Seamless primary and specialty care: Lea’s story

For parents of children who need specialty care on top of their typical visits with pediatricians, CHOC’s growing Primary Care Network offers seamless integration with more than 30 specialty areas represented by CHOC’s mighty brigade of pediatric specialists.

Lea, age 4, has seen a CHOC specialist since before she was born. Lea was diagnosed in utero with hydronephrosis – a treatable condition in which urine gets trapped in the kidney and drains slower than it should into the bladder. A routine ultrasound flagged fluid in Lea’s kidney, and her mom was referred to CHOC’s urology program for a fetal consultation.

Dee Dee, Lea’s mom and a longtime CHOC employee, knew her daughter was in good hands.

“The urologist explained everything in a way that was easy to understand,” Dee Dee recalls. “I was comforted knowing that this condition was common, my daughter would be OK, and that they would continue to monitor her and manage the condition after she was born.”

Dee Dee chose to deliver at St. Joseph Hospital in Orange for its proximity to CHOC. Doctors weren’t concerned that Lea’s hydronephrosis would cause her any immediate harm, but it gave the first-time mom peace of mind knowing that CHOC was right across the street.

Specialty care with CHOC’s urology program

Lea returned to CHOC’s urology program after she was born for additional testing and monitoring.

baby ultrasound
When she was 1 month old, Lea returned to CHOC for an ultrasound.

Urologists confirmed the prenatal diagnosis and also diagnosed Lea with vesicoureteral reflux or VUR, where urine flows backward. Lea’s VUR is due to wide ureters – tubes located between the bladder and kidney, and essential to proper urine flow – and valves that are too small to efficiently direct urine flow.

Some children with VUR grow out of it without the need for medical intervention. This is less common in children with higher grade openings between the kidney and bladder, as is Lea’s case. Doctors explained to Dee Dee and her husband Pat that over time, VUR can lead to infections in the kidneys. Eventually, a high number of these possible infections can lead to kidney damage.

After receiving Lea’s diagnoses, Dee Dee and Pat switched their daughter’s pediatrician to one in CHOC’s Primary Care Network.

“We realized that if we were going to need specialty care for our daughter, we wanted a pediatrician in the CHOC network to fit into that puzzle,” Dee Dee says. “CHOC is the best partner in caring for our child.”

MRI prep
At age 1, Lea underwent an MRI in preparation for her Deflux injection. Before her MRI, she played with her dad.

Lea has remained under the care of CHOC urologists, who continue to monitor her VUR. This has included two voiding cystourethrograms (VCUG). With this test, doctors insert a catheter and dye to fill Lea’s bladder, then take X-rays of fluid flowing in real time. Tests of any kind can be stressful for young kids, so child life specialists from CHOC’s Cherese Mari Laulhere Child Life Department have been present for each of these tests with Lea. Child life specialists are experts in normalizing the hospital environment for kids, but by being an extra source of comfort, they often put parents at ease, too.

“Child life has been amazing with Lea,” Dee Dee recalls. “During one VCUG, the child life specialist asked about Lea’s favorite song. At the time, it was “Wheels on the Bus” so that’s what she sang with Lea. I joined in the song, and before I knew it, every single clinician in the room was signing along to “Wheels on the Bus.” I remember thinking that even though the radiologist was so smart and so focused on performing the test, he was not above singing this song. He knew that is what my daughter needed in that moment to feel comfortable.”

Shortly after Lea’s first birthday, she underwent a procedure called a Deflux injection, where, under anesthesia, doctors injected a protein or ureter material to make the wall of Lea’s ureters thicker, hoping to close the gap and ensure proper urine flow, helping to continue avoiding UTIs.

Lea’s care team – including her parents – remain on high alert for a urinary tract infection or UTI, as a high number of these can contribute to kidney damage. Lea took preventive antibiotics until she was potty trained to help avoid UTIs.

age 3 ultrasound
Lea and her mom Dee Dee take a selfie during a recent visit to CHOC for an ultrasound

Lea sees her urologist Dr. Heidi Stephany a couple times per year, and they’re able to seamlessly communicate with Lea’s CHOC pediatrician, Dr. Katherine Williamson.

Primary care network

As part of CHOC’s growing health system, pediatricians in CHOC’s Primary Care Network not only have full access to any medical records from their patients’ specialty care visits, they can also see notes from recent visits to other providers, meaning they have the latest information on their patients’ medical history.

This coordination was especially beneficial for Lea and her parents on a recent weekend when Lea had a suspected UTI. Although common in children, with Lea’s VUR, potential UTIs are cause for concern.

Thanks to Saturday morning hours at Lea’s pediatrician’s office, they were able to get a last-minute appointment.

“With Lea’s condition being relatively rare, I’m used to explaining it to people,” Dee Dee says. “But when we saw Dr. Ball, he already knew her medical history and was very familiar with her condition. We typically see Dr. Williamson in that office, and she is well-versed in Lea’s health, but seeing Dr. Ball was seamless. It was such a relief not to have to explain anything to a new-to-us provider.”

A urine sample is a routine and necessary part of testing for UTI. These can be hard for children and parents alike, but Dee Dee felt grateful that Dr. Ball and his staff were patient with Lea.

“The whole staff was really patient with us, even though we were the last appointment of the day. They just kept coming in and checking on us to see how we were doing,” Dee Dee says. “The office also felt very safe during COVID-19; everyone was masked, and everything was clean.”

Ultimately, Dee Dee and Lea headed home with instructions to drink more fluids to help Lea produce a urine sample, and a plan to head to CHOC’s urgent care in Orange when Lea was ready. During this time, Dee Dee called CHOC’s urology team to confirm their course of action.

“I called the urologist on call, and even though it wasn’t Dr. Stephany, who we typically see and who is most familiar with Lea, the doctor who called us back had already looked at Lea’s chart and read Dr. Ball’s notes from that morning,” Dee Dee says. “He reassured us we were doing the right thing and validated my choice to bring her to CHOC’s urgent care.”

Lea continued drinking fluids to help produce a urine sample. When Dee Dee and Lea got to CHOC’s urgent care, they saw Dr. Vivi Tran, a CHOC pediatrician. Dr. Tran likewise could see Lea’s complete medical history and Dr. Ball’s notes from that morning, as well.

“I didn’t need to explain a thing,” Dee Dee recalls. “Dr. Tran was already up to speed, and that was such a weight off my shoulders.”

CHOC pediatricians know kids, and they know that rushing a child – especially to do something like produce a urine sample – will often have the opposite effect. Dr. Tran checked in with Dee Dee and Lea periodically, and even brought Lea an apple juice to help her produce a urine sample.

“CHOC made this as stress-free as possible for Lea and me. We were there for three hours trying to get Lea to produce a urine sample, and never once did I feel rushed,” Dee Dee recalls.

Lea’s UTI test was ultimately negative, and she had a regularly scheduled appointment with her urologist the next week.

birthday party
Lea recently celebrated her 4th birthday.

“The seamless coordination of care between Lea’s pediatrician’s office, her specialist and urgent care was unmatched. We could never find that anywhere else. I didn’t have to bring anyone up to speed on what was happening or my daughter’s medical history. They had access to her records and the latest information on her case,” Dee Dee says of her daughter’s experience. “I also know our positive experience wasn’t just because I’m a CHOC employee; everyone receives a high level of care.”

Mom’s perspective

Since joining CHOC’s marketing department in 2013, Dee Dee has had a firsthand look at CHOC’s patient- and family-centered care and has worked closely with a number of CHOC specialists. This recent experience with her daughter gave her a greater understanding of and appreciation for CHOC’s system of care.

“We write about various conditions every day and provide education on CHOC’s coordinated system of care. I already knew these things were true because of my job, but then I experienced it myself as a mom and I truly understood how beneficial these things are,” Dee Dee says. “It seems like the scariest thing in the world, to have a child who needs CHOC’s care, but it’s actually the most comforting thing.”

The importance of well-checks during COVID-19

An upcoming well-check appointment for her teenage son had slipped Courtney Berney’s mind until her CHOC pediatrician called her one day with a reminder.

“I didn’t even remember that we had a well-check,” she says. “I did ask if we should still go, even with COVID-19 happening.”

Dr. Eric Ball gave Courtney an overview of the steps CHOC’s Primary Care Network had taken to keep patients, families and staff safe during the pandemic.

dr-eric-ball-choc-childrens-pediatrician
Dr. Eric Ball, a CHOC pediatrician

Reassured, Courtney and her son, Jackson, headed to the appointment. Upon arrival, they both wore masks, had their temperatures checked and were asked about symptoms and possible COVID-19 exposure. The waiting room was kept largely empty and all staff wore masks.

“It felt very safe,” Courtney said. “I was impressed.”

A routine visit takes an unexpected turn

Including tracking growth, checking in on mental health and ensuring current immunizations, the well-check continued like every other routine visit 15-year-old Jackson had experienced before.

But then, Dr. Ball detected an inguinal hernia during his physical exam.

These can occur when the inguinal canal, which extends down the groin, doesn’t close on its own shortly after birth. If this opening is large enough in these cases, the intestine can come into the canal and create a bulge in the groin region.

This can grow dangerous if the part of the body that protrudes from the hernia becomes stuck, which can compromise blood flow to the trapped body part.

“Apparently, Jackson was born with it and always had it and he didn’t know,” Courtney says. “He’s had this exam every year since, but this year it felt different. I wouldn’t have known that, and he wouldn’t know it without having this visit.”

Because inguinal hernias should be repaired by surgery, Dr. Ball referred Jackson to CHOC’s pediatric general and thoracic surgeons for a follow-up appointment, and Jackson recently underwent a successful outpatient procedure to repair the hernia.

“Inguinal hernias are common but should be taken care of promptly,” says Dr. Ball. “They’re also something that often only a doctor can detect during a physical examination, which underscores the importance of regular well-checks for kids – even when they’re healthy.”

Taking a personal approach

Knowing that parents may be wary of healthcare settings during a pandemic but also how critical seeking both sick and well care remains, Dr. Ball and his colleagues earlier into the COVID-19 emergency made personal phone calls to families. Today, Dr. Ball still regularly has conversations with families about the measures in place to keep families safe.

“I’m happy to connect with them and personally reassure our families about the safety of our office,”  Dr. Ball says. “We want to ensure our patients and families know that we are here for them – during a pandemic and otherwise – and how critical it is to seek both routine and regular care.”

Here’s a look at other ways CHOC is ensuring its primary care practices are safe during COVID-19:

  • separated offices, waiting rooms, exam rooms and times/days for sick visits and well visits;
  • masking for staff, patients ages 2 and older and families;
  • enhanced cleaning practices;
  • screening of all patients for COVID-19 risks, by phone when families make appointments, and upon arrival for well and sick visits;
  • in-vehicle evaluation of children symptomatic or exposed to COVID-19; and
  • limiting the number of people who can accompany a patient to an appointment to one family member.

These extra steps helped reassure Courtney that it was safe to seek routine care for her children, even during a pandemic – and she’ll be coming back.

“My son is really healthy too, but I wouldn’t pass up a well-check,” Courtney says. “I know it might be scary and new, but I trust the doctors. I have to book my appointment for my other son in a couple weeks too.”

Reducing childhood obesity during the COVID-19 pandemic

We know that all parents want to keep their children healthy and safe. Although COVID-19 affects different people in different ways, research has shown that obesity puts children – and adults – at increased risk of severe illness.

According to 2016 data from the Let’s Get Healthy California task force, 20.2% of children age 0-5 were overweight for their age, 12.9% of children age 6-11 were overweight, and 40.7% of adolescents age 12 to 17 were overweight or obese.

Following your doctor’s advice on nutrition and physical activity can help protect you from severe illness associated with COVID-19 – in addition to physical distancing, washing your hands frequently and wearing a facial covering.

Here are some healthy eating and exercise tips for your family. If you have questions about your family’s health, call your doctor.

Healthy eating tips

Limit the amount of added sugar your child eats or drinks.

  • The American Heart Association recommends that children ages 2 to 18 should have less than 25 grams of added sugar per day, and drink less than one 8-ounce sugary drink per week.
  • 25 grams of sugar equals 6 teaspoons, or about 100 calories. The average American child consumes 19 teaspoons of added sugar daily, or more than 300 extra calories.
  • Here’s tips from a CHOC registered dietitian on limiting added sugar in your family’s diet.

Eat Well on a Budget

Eating healthy does not have to be expensive. A CHOC registered dietitian offers these tips for parents who want to follow a balanced diet and stay on budget:

  • Plan before you shop. Compare prices and read grocery flyers to determine what’s on sale. Create a menu for your family for a week at a time, building on foods you already have at home
  • Eat before you shop. Going shopping hungry can lead to spontaneous and unhealthy purchases.
  • Prepare double or triple batches of meals you can freeze and eat later on days you will be too busy to cook a healthy meal.
  • Here’s more tips on eating healthy on a budget.

Tips for Picky Eaters

Is your toddler a picky eater? Dr. Eric Ball, a CHOC pediatrician, offers these tips:

  • Don’t let toddlers decide what food they are served. Parents control the quality of food offered to children. Toddlers control the quantity that they eat.
  • It’s normal for toddlers to have meals – or even days – when they eat little.
  • Mealtime will be more successful if you avoid letting your toddler fill up on liquid calories or snacks. At snack time, give your toddler two acceptable options.
  • Here’s more tips from Dr. Ball on how to deal with a toddler who is a picky eater.

Meal Prep Tips for Busy Parents

When life gets busy, planning and making homemade meals can easily fall to the bottom of your to do list. These healthy meal prep tips for busy parents, from a CHOC registered dietitian, can help.

  • The USDA’s Choose MyPlate program is a great place for recipe ideas. It also offers tips for meeting your nutritional goals. Find tips to incorporate each food group into your diet, and what foods to limit, such as salt and saturated fat.
  • The website also offers the MyPlate Plan – parents can enter the gender, weight, height and activity for their children and get specific energy needs. Then, you can choose the calorie level and servings and suggestions for each food group to meet your child’s calorie needs. Here’s an example MyPlate Plan.
  • Learn more about the healthy eating benefits of the Choose MyPlate program.

Get kids involved in the kitchen

  • Preparing meals together can help children develop healthy eating habits. Talk about the ingredients, and how they smell, taste, look and feel. Be creative when offering new foods. You can make bugs with fruit kabobs or faces with vegetables on homemade pizza.
  • Children learn by example. If they see parents and siblings preparing and trying healthy food, they are more likely to accept a new food.
  • Make mealtimes family time. Children who eat meals with their families at home have higher quality diets and higher intake of fruits and vegetables.
  • Here’s more tips on developing healthy eating habits in kids.

Drink enough water

How much water should children drink every day? We recommend they drink the number of 8-ounce glasses equal to their age, with a maximum of eight glasses for children age 9 and older. For example, a 3-year-old should drink three 8-ounce glasses of water per day. Here’s a helpful chart to keep track of this advice.

Promote physical activity

Daily exercise helps keeps kids fit. Try to get at least one hour every day. This doesn’t need to be all at once. It can be short bursts of activity for 15 minutes at a time.

Be active with your children. They are more likely to stay active when they are having fun with their parents. Tap into activities or sports they’re already interested in, that you can do while respecting physical distancing, such as waking the dog, playing catch, soccer, riding a bike, or setting up an obstacle course in your backyard.

Limit screen time

Screen time is considered watching TV, playing video games or using a computer, tablet or smartphone. The American Academy of Pediatrics offers these screen time recommendations for kids:

  • 18 months or younger – no screen time is best. An exception is live video c hat with family and friends.
  • 18 months to 2 years – limit screen time and avoid solo use. Choose high-quality education programming and watch along with your kids to ensure they understand what they’re watching.
  • 2 to 5 years – limit screen time to an hour per day. Parents should watch with their kids to make sure kids understand what they’re watching and can apply it to their world.
  • Age 6 and older – parents should place consistent limits on screen time. Don’t let screen time affect sleep, exercise or behavior.

Call your doctor

If you have questions about your child’s weight, speak to your doctor. Doctors use body-mass index charts, based on age and gender, to determine a range of healthy weight for kids.

Eczema Treatment for Kids

By Dr. Eric Ball, a CHOC pediatrician

What is eczema? Atopic dermatitis, more commonly known as eczema, is a common skin condition that can plague everyone from babies to grown-ups. It can be as mild as a nuisance, or more serve with skin so dry it cracks, bleeds or gets infected. Most kids will get an itchy skin rash at some point in childhood, but about one out of every 10 kids will develop eczema.

Eczema causes are unknown, but it’s believed to be a combination between genetics and a trigger, which could be certain foods, seasonal or environmental allergies, stress, hormones and weather. Diagnosing eczema can be tricky because each child has a unique combination of symptoms that can vary in severity, and there is no test to diagnose it definitively. If you suspect your child has eczema, consult your pediatrician. They will conduct a physical examination, and help you identify things in your child’s environment that may be contributing to skin irritation.

Eczema is not contagious, so there is no need to keep a child with eczema home from daycare or school.

Eczema symptoms

Eczema symptoms typically appear within the first few months of life, and almost always before a child turns 5. More than half of all children who suffer from eczema will outgrow it by the time they’re teenagers.

Between 2 and 6 months of age, kids with eczema will have itchy, dry, red skin and small bumps. These eczema symptoms can appear on their cheeks, forehead or scalp. It may spread to the arms, legs and trunk; in the bends of the elbows; behind the knees; or on the backs of the wrists and ankles.

Eczema symptoms tend to worsen and improve over time. For many kids, it begins to improve by the age of 5 or 6; others may have flare-ups into adolescence and early adulthood. In many cases, eczema goes into remission and symptoms may disappear altogether for months or even years.

How to treat eczema

There is no known eczema cure. However, your child’s pediatrician may prescribe a topical corticosteroid, also known as cortisone or steroid creams or ointments, which are commonly used to treat eczema. These “eczema creams” are usually applied directly to the affected area twice a day. Continue using these corticosteroids for as long as your doctor suggests.

These creams and ointments vary in strength, so do not apply a topical corticosteroid intended for someone else.

Your doctor may suggest nonsteroidal medications instead of a topical steroid. These may also prescribe antihistamines to help control itching, or an oral or topical antibiotic to prevent or treat secondary infections common in kids with eczema.

How to help your child with eczema

  1. Avoid frequent hot baths or showers, which dry out the skin. Use warm waters and mild soaps during bath time. Gently pat their skin dry, instead of scrubbing or toweling.
  2. Avoid fabrics that may irritate their skin including wool or coarsely woven materials. Favor materials that “breathe” such as cotton.
  3. Apply moisturizing ointments like petroleum jelly, lotions or creams to their skin two to three times per day. Always apply within a few minutes of bathing after a gently pat dry, before the skin has fully dried. Do this in addition to using a cream prescribed by their pediatrician.
  4. Apply a cool compress to the skin to ease itching.
  5. Eliminate known allergens from your home, including certain foods, dust or pet dander.

How to Deal With a Toddler Who is a Picky Eater

By Dr. Eric Ball, a CHOC pediatrician

Most babies are great eaters. The average twelve-month-old will eat most of what he is offered. At my son’s first birthday party, I remember that he happily ate broccoli and strawberries, and only nibbling on his birthday cake. Three months later, my wife and I were begging him to just try or lick a piece of broccoli. What happened?

Some studies suggest that over 90 percent of toddlers and preschoolers are described by their parents as picky. I have a few theories about what happens to these formerly stellar eaters:

  • Children’s growth velocity slows down dramatically after their first birthday. The average child gains 15 pounds in the first year of life and only 5 pounds in the second year. Most of the food your baby ate went to growth, whereas most of a toddler’s food will go to running around and playing. Therefore, a toddler’s hunger will be variable. There will be days when they are hungrier than other days. It is normal for toddlers to have meals― or even days― when they eat little. There are also days when a toddler might eat more during a meal than their parents.
  • The last thing a toddler wants to do is sit in a highchair for thirty minutes and eat a meal. They want to play and explore. The average toddler or preschooler will eat just enough to get the energy to play more. When their tank is refilled, off they go!
  • Kids get smarter as they get older. Eventually my son realized that chicken nuggets taste better than broccoli. Since toddlers have no knowledge of nutrition, they want to eat what they like the most. At this stage, the biggest pitfall parents can make is to start allowing their toddlers to decide what food will be served. They will obviously choose the junk food that tastes best to them.

So, what do you do with your newly picky eater? I was raised in a strict household where my brothers and I were forced into eating our food. My brothers and I all struggled with obesity as children and were all very picky eaters. My wife’s family had one rule for the table, “Eat what you want, leave the rest.” There was no arguing or bargaining around the dinner table in their home. My wife and her brother were always a healthy weight and ate a good variety of foods. Here are some tips that I learned from my wife’s family that I try to pass onto my patients and my own children:

As parents, we are in control of the quality of the food offered to our children, and they are almost 100 percent in control of the quantity that they eat.

Toddlers have a fierce independent streak and the more they are pushed, the more they push back. Do not bribe, coerce, or force your children to eat. Sit your toddler down for three well rounded meals per day and at least one healthy snack per day. Make sure that he is offered a variety of healthy foods at each meal. If he eats what is served, that is fantastic. If he does not eat what is served, that is okay, too, but do not offer him anything else. We parents are not short order cooks. If the family is eating chicken, rice and broccoli, then that is what the toddler should be served. If he is offered macaroni and cheese after he whines that he does not like chicken, then you have essentially taught him that in order to get macaroni and cheese, simply whine and refuse your food. This is the first step in the making of a picky eater. It is better to excuse him from the table if he does not want what he is served rather than give him something else. Children do not starve themselves to death. Place the dinner plate in the refrigerator, and he can have a second chance at eating his dinner later that evening if he decides he’s hungry.

Maximize your opportunities for successful meals by not filling up on liquid calories and snacks

I do not serve milk or juice with meals, only water. When my son was a toddler, if he had milk with his dinner, he would chug the milk until he was almost completely full, and then eat little or no food A ten-ounce cup of whole milk has more calories than an equivalent sized soda. I would save milk or juice for snack time and limit my children to no more than 16 ounces of milk per day. In fact, I filled a 16-ounce measuring cup with milk each morning so that my children could see exactly how much milk would be allotted for the day. When the cup was empty, the milk for the day was over.

Give your toddler mutually acceptable choices for snack foods

I will offer my children an apple or a pear for a snack. If they respond that they want Goldfish crackers, I will remind them again that their choices are between an apple and a pear.

Eat as a family whenever possible

Children are much more likely to eat their food if they see others eating the same food. It is hard to expect a toddler to eat peas if he is the only one eating them. Even if work schedules make a true family meal impossible, try to have one parent sit with the children and eat small portions of what the children are served.

Allow children to participate in food preparation

Most people are more willing to eat something of which they have ownership. Even something as simple as having your toddler stir the peas and corn may increase the odds that he will eat them.

If there are foods that you do not want your children to eat, do not buy those foods

Good nutrition starts at the grocery store. If a child’s only options for snacks are fruits or vegetables, it is likely that he will eat them. Most toddlers and preschoolers eventually are smart enough and agile enough to find that stash of Oreos in the cabinet.

In medical school, I was repeatedly taught that parents should not make mealtime a battle. That lesson didn’t fully sink in until I had my own children and I realized how quickly a lovely family meal could degenerate into a stress-filled ordeal. By applying the simple family rule of “Eat what you want, leave the rest,” mealtime at our home is once again a pleasant experience.