, De Jesus VR. Galactose-1-phosphate uridyltransferase dried blood spot quality control materials for newborn screening tests. Clin Biochem. 2015;48(6):437-442.

 

2. Freedman SB, Willan AR, Boutis K, Schuh S. Effect of dilute apple juice and preferred fluids vs electrolyte maintenance solution on treatment failure among children with mild gastroenteritis: a randomized clinical trial. JAMA. 2016;315(18):1966-1974.

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