Friday, March 8, 2019

Tips for making the most of your child’s checkup

It’s that time of year again, when people gather with friends and family to celebrate the holiday season. The festivities often feature wine, champagne, and other alcoholic beverages. But before you raise your glass, make sure you’re aware of just how much alcohol you’re actually consuming — and how it may affect your heart.

For the most part, moderate drinking — defined as one drink per day for women and two drinks per day for men — is considered safe. But there are some caveats.
Defining “one” drink

“We ask people about numbers of drinks, but you have to be careful about what they really mean by that,” says cardiologist Dr. Stephen Wiviott, associate professor of medicine at Harvard Medical School. For some people, “one drink” may be 6 ounces of whiskey, which is actually four drinks, he notes. One standard drink contains roughly 14 grams of pure alcohol, which is found in:

    12 ounces of regular beer (about 5% alcohol)
    5 ounces of wine (about 12% alcohol)
    1.5 ounces of distilled spirits, such as whiskey, rum, and vodka (about 40% alcohol)

Despite popular belief, the evidence that alcohol is good for your heart is fairly weak and based solely on what researchers call observational data. “We observe that people who drink moderately have lower rates of heart disease and death from heart disease, but that doesn’t prove cause and effect,” says Dr. Wiviott. For example, light-to-moderate drinkers tend to be educated and relatively wealthy, and they’re likely to have heart-healthy habits that may explain their lower risk.
Holiday heart

There’s a well-established connection between binge drinking and atrial fibrillation or afib, an irregular heart rhythm that can increase the risk of a stroke. It’s known as holiday heart syndrome because it typically happens around the holidays and on weekends, when some people drink to excess. It’s not exactly clear why binge drinking (defined as consuming about four to five drinks over a two-hour period) triggers afib. But it can happen in people with and without a history of the heart rhythm problem.

A recent study found that even as little as one drink a day may enlarge the heart’s upper left chamber (atrium) and increase the risk of developing afib. Researchers found that every 10 grams of alcohol consumed was linked to a 5% higher risk of developing afib. About 24% (and in some cases, up to 75%) of the higher risk could be traced back to an enlargement of the left atrium. Stretching of the atria — which can also result from longstanding high blood pressure or a genetic problem — seems to make the heart more electrically unstable, Dr. Wiviott explains.
So what should you do?

These new findings don’t change the observation linking moderate drinking to a lower risk of heart attack noted in some studies. But no one should ever start drinking in hopes of avoiding a heart attack, he says. For his patients who do drink alcohol, he suggests no more than one drink a day, even for men. If you have afib and drink alcohol, you should probably have a discussion with your doctor, Dr. Wiviott advises.

The National Institute on Alcohol Abuse and Alcoholism already advises people ages 65 and older to limit themselves to one daily drink. Age-related changes, including a diminished ability to metabolize alcohol, make higher amounts risky regardless of gender. As a headache specialist, the topic of sinus headache is a frequent point of discussion. Many patients deny that they have migraines, believing sinus problems are the cause of their headaches. Some of the more tech-savvy patients believe that they have both migraines and sinus headaches after consulting with “Dr. Google.” The reality of the situation is that 86% or more of patients who suspect that they have sinus headaches in fact have migraines.
Why the confusion between sinus headaches and migraines?

It begins with the many symptoms that both migraines and sinus headaches share, which include pressure in the face, an association with barometric/seasonal weather changes, and autonomic nervous system dysfunction. The autonomic nervous system controls many of the involuntary functions in your body including heart rate, blood pressure, and sweating. In the case of migraines, autonomic dysfunction can cause eye redness, eyelid swelling/drooping, tearing, sinus congestion, and even a runny nose.

Response to treatment can also further drive patients to believe that they have sinus headaches rather than migraines. For example, a patient may have a headache involving a pressure sensation in the face, and calls their primary care physician thinking a sinus infection is causing the symptoms. The primary care physician then prescribes antibiotics and steroids to treat this assumed sinus infection. The patient feels better after taking these medications, and believes that the infection is cured. The reality of the situation is that steroids can be effective for the treatment of sinus issues and migraines. Even without steroids, antibiotics can be perceived as an effective treatment for two reasons. First, the patient truly believes he or she has an infection, so the antibiotic has a powerful placebo effect. The other reason is that with time, the migraine would have gone away anyway.

Unfortunately, this cycle of antibiotics with or without steroids for the treatment of a migraine masquerading as a sinus infection can go on periodically over years and even decades. Taking steroids can cause many problems including weight gain, hair loss, and bone weakness. Inappropriate use of antibiotics can contribute to the rise of antibiotic-resistant bacteria. Conversely, if a sinus headache responds to a migraine-specific treatment like sumatriptan, migraine is more likely the diagnosis than sinus headache.
Here’s why you want to know whether you have migraines and not sinus headaches

An incorrect diagnosis of sinus headaches can also serve to skew a patient’s family history. Migraine is a genetic disorder that is passed down through family members. Patients often deny that any of their family members have migraines, but when asked about sinus headaches, they will often respond, “Actually, my mother had sinus headaches.” When questioned about the mother’s sinus headache behavior, the same patients frequently respond, “She would lay down, and insist that the room be dark and quiet. She would also ask for a bucket to be placed by the head of the bed even though she rarely ever threw up.” Such responses tend to lead the physician and patient to the conclusion that migraines actually do run in the family, as sinus headaches are not typically accompanied by light sensitivity, sound sensitivity, and nausea. The same patients will also return for a follow-up appointment noting, “It turns out that my sister, cousin, and aunt all have migraines, which they thought were due to sinus problems.” In a jocular way, I at times reply, “Discovering family members that suffer from migraines can be both unfortunate and comforting, but such discovery is not as devastating as routinely encountering a family member who regularly causes headaches, which I refer to as ‘mother-in-law syndrome.’”
Three telltale signs it’s a sinus headache and not a migraine

While I was lecturing on distinguishing sinus headache from migraine with some Harvard medical students, they came up with the phrase Mathew’s Sinus Triad to encompass three features that are more suggestive of sinus headache than migraine. These are:

    Thick, infectious looking mucous. A little clear drainage can be seen with a number of conditions, and is not necessarily indicative of a sinus infection.
    Fever. It would be very unusual for migraine to present with fever, but fever is a primary symptom of a sinus infection.
    Imaging. If an imaging study or evaluation with an endoscope looking up the nose shows a sinus problem, then the headaches are likely related to that — unless the headaches continue after the sinus problem is successfully treated.

In conclusion, if you suffer from frequent sinus headaches, there is a good chance that you are actually experiencing migraines. Making the correct diagnosis and formulating an appropriate treatment plan can reduce the frequency and intensity of headaches, as well as avoid unnecessary testing, visits to specialists, and taking medicines that are not actually treating the problem. The yearly check-up: it’s the time when your child gets a total look-over. As a pediatrician, I’m often struck by just how much I need to cover in that appointment. I need to find out about eating, sleeping, exercise, school, behavior, even about peeing and pooping. I need to ask about the dentist, about screen time, about changes in the family’s health or situation. I need to do a full physical examination and check on growth and development. I need to talk about and give immunizations — and make sure parents have the health information they need and want. And of course, I need to address any chronic health problems the child might have, and any concerns the parents have.

In our practice, the longest I have to do this is 30 minutes. Usually I have 15 minutes.

After 25 years of being a pediatrician and doing thousands of check-ups, I’ve learned about what can help parents get the most out of whatever time they have. Here are some tips:

    Think about what you want to talk about before the visit. This sounds really obvious, but too often parents don’t do it. They get caught up in scheduling and getting to the visit, or in the forms they need, and don’t take the time to think about what they want to ask the doctor. Keep a list somewhere (like on your phone, so you don’t leave it at home); jot things down. As you go along, prioritize the concerns: what is most important to cover at the visit? Which leads me to…
    Don’t leave it all for the visit. This happens all the time. Parents store up all their worries— and have a list that is so long and complicated I can’t possibly tackle it all and still do what I need to do medically. While sometimes we schedule a follow-up visit to finish up (more on that below), another alternative is to find ways to get some of your questions answered ahead of the visit.

    Most practices have nurses that can answer common health questions and otherwise help families. You may be able to leave a message for your doctor and have them call you back; this can be particularly helpful when there are concerns, such as behavioral problems or bullying, that might be best discussed without the child present.
    Use portals or other forms of communication. More and more, practices are devising ways for families and doctors to communicate. You can use these to get a question answered or get advice. I’ve also had parents send me written information about their child ahead of a checkup exactly to save time at the visit — and allow us to be more efficient and focused when we are together.
    Consider making an appointment before the checkup. This sounds odd, but it can be really helpful, especially when there is something complicated going on — like asthma acting up, school problems, worries about behavior, or a family crisis. That way, I can fully focus on the problem, instead of having to ask about sleep or poop or daily servings of vegetables. Plus, it gives us a chance to try something — and then at the checkup, see if it helped or not.
    Ask your doctor which health and parenting websites they recommend. There’s a lot of great information out there.

    Have any forms or papers ready — and have your child undressed before the doctor comes in. Little stuff, but it really helps things move smoothly. If you have to fill out something for the visit, get it done. Have the argument with your modest child about the gown before the visit starts. If you have forms you need for school or sports, let the nurse or clinical assistant know; sometimes they can help.
    Work with your doctor to set an agenda for the visit. Too often, we docs come in with our own agenda. Or, parents start in with their first concern — and then time runs out before they get to the second or third. As soon as the doctor comes in, say something along the lines of, “I have three things I want to be sure we talk about today, and I know you have things you need to ask. How can we best make this work?” Planning it out together can make all the difference.
    Be brief whenever you can. I’m not saying you shouldn’t say everything you need or want to say. But if all is going fine in a particular area, say it’s fine rather than giving lots of details. Or if all isn’t going fine, just say it’s not, rather than defending or giving excuses. Save the time for questions and conversations that can help you and your child.
    Let your doctor know if your needs aren’t met. Sometimes we just can’t pull it off in that one visit, but that doesn’t mean that you can’t get all of your needs met. As I said before, sometimes a follow-up visit makes sense. Maybe there is a nurse who can spend some time helping you before you leave or a social worker who can give you a call. Maybe you can get a handout about a topic you are interested in or a recommendation for good online information. Never just leave saying, “Oh well, maybe next year.” That’s not how primary care works; it’s an ongoing relationship. We are here to support you, every step of the way.

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