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Growing Stronger Together is a podcast for people who care about children.
Growing Stronger Together was developed by faculty at East Tennessee State University, including members of the ETSU Health Department of Pediatrics, the ETSU Center for Early Childhood Learning and Development, and the ETSU Child and Family Health Institute.
East Tennessee State University is located in the beautiful Appalachian Highlands. We appreciate the financial support provided through a Community Health Improvement Site Investment from Ballad Health’s Department of Population Health.
Dr. William Dodd (00:02)
I'm your host, Dr. William Dodd, from the East Tennessee State University Health Pediatrics Adolescent Medicine Clinic.
This podcast is not intended to provide medical advice. If you or a loved one are working through medical problems related to today's topic, please consult a personal physician. I have no conflicts of interest to disclose.
Today we have a discussion of preventative care in pediatrics, all the way from infants to adolescents.
I’d like to welcome everybody to today's program. I'm your host, Dr. William Dodd with ETSU Health Pediatrics. And today it's my pleasure to welcome our guest, Dr. Suki Singh. Dr. Singh ⁓ is a fellow pediatrician here at ETSU Health Pediatrics. ⁓ Prior to joining us as an attending, he was a resident here at ETSU in pediatrics. And ⁓ previously to that, he went to Des Moines University where he attended med school. It's a bit of a change in scenery, Dr. Singh.
Dr. Sukhvir Singh (01:27)
Yeah, I grew up in California and moved out to Iowa. And then here I live in Piney Flats in Tennessee. I think the smaller I go, the more I like it. So I think we're here to stay for a while.
Dr. William Dodd (01:43)
Well, you can't beat the traffic.
Dr. Sukhvir Singh (01:46)
No, you cannot.
Dr. William Dodd (01:47)
⁓ So today, I wanted to bring Dr. Singh on to have a discussion about kind of a very important topic. It's kind of the bread and butter of a lot of what we do in pediatrics. And I also think it's a thing that a lot of people don't think about from a ⁓ systemic standpoint. You know, anybody with kids brings them to well visits and pediatricians talk about a lot of topics at those well visits, but... ⁓
But I think it's important to kind of look at in its own right and think about things from the standpoint of preventative care and screening and kind of a lot of the things that we do. It's an interesting topic. It's a broad topic. And today we're just going to kind of talk about a broad overview of this topic. And maybe we can go a little bit more in depth here in the future.
So, Dr. Singh, ⁓ what exactly do we mean when as a doctor or health professional we say preventative care?
Dr. Sukhvir Singh (02:58)
⁓ That's a great question. I feel like lot of folks sometimes have this misconception that, you know, I don't need to see the doctor unless I'm sick and my kid doesn't need to see the doctor unless they're sick just because, ⁓ you know, they might bring the child in when they're concerned about things like, you know, upper respiratory infection. Maybe they're sick at school and they need a note for that. They've got an infant who's been pulling out their ears and they're worried, hey, is this teething? Is this... an ear infection or, you know, my teenager's been coughing for three weeks and now has fevers. I'm worried about things like like a pneumonia because he's complaining of shortness of breath. And we do like to treat, you know, lots of acute illnesses and try to help prevent them from becoming chronic ones if possible. But for present, preventing illness is just as important and arguably sometimes more important ⁓ than treating illness before it happens.
Dr. William Dodd (04:03)
Yeah, absolutely. I mean, especially in pediatrics, if you catch an illness in a baby or like depression in a teenager or something, that disease could impact their entire life. you know, we're assuming that the children have their entire lives ahead of them. you know, if you can prevent an illness, you not only prevent, you know, disability from that illness, but you prevent a lot of pain and suffering on the part of the child.
Dr. Sukhvir Singh (04:38)
Exactly. I think the goal really with the preventive health is that sometimes mitigating risks and preventing problems before they turn into big, big problems down the road and as the child grows. We can do lots of things for preventative care. Some of them are a little bit more active, but we can do things like screening with verbal questions and sometimes questionnaires that we put out for families that can help us dictate whether or not we need to delve into any specific issues that the children and families might be having, and also making sure we introduce things like vaccines to help protect against preventable diseases and counseling. So the family understands how the child's needs and care may change as they get older, you know, and that can very greatly - the counseling, obviously, that we're going to do for an infant's family versus a teenager's family is going to be very, very different, but it's ⁓ just as important in either case.
Dr. William Dodd (05:45)
Yeah, absolutely. ⁓ I mean, it's kind of like the thing that we do at well visits. ⁓ I mean, if you're looking at prevention kind of as a broad topic, ⁓ is there any way you can ⁓ maybe split up prevention or look at prevention as subtopics or the different types of prevention?
Dr. Sukhvir Singh (06:10)
⁓ Yeah, think one of the two main ways we can split that up is ⁓ primary prevention. That can be things like talking about the safety of ⁓ medications and things like that. Secondary prevention might be ⁓ things like ⁓ protecting cholesterol issues early and then treating early before it becomes a bigger problem down the road.
Dr. William Dodd (06:45)
Okay, so primary prevention might be something like where you're intervening on an illness that the child does not have to prevent that illness. So for example, when we have a teenager or an adolescent and we're talking about HPV vaccination to prevent cervical cancer, they don't have cervical cancer. They don't have cervical dysplasia. They hopefully don't have HPV that would
cause that, but by...
vaccinating them, we prevent them from getting that illness in the future, hopefully, which, you know, is a devastating illness and worth preventing. It's the leading cause of cancer death among young women. And, you know, if we can prevent that illness, it's very important. It's no less important than treating an ear infection, for example. You know, prevention is...primary prevention is very important for the patient's health. What about...
You know, in terms of secondary prevention where they have an illness and where they may not have symptoms of that illness. What are some examples of that, Dr. Singh?
Dr. Sukhvir Singh (07:55)
Yeah, so secondary prevention would be maybe doing things like screeners that would help us identify a problem that maybe the parents have not seen yet, or maybe they've been a little suspicious of, but have been unable to put their finger on what might be going on. So sometimes we might be asking, know, six month old, maybe the families for six month old babies, you know, what is your baby able to do motor wise and if they say, well, my baby's having a lot of trouble, you know, holding things and doesn't really have a whole lot of tone at all to be able to sit up with some support. And that might raise some alarm bells as to maybe things might be going on when it comes to neurological issues or motor issues for the infant. If the child has a delay, it would allow us to put in for like a physical therapy referral so that we might be able to mitigate the risks of any long-term consequences of that in the future.
And if a child might have something like autism, screening for that when they're 18 months old and 24 months old, that's something that the child would already be showing symptoms of at about that age. And if we are able to identify it, then we're not able to always fix the issues. But for things like autism, it will allow us to make sure the family and the child get support so they can thrive as much as possible with their issues.
Dr. William Dodd (09:30)
Yeah. And that's, that's so important as well. I mean, so much of parenting is trial and error and instinct. know, somebody who has a six month old and is waking up all night and dealing with, I don't know, teething and, ⁓ and introducing foods and changing diapers and all the other chaos of everything may not, pause to think, you know, if my baby is not rolling over, is that abnormal? You know, it's not something that leaps to mind. So. having that well child check and getting that screening and intervening if there is a delay, so important.
What about ⁓ in terms of the primary prevention, you know, that ⁓ preventative counseling, you know, what sort of counseling or advice do we give at Well Child Checks that would fall into that category?
Dr. Sukhvir Singh (10:31)
Yeah, that's a great question. So that the primary prevention and the counseling that we're going to give to families as the children are growing during their well child checks is going to change, you know, based on the age of child. So, for example, for, you ⁓ know, during a nine-month-old well child check or a 12-month-old well child check, you know, the most important things I need to talk to the parents about is making sure the house is safe. making sure we keep firearms and chemicals and medications locked up, making sure kids get to things that they can choke on, things they can pull down on themselves. And then for a teenager, it might be something very, very, very different. Are we making sure that they're exercising? Are we making sure that we're eating healthy, avoiding junk foods, making sure we're maintaining, know, parents are in tune with their children's mental health, things like that.
Dr. William Dodd (11:31)
I mean, I always like to tell parents and teenagers, like the habits that they build when they're teenagers and their adults in their life are ⁓ helping to direct them to form these healthy habits. You know, they're going to carry those the rest of their lives. It's hard to start eating vegetables and exercising if you didn't kind of grow up doing some of that. You know, it's just we're creatures of habit.
Preventative counseling is one way to kind of change the course of somebody's life. What about screening? What's screening?
Dr. Sukhvir Singh (12:11)
⁓ So the goal of screening really is try to catch a problem before it turns into a bigger problem or before it really even starts. The main goal is we're trying to ⁓ detect a potential health issue and then early enough that we can timely intervene and decreases ⁓ the chance of an adverse consequence. So really the goal is to improve the long-term health of the child and improve the chances of appropriate and then quote-unquote normal development. And we find that if we do appropriate screening, it can really, really, really help set them up for success ⁓ later on by decreasing the chances of kids getting to a point or chronic illnesses getting to a point where it's harder to fix.
Dr. William Dodd (13:08)
Yeah, so, you know, I always like to say screenings are like a check engine light, which, you know, check engine lights are extremely annoying, but, you know, when it comes on, you don't know what's causing it, but you probably should figure it out because, you know, if you don't figure it out, it could lead to a worse problem. It's worth investigating. And sometimes it's nothing. I used to have a minivan. The check engine light would come on all the time. because the gas lid wasn't ⁓ detecting itself being screwed on enough. And so that would be like a false positive screener, but still worth figuring out. ⁓ You know, an example in teenagers, we use a tool called the PHQ to assess teenagers for depression, which isn't always obvious in teenagers. They don't always feel depressed. They can also feel disengaged or feel apathetic about ⁓ doing things. ⁓ And so we have a screener called the PHQ that asks a bunch of questions that are all symptoms of depression. The adolescent ⁓ marks on that form whether they experience those symptoms ⁓ infrequently or frequently. And you can kind of use that as a tool to screen for depression. But there's a lot of stuff that can mimic depression. ⁓
You'll have a positive PHQ, but it doesn't mean a child has depression. For example, if a child is using their cell phone when they're trying to go to sleep and they're getting like three hours of sleep, they may put on that form. They're tired, they have low energy, they speak slowly, they have trouble concentrating. ⁓ They may even kind of feel a little bit depressed because they're sleepy a lot. But that doesn't mean that they have a clinical depression. So when you have a positive screener is important to kind of drill down and figure out why that screener is positive and what that screener means. Are there any examples from early childhood that you might have a screener that you or a screening test that you do that may have different meanings?
Dr. Sukhvir Singh (15:24)
Yeah, I would say maybe for infants one of the earlier things that we can do that ⁓ you know that can detect issues later on is maybe checking for head circumferences. You know, sometimes parents wonder why do we do that for, you know, making sure make each other brains grow? I’m like, yeah, that's that's one of the main things to make sure the brains are growing appropriate because the brains are growing that means your skull is gonna grow too. We want to make sure that the sutures the bones and the head where they kind of align together, those are, you know, fusing appropriately and at the right times. You know, just because sometimes there can be some true pathology and abnormally, you know, low head circumference or a decreasing percentile there or an increasing percentile can help us, can clue us into, hey, maybe we need to look further as to what's going on here. Are these sutures kind of getting glued together a little bit more quickly? Are we having problems with hydrocephalus and we didn't see that earlier? Do we need to do any imaging to figure out kind of what's going on? I mean, most of the times, you know, the baby's just got big heads and usually you can tell if the
dad's got a big head, it's going to happen in the kid too. yeah, that's really helpful. And I really liked your check engine light kind of way of looking at things because you know, just like a check-in, generally, the screenings and help us, ⁓ you know, clue us into, something might be going on and we should probably jump on it, take care of it quickly because otherwise it can become an expensive problem later, both financially and when it comes to, you know, the prices we have to pay with our health.
Dr. William Dodd (17:02)
Sure, yeah, you don't want to miss an intracranial problem for sure. I will say I have to buy special bicycle helmets because my head's so big.
Dr. Sukhvir Singh (17:13)
I used to have to always buy the small ones because the regular size stuff didn't fit on me.
Dr. William Dodd (17:17)
You're lucky. Dr. Singh, what makes a, if you were designing a screening test, what would make it a good screener? Like, what do you look for in a good screening test?
Dr. Sukhvir Singh (17:19)
What?
⁓ I think maybe some ⁓ questions should be easy for the families to understand, easy for us to ask. The barrier should be pretty low as to administering the test. And you want the test to be very, very ⁓ sensitive. So you want to detect everybody who might have the problem. ⁓ It doesn't mean that ⁓ the problem absolutely 100 % exists in that patient or for that family, but
⁓ you want to make sure that you always detect it just in case it is happening. And of course, that's going to lead to over detection, that's going to lead to some false positives. But as long as we're asking the appropriate questions in order to rule out those false positives, that's a ⁓ reasonable price to pay so that we can make sure we get the help to those folks that need it.
Dr. William Dodd (18:24)
Sure, yeah, it's always a balance though, because I feel like there can be some harm associated with false positives. I've had patients with false positives on HIV screening with kind of borderline cholesterol results that don't really show a good path forward in terms of lifestyle changes.
You know, the test itself can cause some worry when there's not really a medical intervention to fix something. So I feel like that's one of the harder parts of preventative counseling is when you have a false positive kind of counseling the family and ⁓ working out a reasonable plan forward. Are there any other qualities of screener tests that you would look for?
Dr. Sukhvir Singh (19:22)
I mean, so I think it's also important to screen for things that we can actually ⁓ do something about. ⁓ One, because we'd have limited time when we're speaking to families and we want to make sure that the questions we ask are pertinent to things that we might be able to fix and help them with. One example that can be, know, checking for ⁓ serum lead levels when a child is 12 months of age.
⁓ Just because that can really help decrease the chance of neuro-hognitive issues later on in life. If we're able to help families decrease the lead levels in a child where it might have been elevated at that age. Sometimes we have some false positives there too, and that's okay. Sometimes you got to do some serial checks in order to make sure that the level is coming down. I think in 2021, kind of the level that we're looking for is for the serum level to be below 3.5 micrograms per deciliter. And if it's not, then we ask the families, hey, let's do some ⁓ iron supplementation. Let's make sure we eat healthy. Let's make sure that if there's any environmental changes that we can make by making sure we removed any exposure to lead-based paint, that we do that.
Dr. William Dodd (20:45)
Yeah, absolutely. Sometimes they'll touch something with their finger and we do a finger stick and they'll sample whatever's on the finger along with the blood and get a false... I did that one time when my kid was a toddler. They were vomiting and I ⁓ did a finger stick blood glucose. I had one at home and like one of those machines that tests and glucometer and... it came back like 500, and I just panicked. Cleaned his hand off really well, rechecked it, it was 70. But you know, in adolescence, I agree, all the screening that we do, we can act on. Like we screen for depression, we screen for substance abuse. If a child indicates that they're vaping on the substance abuse screener, you know, there are a ton of behavioral interventions that we can do to try and reduce that behavior that could harm them the rest of their lives. And so much of screening too is related to harm reduction. If somebody has a condition, you want to know about it. Even if you can't, even if they're not willing to stop vaping, maybe there are some things you can work on that'll reduce the risk. Or even if they're in a situation, let's say you have a college kid who's drinking and they're unwilling to change that behavior, you can always make sure that they're not riding around with people who are intoxicated, you know, getting in cars, putting themselves in risky situations, you know, that could cause potential harm. Yeah, even if you're not fixing the problem, sometimes screening, can use it to work on plans to help the child's health. ⁓ How does screening change over the course of child's life?
Dr. Sukhvir Singh (22:51)
⁓ So screening is going to change because obviously our needs and health-wise and the things that we're exposed to changes as we get older. ⁓ But for infants, the screening might be, you know, they can't do a lot of talking to tell them about what's wrong. So we might have to look for things like biological abnormalities. So, you know, we do a CCHD where we're going to check the the oxygen level and that indirectly tells us oxygen level one of their hands that indirectly tells us whether or not there's any anatomical pathologies with the heart that we need to look into. We'll do a newborn screen when the kids turn about 24 hours old that will help us clue into any preventable chronic illnesses that could affect the child. And a lot of times that's done at 24 hour mark, just because sometimes the interventions can be lifesaving or even prevent long-term cognitive deficits if we start with an intervention early. We also want to make sure that the interactions between the family members are appropriate. That means things like making sure that mother-baby interactions are as healthy as they can be. Sometimes postpartum depression is something our, you know, about 20 % of our moms can sometimes deal with, about 10 % of our dads. It's normal almost with how often it occurs, but we want to make sure that we ask those questions so that we can get those families the help they need if they are dealing with it.
Dr. William Dodd (24:43)
Yeah, it's kind of a unique situation screening, guess, because you're not even screening the patient. You're screening them, their mother. But it's so important for the patient.
Dr. Sukhvir Singh (24:53)
Yeah, exactly. And, you know, and those, the screening is going to change as they become, you know, older babies and some toddlers. We want to make sure that the rest of their development is appropriate. You know, talked about at six months of age that making sure that the kids
are sitting up with maybe like some minimal support. Maybe if they're 12 months of age, we're going to ask, you know, are they pulling up to stand?
Are they're saying maybe saying mama or dada or one other word? For toddlers if they're, you know, three or four years old, we want to make sure that their speech is progressing appropriately. If there are two that they're sticking two word sentences together. When they're about four to five, I'm going to make sure that we understand a hundred percent of what they say. And that'll indirectly tell us that they are that they are growing appropriately, that they are developing appropriately. And it'll help us understand and talk to families about, these might be the interventions that we can do early that will help catch the development up to kind of where it should be if a child should be falling behind. And if sometimes the interventions that we talk to families about aren't working as to things that they can try at home then that can help us understand, we probably got to put in for physical therapy or speech therapy or occupational therapy or anything else that the child may need at that point.
Dr. William Dodd (26:25)
Yeah, absolutely. Screening evolves with the growth of the child. And even for adolescents, adolescents sometimes have adult type health conditions, like more and more kids are getting diabetes. So it's important to screen for sugars if a child's at risk for that, or depression, or substance abuse, you wouldn't screen a toddler, hopefully, for substance abuse. But it's so important for ⁓ teenagers.
Dr. Sukhvir Singh (27:06)
Yeah, exactly. And I forgot to mention earlier, and we're just talking more about babies and toddlers just because I love taking care of babies and toddlers. But you know, when kids get a little bit older, we also want to make sure that they're doing well in regards to their behaviors at school, how they get along with each other, how they're along with their teachers. Sometimes parents can say, ⁓ he's just a kid being a kid. But sometimes we can detect behavioral patterns at that point where we can say, hey, know, mom, dad, kids are trying to understand how to interact with the world.
And some of these behavioral issues might be things that we can help fix when they're young so that their interactions with their peers and their teachers are a little bit more positive in the future. And their interactions with you will also be better in the future. And we want to normalize, hey, we're not trying to change their personality. Kids are going to be kids. We just want to make sure that they're in a healthy place when it comes to being able to interact with other peers appropriately.
And, know, of course at that age we want to make sure that they're growing appropriately in regards to their length percentiles, making sure that their weights are appropriate. Because
sometimes if they're not, that can clue us into, are there any unhealthy eating habits that we can, you know, gives us the opportunity to talk about with the families. And sometimes that can indirectly improve the health of everybody in the family. If you get to talk about, let's increase the amount of junk food that we're eating.
Maybe let's start with learning one healthy recipe and doing that once a week before we expand on that and do that a couple of times a week. And just even talking to them about the growth of their child, you can end up doing good for the whole family when it comes to things like inspiring families to make changes to their diet and health.
Dr. William Dodd (28:57)
Yeah, absolutely. I think every parent wants their kid to grow up healthy and happy and do well in school and socially and reach their potential. I mean, we've talked about a lot of screening, a lot of intervention, a lot of counseling. Is there any, I mean, it just sounds like a lot. How do pediatricians keep track of all of this? Is there any guiding guidelines or any schedule that they follow.
Dr. Sukhvir Singh (29:33)
I'm glad you asked Dr. Dodd. American Academy of Pediatrics, Bright Futures is what we like to use. That was originally composed in about 1994. Just a group of pediatric healthcare experts and a representative from families got together and said, we should probably make guidelines as to what are the things that we should follow and make sure our, least, I guess, for lack of a better word, screened for, you know, when children, as children are growing. It was an attempt to kind of standardize pediatric care and the things that we should be checking as pediatricians who want to do the best that we can for our patients and our families.
And what it basically does is there's a whole list of things that ⁓ it outlines that we should do or consider doing based on risk factors that the child family might have in terms of preventative pediatric healthcare. And all those the things that we can do are guided and are different depending on the well check, ⁓ the age of the child at the well check and now we're seeing them.
Dr. William Dodd (30:59)
Yeah, it's really interesting. You know, I have thought that the AAP would have likely had some preventative care schedule that they would recommend prior to 1994, which, you know, I may be old, but that seems relatively recent. You know, modern medicine really is a lot different than... medicine's always evolving, but...
I feel like this sort of thing that defines our practice is so important. It's amazing to think it's only been around for, what, 30 years. And a lot of that has to do with the treatments we can offer too.
If you think back to the first pediatrics practice, you know, it was around the time of the Civil War in New York City. You know, what... medicines were really available then. They didn't have steroids, they didn't have antibiotics, no real vaccinations to speak of. And, you know, kind of as these treatments became available, the things that we can do to help patients kind of increased. ⁓ You know, we have so many ways to prevent harm. ⁓ The Bright Futures guidelines are very important to practice. And, ⁓ you know, when well checks, which are an integral piece of preventative care, ⁓ an integral tool for preventative care in ⁓ pediatrics, there are a lot of well checks. ⁓ Bright Futures recommends that we see first-time parents or any high-risk patient in a prenatal visit. So we would counsel the parent. We would see them at newborn, a couple days into life, one month, two months, four months, six months, nine months, 12 months, 15 months, 18 months, 24 months, 30 months, and then yearly after that. But it's a ton of visits early on in life just to make sure we get their growth monitored, their development monitored, and prevent illnesses that we can prevent with vaccines.
Looking at the Bright Futures schedule is very detailed. We can kind of go into detail on some of these topics at a different time. But Dr. Singh, would you mind running through some of the domains that the American Academy of Pediatrics has identified that are important to discuss at these well visits?
Dr. Sukhvir Singh (33:43)
Yeah, sure. So there's a couple of things that we try to do during every visit and there's some that we do, you know, only during some like kind of key visits depending on what's recommended by the AAP Bright Futures kind of guidelines and, you know, based on risk factors and things that we might see whenever we're taking care of patients and ⁓ talking to their families. So we always want to make sure we get a very good thorough history at pretty much all the visits of ⁓ kind of concerns that the parents might have about the development of the child. When the kids are a little bit older, if they're teenagers, always, you know, we want to ask them, hey, what do you feel is going on? Because sometimes parents might not be clued into things that ⁓ are really bothering the children.
We want to make sure we're doing things like, you appropriate measurements. We always want to make sure that the weight is normal and the kids are growing appropriately. When the kids are young, we want to make sure that their heads are growing appropriately because, like I said earlier, it tells us indirectly whether or not everything's okay inside the noggin. And, you know, but we're not going to do that the whole time. We'll do that until they're about, you know, two years old. And after that, if things are normal when it comes to head circumference, then we don't have to continue, you know, checking that height is something that we'll be checking the whole time. If a child might be growing way too fast when they're young, that might tell us, there a hormone issue going on? Or if they start, their height percentile starts dropping off, then we have to start asking ourselves, are growth plates closing a little bit too quickly? And once kids get a couple years, that's when we old them, so we start checking for things like blood pressure. Of course, we're not going to do that for an infant.
But for older children, can help clue us into are there any issues when it comes to hypertension that runs in the family that can affect children? Are there any renal issues that might be causing blood pressure issues for children? Kids are a little bit older and we want to check for hearing invasion. So we'll do a screen to make sure they're hearing the appropriate frequencies. Because if they do have a hearing deficit, that might impair how well they're doing in school.
And sometimes the teachers might tell the parents, you know, the kid's got ADHD and we need to get the kid medicated. And it turns out actually the kid just can't see the board. Yeah. And we've got the kids sitting in the front. And he still can't see it. And once we get classes on him, know, little Timmy starts doing great at school. Yeah. And, you know, we always want to make sure that developmentally they're reaching their milestones the way they should - that they're interacting with other children the way they should, with their parents the way they should. ⁓ So that just in case there are any deficits or signs of things like autism that we can make sure that we give them the support that they need early on. When they're teenagers, it's a little bit less when it comes, you know, they are trying to be social and sometimes trying to be...social in the way they feel is appropriate can lead to mental health issues. And we have to talk about, it's appropriate to be social. We don't want to be, you know, we don't want to be doing things like smoking and drug use and alcohol use because that can lead to issues with ⁓ your mental health. What else do I want to talk about? Let's see. Well, we're going to do a physical exam ⁓ during every visit just to make sure that we don't have, yep, making sure there's no gross abnormalities, making sure we don't have any murmurs that are popping up out of nowhere, making sure our lungs sound great, that our limbs are working appropriately because sometimes there are issues that can pop up later on in life and kids can appear completely normal and sometimes during physical exam we can discover things like a heart murmur that we didn't discover earlier and it might tell us, hey, we've got to get you seen by cardiology because it's really important to keep your heart healthy. Let's see. And there are labs that we need to do and other types of, I guess, to qualify as a procedure. So we'd want to check things like lead levels when the kids are about 12 months old. When they're 9, 10, 11 years old, we want to look for signs of dyslipidemia because sometimes ⁓ very high levels of cholesterol can run in the family and identifying that early and getting a child started on medications early if needed or hopefully making dietary changes as appropriate can ⁓ kind of mitigate the chances of dyslipidemia causing issues for the child's heart and blood vessels in the future. We want to make sure we do ⁓ the screening for ⁓ sexually transmitted ⁓ infections for children that are sexually active, teenagers when they're sexually active. And some of those can be things like gonorrhea and chlamydia screenings every year, maybe doing HIV screenings ⁓ at least once, that kind of stuff. And that also, doing the screening also helps us kind of open up counseling so we can talk to them about - we got to make sure that we practice safe sex and that you're using condoms during sexual activity in order to decrease the chances of transmitting or getting an STI.
Dr. William Dodd (39:35)
Yeah, absolutely. And screening, you know, kind of underscores the risk that is associated with certain things. Like, even like cholesterol screening in the setting of a child who's struggling with, you know, healthy eating or weight kind of underscores the importance of working on that, you know, for longer term health.
Dr. Sukhvir Singh (39:58)
Yeah, absolutely. Let's see.
When the kids are little bit younger, we always want to make sure, hey, it's really, really important to set up the habit of brushing your teeth every day, making sure we're using chlorinated toothpaste, maybe doing four-eye varnishes whenever kids are young, making sure that they get set up with a dentist in our area. I'm sure many people are having this problem. have a kind of a need for dentists who are willing to see patients with TENNCARE just because we have so many families that know that they need to see a dentist but are unable to find one. So this also gives us an opportunity to give them lists of folks that are able to take their insurance so they can actually get seen. And of course, we're going to give the appropriate anticipatory guidance during every visit about things that the family should be looking for when it comes to ⁓ the children growing, ⁓ to make sure that the development is normal, and advice on things that they can do to help the child thrive and do even better they're doing when they see it.
Dr. William Dodd (41:11)
Yeah, absolutely. Anticipatory guidance has no side effects. But Dr. Singh, I think we're running out of time here, but it's been a really interesting conversation. I really appreciate you coming on the show, and maybe we can have some more conversations a little bit more in depth about a few of these topics.
Dr. Sukhvir Singh (41:34)
No, absolutely. Thanks for having me on. This was a lot of fun.