As summer sneaks up on us, it’s important to recognize that children typically have more outside play time, less structure and more exposure to health related risks. Here are a few things to keep in mind.

1. Sun Exposure: Sunshine is a great source for vitamin D, but fair skinned children need only 10 to 15 minutes of face and arm exposure midday for natural vitamin D intake. After that, sunscreen is needed for protection against skin cancer and sunburn. Apply sunscreen with SPF of 15 or more, 30 minutes pre-exposure and every 1½ to two hours while outdoors. Loose, light clothing and hats should be worn and try to limit exposure from 10:00 am to 4:00 pm.
2. Heat Related Illness: Children are more susceptible to heat related illness than adults. Risk factors include high temperature and humidity (during monsoons) during activity. Intermittent rest, drinking water (as much as six to ten ounces per hour) and eating some salty food (if children are active for at least an hour) are important for prevention. If cramps or symptoms such as nausea, dizziness, and weakness occur then immediately provide rest, cooling, cool fluids and salty foods or sports drinks.
3. Water Safety: Supervision is key. Lifeguards, swim partners, life vests, and swimming lessons beforehand are all good strategies.
4. Injuries: We encourage active play, sports and fitness as all lead to good health. But if unsupervised and without protective equipment, injuries are more prevalent and serious. Require children to wear helmets and appropriate body protection for all motorsports, bicycling, scooters and skateboards. Diligently enforce trampoline safety with supervision and nets. Guide their activities and lead by example to prevent the “hey watch this one” risks, especially with motorsports.
5. Toxic Exposure: Every summer we see toxic plant rashes. Poison ivy, poison oak and poison sumac grow best in moist areas near streams and water sources. Everyone should be wary of reaching, stepping or jumping where they can’t see to avoid rattlesnakes and other poisonous creatures.
6. Infection: Injuries, wounds, or any skin break can become infected. Ingested infectious agents from water or food can also lead to illness. Warn children to not drink stream or lake water and take precautions to keep food cold until eating it.
7. Staying Safe: Know where your children are and who is supervising them. Advise them to stay in groups, public places, be alert to loitering strangers and to not accept rides from anyone they don’t know. Discuss safe touch with your children – even by family, neighbors or others they know. The best practice is prevention and reducing scenarios for molestation.
8. Screen Time Supervision: In order to promote exercise and broaden your children’s experience, it’s wise to limit screen time (TV, computer, video games) to two hours per day or less. Likewise, keeping TV and computers out of children’s bedrooms and only in “public” areas in the home allows for better control, supervision and sleep.
9. Healthy Food Choices including Plenty of Liquids: Five servings of fruits and vegetables along with one hour or more of exercise daily is a great combination to help prevent childhood obesity. Our “dry heat” requires plenty of water intake, and don’t forget the electrolytes!
10. And Lastly: Remember to schedule you child’s sports physical and/or yearly medical check-up, including immunization updates, earlier in the summer to avoid the rush in late July and early August.

No matter how diligent we are with prevention, illness and injuries happen. Ponderosa Pediatrics maintains morning walk in hours from 7:45- 9 a.m. Monday-Friday, from 4-7 p.m. Monday-Thursday and sick appointments every Saturday morning. We guarantee same day appointment availability. During summer months, we accept new patients during walk in hours, so costly and time consuming trips to the emergency room can be prevented in these not emergent situations.

“I believe that as parents, we need to set an example by what we do. It doesn’t matter what we say if we don’t set a good example.”

-Jeanne Gibian, Pediatric Nurse Practitioner

When families do things together that are active and stimulating, children are more likely to make better choices for themselves. These local family day trips facilitate discussion, learning and exercise, cost less than a movie and support healthy living.

1. the spot….a Child’s Museum is at Prescott Gateway Mall and is open every Friday and Saturday from 1-5 p.m. With activities designed to be done as families, a trip to the spot is a perfect way to help your children with problem solving, exploratory and other critical thinking skills while having fun. Their Facebook page and website list special events (April 13 is Science Café) and everyday admission is only $3 per person. You can’t just drop your kids off…the spot is a family activity! (www.thespotmuseum.org & on Facebook)
2. Highlands Center for Natural History is on Walker Road before the first entrance to Lynx Lake. Per their website “The Highlands Center helps children and adults discover the wonders of nature and become wise caretakers of the land.” Their classroom without walls includes a three mile nature trail perfect for family hikes. Combine the trip with a picnic at Lynx Lake and it’s a great family day out. The Highlands Center also offers many children’s activities and camp adventures. They operate on a donation basis, but have memberships and special events at reasonable rates. (www.highlandscenter.org & on Facebook)
3. Yavapai College Nature Trail & Sculpture Garden are fun add-on activities for Saturday morning trips to the Prescott Farmers Market. Located on the Prescott Campus, the Nature Trail is 1.5 miles long, has some climbing and takes about 45 minutes to walk. Included on the trail is the Sculpture Garden with several local artists’ work including wind sculpture and a water feature. Parents please supervise your children. Sculpture is to observe and enjoy, and is not a playground for climbing. Combine getting healthy foods, a family hike and cultural education in one trip! (Sculpture Garden: http://goo.gl/UvByF; Nature Trail: http://goo.gl/DNdrB; www.prescottfarmersmarket.org)

Please share your favorite family adventures by making a comment on the Ponderosa Pediatrics blog (www.ponderosapediatrics.com) or on our Facebook page (www.facebook.com/ponderosapediatrics).

Considering the wide variety of marketed products and confusing information on vitamins and supplements for children, it may be difficult to make sense of what is recommended at what ages and for what reasons. Thankfully, we have excellent scientific data and standardized recommendations by pediatric experts such as the American Academy of Pediatrics to help guide us. This article covers some of the specific nutritional concerns for children and summarizes current recommendations to help make the best choices for ensuring optimal nutritional health for your child.

Vitamin K
Vitamin K is used to form clots in the pathway that help stop bleeding. Newborns don’t have enough vitamin K at birth and may be at risk for bleeding until they are three months old. Newborn infants need an injection of vitamin K shortly after birth to help prevent potentially life threatening bleeding problems. After this neonatal period, vitamin K is made by bacteria that live in the intestinal tract and can also be obtained by eating foods such as spinach, kale and other green leafy vegetables.

Vitamin D
Vitamin D is involved in healthy bone formation and maintenance, function of the immune system and can help prevent other diseases. Infants with adequate vitamin D levels show a lower risk of childhood diabetes, and sufficient vitamin D intake later in life lowers risks of multiple sclerosis, rheumatoid arthritis and certain types of cancer (breast, ovarian, colorectal and prostate). Vitamin D is available naturally in the diet via fatty fish and fish oils, as well as egg yolk and is added to cow’s milk and cereals. Small quantities of vitamin D are present in breast milk and formula, and it is made in the body when exposed to sunlight. In infants, research shows that these sources do not produce adequate or stable vitamin D levels. As a result, vitamin D supplementation is recommended for all infants starting in their first month. The dose is 400 IU (International Units) daily and is available over the counter and via prescription. For children one year and older, the recommended daily intake of 400 IU is typically met through normal dietary intake and sunlight exposure. However, children with diet restrictions may require vitamin D supplementation.

Iron
If iron levels are too low, the child is at risk of developing anemia. In purely breastfed infants, the iron stores present at birth gradually decrease over the first three to four months. Breast milk does not contain enough iron to replenish these supplies. Adding an iron fortified infant cereal twice a day between four and six months is recommended. Otherwise, iron drops or multivitamin with iron drops may be prescribed by your pediatrician. Iron intake is typically adequate with a normal diet after six months. Iron is present in the diet via meats, fortified cereals and grains, soy products, beans and spinach.

Calcium
Calcium’s most notable role is related to the maintenance and formation of strong bones. Inadequate calcium intake during early childhood can affect skeletal development, lead to low calcium in bones and increased risk of broken bones or osteoporosis later in life. The pre-teen and teenage years are the most important for calcium intake when the majority of calcium is deposited into bones. Calcium is present in formula and breast milk, dairy products, certain vegetables and is fortified in other foods such as cereals, soy milk and orange juice. Go to http://bit.ly/xeJW0M for a table with calcium contents of common foods.

Infants and younger children typically meet their calcium needs via a regular diet with two to three servings per day of yogurt, cheese and milk. Children who have restrictions on dairy intake may meet calcium requirements by eating fortified foods or calcium containing vegetables, or may take a daily multivitamin with calcium supplement. Children from nine to 18 have need 1200-1300 mg per day. This may be met by three consistent servings of a dairy product daily as well as varying amounts of other fortified foods or calcium containing vegetables, but a calcium supplement may be needed where dietary calcium intake is inconsistent.

Other vitamins and supplements
Most healthy children with diets consisting of a wide variety of fruits, vegetables, grains, dairy products and legume (beans/lentils), and protein sources should not need supplementation except as described in these two articles. Doctors identify dietary deficiencies via routine screening and recommend supplements in specific instances. A standard children’s daily multivitamin is generally considered safe for children over one year of age and may be recommended by your pediatrician.

For links to reliable sources of children’s health information, go to www.ponderosapediatrics.com.

Dr. Eckman is a board certified pediatrician who completed her pediatric residency at Phoenix Children’s Hospital in June 2010. A Yavapai County native, she joined Ponderosa Pediatrics in October 2010.

This workshop is designed for parents, educators, students and community members. It focuses on the nature of bullying and aggressive behaviors in childhood from ages 2 – 12. This workshop will give insights to the behaviors and strategies to prevent and/or reduce the impacts of bullying.

This is the 4th in a series of workshops being offered through collaboration with Prescott Unified School District, Community Counts and First Things First and is contributing to Prescott College’s Diversity week, February 21 through 24, 2012.

Presenter information:

Beth Dunn earned her B.A. in Psychology from The Catholic University of America in Washington D.C. and her M.S. from St. Cloud State University in Minnesota. Over the last 22 years, she has worked in residential treatment centers, as an in-home therapist, in a community mental health clinic, and as a private clinician. Beth’s work focuses on the treatment of children with early childhood trauma and assisting children and families with relational skills. Beth’s current work focuses on working with children/adolescents within a school setting providing counseling, social skills groups, divorce groups and bullying response programs.

Wendy Watson, M. Ed. is Early Childhood Faculty at Prescott College. She has worked with young children and their families for over 25 years through the YMCA system and Head Start. She operates her LLC, A Delicate Xplosion, which is committed to facilitating workshops for parents and teachers on a broad variety of topics dealing with Early Childhood. She is one of several Love and Logic facilitators in Yavapai County.

To help parents and guardians who need to leave a child in the care of another adult, we have created a form consistent with the Arizona Revised Statute (A.R.S. 14-5104) which states: A parent or a guardian of a minor or incapacitated person, by a properly executed power of attorney, may delegate to another person, for a period not exceeding six months, any powers he may have regarding care, custody or property of the minor child or ward, except power to consent to marriage or adoption of the minor. This new form can be found on the Other Forms page (http://www.ponderosapediatrics.com/forms/other-forms/). For the Power of Attorney form, click here.

We’ve also added a simple Revocation of Power of Attorney in case the parent/legal guardian want to remove these rights (Click here for the form). Power of Attorney is the simplest way for a parent to authorize others parental rights and responsibilities. Per law, the maximum period this can be valid is six months, so if the expiration date is left blank, we assume the maximum legal period of six months. If the parent wants to extend this for a longer period, a new form must be completed for every six month period.

This does not relieve parents from their legal responsibilities, nor does it assign those responsibilities to the person designated. It is designed to allow parents to leave their children in the care of others for a period of up to six months. Other documents, typically associated with Superior Court proceedings, can authorize temporary or permanent guardianship or custody. Adoption is typically done through the court system as well.

We see this form helping in a variety of situations, but we are not experts in family law, so consult a lawyer if you have questions. Here are a few of the scenarios we see:

1.    Parents are taking a vacation for a few days or weeks and are leaving children in the care of a friend or family member. (Copays, payments for service and coinsurance still need to be paid at the time of service, so parents need to ensure methods of payment in the event services are needed.)

2.    Parents have personal medical, emotional or other reasons that they cannot fulfill responsibilities for a short period of time and ask for family or friends to help. Unfortunately, we see this when parents separate and their ill feelings toward each other impact their influence on children or they cannot functions. Other reasons are substance abuse programs or mental health in patient programs. As long as the person granted Power of Attorney is a competent adult and consents, this can be used for up to six months.

3.    Separation due to incarceration. If the parent in prison or jail for up to six months, this form can be used. Recently, we received a Yavapai County Jail form for a baby whose mother was in jail at the time of birth. If parents are incarcerated for extended periods, temporary or permanent guardianship or custody through the court system is advised.

As we learn more, we’ll attempt to provide processes and forms to help. For instance, as we understand Arizona law, step parents have no rights for their step children, and to permit step parents decision making ability, both birth parents need to consent. We know this can be problematic in cases where the step parent is not liked or trusted by the other parent
Our job is to take of and protect children to the best of our ability and consistent with the law. We only ask questions and look for authorization for that purpose, not to be troublesome! If you have ideas, forms, resources or other thoughts you’d like to share, please let us know through Facebook comments or blog article responses. Please do not disclose protected health information if you make any type of public post! Thanks.

When I was in college, I remember a professor making this statement about a problematic student, “I don’t believe in ADHD, but she has it!” That sums up what many think about this psychiatric condition; they don’t believe it’s real, yet they know when children have behaviors consistent with it. I hope to shed some light on this intriguing condition and review some of the ways we try to help children and their families.

The acronym ADHD stands for “attention deficit hyperactivity disorder.” The name is a pretty good description of the symptoms, that is, some people with this condition have problems paying attention, some have problems with being hyperactive/impulsive, and most actually have problems with both attention and hyperactivity. It is a common disorder as psychiatric conditions go with up to eight percent of school age children meeting the diagnostic criteria.

Typically, children with ADHD struggle with school, forget to do (or turn in) homework, take much longer to complete assignments, and in general seem disorganized. They often get in trouble at school and at home. They “bounce off walls” and seem to have excess energy that drives them to constant motion and activity that the Energizer Bunny would be hard pressed to match! There can be a high degree of stress in the home attributed to these symptoms. ADHD can co-exist with other conditions like bipolar disorder, depression, oppositional-defiant disorder, etc.

A proper evaluation for this condition is one that takes into account both parents’ and teachers’ impressions of the child.  Children should also be assessed for other problems, both mental and physical that can cause or mimic the symptoms.

Fortunately there is hope for children (or adults) with ADHD. Behavioral therapy, done by trained therapists, can be helpful. There are also well studied and very effective medicines that can be used. These include stimulant medications as well as non-stimulants. While medications are not for everyone, if they are used wisely and in the right setting, they can make a huge difference.

If you have questions about ADHD or are concerned that your child may suffer from this condition, talk to your doctor about it. It may be one of the best things you can do for your child.

Dr. Matt Hinton is a Prescott native and board certified pediatrician. He graduated from Prescott High School and went to Yavapai College before completing his undergraduate degree at Brigham Young University. He came “home” to care for the Quad-Cities children after completing his MD at the University of Arizona. More health information and links to reputable sources can be found at www.ponderosapediatrics.com.

It’s that time of year again – the holidays! It is also flu and RSV season. Both influenza (the flu) and RSV are viral infections and cannot be treated with antibiotics.

Influenza comes on suddenly with fever, chills, headache, muscle aches, tiredness and a dry cough. Progressively sore throat, runny and stuffy nose, and cough become more prominent. Occasionally croup or pneumonia can develop.

Influenza can be prevented by vaccine, either a live nasally administered version (flumist) or a killed injectable type (flu shot). Vaccination is recommended for everyone six months of age and older. It should happen every year, since immunity wears off and the vaccine is updated to cover new strains and other changes in the virus. Vaccinations are available at most pediatrician offices, Yavapai County Health Department and many pharmacies. Most insurances cover all costs of flu vaccines, and children without insurance are eligible for free vaccinations through Vaccines for Children (VFC).

RSV (respiratory syncytial virus) causes respiratory infection in all ages, but tends to cause lower respiratory tract infections (bronchiolitis, pneumonia) in infants and young children. It is especially worrisome in the first year of life and in infants who have heart or lung disease. Signs of illness include common cold symptoms, wheezing, working hard to breathe, poor feeding and sleeping, and occasionally lethargy and long pauses between breaths.

Those at high risk with predisposing conditions (prematurity, weak lungs or heart) can have expensive monthly antibody shots. The best preventative measures are still routine thorough hand washing and avoiding exposure to illness, especially between November and April. There is no vaccine like there is for influenza.

Once a child contracts RSV, there is no antiviral medicine available for treatment. For influenza, antiviral medications have some benefit if given within the first 48 hours of illness. Treatment for both includes measures to reduce aches, cough and other symptoms. If necessary, oxygen, IV fluids and hospital care are available. In other words, the old adage, “an ounce (or less) of prevention” still applies.

Have a healthy, happy Holiday Season!

Dr. Mick has been caring for local children since 1986 at Ponderosa Pediatrics, PLC. For more information on children’s health, go to www.ponderosapediatrics.com.

Technology and the internet impact healthcare in many ways. Ponderosa Pediatrics works hard to embrace new technologies and give patients opportunities to access information and research various health related issues.

Our website, www.ponderosapediatrics.com, contains links to various sources of reliable health related information. Sources like the American Academy of Pediatrics, Mayo Clinic, Centers for Disease Control and WebMD offer reliable and proven information widely accepted by pediatricians nationwide. However, this information cannot replace the training, expertise and experience offered by licensed clinicians and should never be used in lieu of medical care and doctor’s attention. These sources are interesting reads and provide good general information, but outside the context of doctors, could prove wrong and have serious consequence.

The website also offers information about providers, policy, hours and appointments, patient forms, our blog where we publish all articles (including this one), and the ability to contact us for general information. Our Facebook page is great for lighter discussions, blog posts, contests and general information. Per federal law, we cannot publish any private or protected medical information on any unsecure media, including our website, email, and Facebook.

To answer the need for secure communication, Ponderosa Pediatrics now has a secure patient login system accessible from ponderosapediatrics.com. Patients need to enable an account through our office, and they can log in to access and/or discuss protected patient information. Currently, patients (parents) can review and print medical records, immunization records, appointment history, statements, etc. Those with accounts established also receive appointment verification via email, and receive notices when we publish protected information to their accounts. They can send messages (not directly to providers yet, however), request appointments, and update demographic information. Shortly, they will be able complete medical history and screening information, new patient forms and pay bills online.

While we have not “formally” rolled these capabilities out as we are working the bugs out, the system is online and active. Several hundred parents have logged on and have provided feedback. Patients interested in learning more should call the office or send an email (without divulging protected health information).

Please feel free to post general questions on the Ponderosa Pediatrics Facebook page or comment on this article at www.ponderosapediatrics.com.

By Matthew J. Hinton, M.D.

In the course of a typical day at the office, one particular scenario frequently comes up. While examining a patient, I will detect a heart murmur. When I mention this to the parent, usually there is a look of alarm, ranging from simple anxiety to bordering on panic. Because this is such a common situation, it is appropriate to shed some light on what a murmur is, and what it typically means.

A murmur is best described as a sound the heart makes. That sound could be from any number of things, but basically is categorized as either pathologic or non-pathologic. In other words, is the sound (murmur) because there is a problem with the heart (pathologic), or is the heart normal (non-pathologic)?

The good news is that the great majority of murmurs are non-pathologic. That is, the heart is completely normal and is creating a slight vibration as it is doing its job of pumping blood to the body. Think of the appliances in your home that make noise while functioning – the refrigerator, the dishwasher or even a toaster. We get concerned that something might be wrong only if the noise gets unusually loud or changes out of the ordinary.

In a similar way, the heart makes a soft vibration when beating. In children, this vibration is easily heard because of their thin chest walls and relatively rapid heartbeats that “hum” right along. This is typical and we call it a vibratory or innocent murmur. It is almost always normal, of no concern whatsoever, usually gets softer with time and eventually disappears. I hear these murmurs almost every day. In fact, I believe that just about everyone has a murmur at some point in their life!

A small percentage of the time, the sound could be from a problematic source. Perhaps there is a heart valve not working properly, a hole in between the chambers of the heart, or some other abnormality. Most, but not all, of these will be identified early in the child’s infancy. Some are more worrisome than others. Your child’s healthcare provider will decide what further evaluation may need to be done in these instances.

If you have any concerns about what your doctor is hearing, please ask. Most heart murmurs, or sounds, are a just normal part of growing up!

Dr. Matt Hinton is a Prescott native and board certified pediatrician. He graduated from Prescott High School and went to Yavapai College before completing his undergraduate degree at Brigham Young University. He came “home” to care for the Quad-Cities children after completing his MD at the University of Arizona and has been with Ponderosa Pediatrics since 2004. Additional information and articles about child healthcare can be found on the Ponderosa Pediatrics website at www.ponderosapediatrics.com or on our Facebook page.

One of the realities of healthcare is that it takes time. I’ve had only one primary care physician who I could always count on to be on schedule. However, if I wanted an appointment where I could discuss issues in detail, I had to tell the scheduler in advance the specific details to include. If I did not, I had to schedule a second appointment. That was great for time conscious patients, but not so great for patients who wanted their providers to really know them and understand their health. This takes time.

Things like computer problems, power outages, sick doctors, medical emergencies, or just an overwhelming number of sick children are out of our control. There are things that patients can do to help providers stay on time.

1. Always try to arrive at least five minutes early for routine appointments and earlier for appointments where additional paperwork (new patients, well child checks) needs to be completed. If available, download paperwork from the web and complete it beforehand.
2. Plan extra time with the provider! Most appointments are scheduled for 15 minutes. This includes time to take vital signs, history or other information before the provider sees the patient. If you tell the person scheduling your appointment of everything you want to discuss, they can schedule adequate time.
3. Know what your insurance will cover and how much you should expect to pay for the visit. Then be ready to pay at the time of check in. If you have balances due, expect to be asked about them. Always bring current insurance cards with you. The less time required before the appointment, the faster you will be ready for the providers.

The most common reason providers get behind schedule, resulting in longer wait times, is that they want to provide each patient the best possible healthcare. If a parent wants to discuss things outside the reason for the appointment, it takes longer. Providers must balance how much they can reasonably accomplish with the number of patients scheduled. If we can plan adequate time based on patient needs, there will be fewer times we get behind schedule.

Please feel free to post general questions on the Ponderosa Pediatrics Facebook page or comment on this article at www.ponderosapediatrics.com.