Celebrate with these tips to freshen your practice.
DR. BENNETT is a clinical professor of pediatrics at George Washington University Medical Center, Washington, D.C. He is the author of Waking Up Dry: A Guide to Help Children Overcome Bedwetting, published by the American Academy of Pediatrics.
Is follow-up always needed for corneal abrasions?
The standard recommendation for corneal abrasions is to see patients the day after the diagnosis and to repeat the fluorescein test to ascertain that the abrasion has healed. In my experience, most abrasions are small, and 95% are completely healed by the time of the follow-up visit. Moreover, I have never found a residual abrasion in a child who is asymptomatic. Consequently, my current approach is to call parents the morning after I see the patient. If the child has any symptoms, I schedule a follow-up visit to reassess the eye. If not, I have the parent watch the child and call immediately if anything changes during the day. If the abrasion is large or the patient is difficult to assess-an infant or developmentally handicapped child, for example-I always do a follow-up examination.
Most patients with diarrhea have viral gastroenteritis that does not require lab work, but sometimes you must rule out a bacterial or parasitic infection. Collecting a stool specimen during an office visit can be difficult because it is hard for a child to produce stool on command and because the child may be embarrassed to do so.
You can avoid the problem by asking parents to bring along a stool specimen when they bring their child to the office for significant gastrointestinal symptoms. (Your office staff can make this request when scheduling the visit.) Remind parents not to scoop the stool out of the toilet and to keep the sample in the refrigerator until they leave for the appointment. If it turns out that you don't need the specimen, you can dispose of it easily in the office.
Pet funerals minus a pet
When a pet dies, parents often want to give the animal a funeral so their children can memorialize the pet as a member of the family. In many parts of the country, however, local laws prohibit burying a pet because animal burials attract scavengers such as rats. In these jurisdictions, the family's veterinarian disposes of the body.
Because I practice in an area where animal burials are not allowed, I encourage families to go ahead and hold a memorial service but bury a memento instead of the pet. Children can pick a favorite toy, a picture, or even write a poem or heartwarming anecdote about the animal. This approach permits children some closure regarding the pet's death while obeying community rules.
Ask about bedwetting at routine visits
When giving anticipatory guidance at well-child visits, we rely on parents to raise areas of concern. Unfortunately, when it comes to bedwetting, it turns out that parents do not usually ask for help. A recent study (Dunlop A: Clin Pediatr 2005;44:297) found that although 82% of parents want health-care providers to discuss bedwetting, most feel uncomfortable initiating the conversation themselves-and 68% said their child's doctor never asked about bedwetting at routine visits.
In my practice, starting at 4 years of age, I ask parents if their child is wet at night. This approach not only lets me follow the child's progress but opens a dialogue so that I can teach parents about the natural history of nighttime bladder control. It sets the stage for future treatment of bedwetting and helps prevent punishment of the child because parents are uninformed about the condition.
The trouble with retractile testes in ticklish kids
Retractile testes are a common finding before adolescence. Textbooks suggest having the patient squat during examination to "bring down" the testes so they can be palpated in the scrotum. This maneuver works for most patients, but some children are so ticklish that you can't examine them in any position. In that case, I ask the parent to examine the child's testes carefully while the child is taking a bath. This works because the warm water stimulates the testes to descend into the scrotum and the child is less ticklish when his skin is wet. If this procedure doesn't work or I'm not confident that the parent can carry out the examination, I refer the child to a urologist.