It's the Little Things

What To Do When You Don't Like Your Doctor's Nurse

Dear Dr. Cason,

I just need some advice on a certain situation. My pediatrician used to have a fabulous nurse in the office that recently left and was replaced by a horribly incompetent one. She was awful at giving my 15 month old her shots and it really traumatized her, not to mention the needle came apart from the syringe as she injected one of them and the needle was stuck in my daughter's leg and some of the vaccine got on me instead of in my daughter. That's just one example of the horrible experience. What my question is, is how should I handle this situation? How would you prefer a mom to handle this situation if it was your nurse? I just really don't want this nurse to give my daughter any more shots. She has never been so traumatized by shots before, they have never been a big deal to her or me. I am already nervous about her next checkup. I want to handle the situation correctly but not get anybody in trouble. My pediatrician is just as caring as you are, so I would guess she would want the same actions taken that you would. Thanks so much for your time! - R



Dear R,

Oh no, that sounds like it wasn't a good moment for anyone! Situation like this happen all the time. I'm sure that there are many different ways you could handle the situation. For example you could go to the nurse and explain your concern or go directly to the office manager as they are trained to handle patient complaints. However the simplest thing is just to go directly to your child's pediatrician. She'll definitely want to know that something occurred and how she can best help you feel comfortable.

Don't rule out that this nurse may be very good and just have made a mistake. She also may be inexperienced and need more training. But then again she may truly be incompetent and need to be relieved of her duities. Having said all this, regardless of why it happened, someone needs to know so they can ensure that it doesn't happen again. I hope that this works out for you. Already it's stressful to bring your child in and watch them anxious but to worry if the nurse is doing the best of their ability is extra stressful.

Don't feel guilty about getting anyone in "trouble". As human beings we'll make mistakes and it's critical to receive constructive feedback. This is how we become better and grow as individuals and professionals. I do hope though at some point you'll talk directly to the nurse. She may have been having an off day and feel just as terrible as you do. I know that I've made mistakes and have been immensely grateful when I'm allowed the chance to make it better. If only just to say that I'm sorry.

Please let me know if I can be of any other help.

Sheila Cason MD

ADHD Meds and Your Underweight Child

Dr. Cason,

Hello. I have a 10 year old little girl that is being treated for ADHD. She is currently on Vyvanse. The medication is working well for her. My problem is she is very underweight. She is 50 lbs. You can see every bone in her body! Protruding hips, ribs, and back bone. She is just scant of the 10% percentile on her growth chart so her pediatrician says not to worry unless she is 5% percentile. I could not even imagine what she would look like then!

We have tried to add other medications to increase appetite like Mirtazapine, but this is an extremely strong medication and knocks her out for a day. I don't want her to take that at 10. She eats high fat foods, (cheese, beans, ice cream, peanut butter, pasta etc.)I also give Pediasure once a day; she eats normally for her age but does not gain weight. I hear often from other people how skinny she looks too, so I don't think it's just me being too concerned.

She also seems to have a decreased immune system, she is sick often, and seems to catch everything going around. I am tired of being told not to worry when my child is always sick and is (not matter what the chart says) way under weight. Any suggestions?

Thanks so much... -K

Dear K,

Loss of appetite is a very common side effect of ADHD medications. ADHD meds can be very helpful for those kids where other options to treat ADHD meds haven’t been found to be helpful. Vyvanse (Lisdexamfetamine dimesylate) is a prodrug of dextroamphetamine which belongs to the group of medicines called central nervous system (CNS) stimulants. Stimulants are the most effective medications available for the treatment of ADHD as they increase alertness and concentration. Unfortunately the way that ADHD meds work also is the specific reason why your child is underweight. It suppresses appetite.

It sounds like you’re doing all the right things. Some people do add Remeron (Mirtazapine) because at low doses it acts as a antihistamine which increases sleepiness and stimulates appetite but there has been some concern over the use of anti-depressants and suicidal ideation in children. You definitely need to have someone experienced with ADHD
manage your child’s case.

Probably what will be most effective in helping your child gain weight is to give your daughter a
medication holiday if that’s feasible and okay with your doctor. You can give them a rest over the weekend and on vacations when increased attention won’t be as necessary for school or homework. I’ve also had some parents focus on feeding their children calorie rich foods as the medication wore off. This would be a time where the “No food before bedtime” rule could be bent.

I think your child is very thin as well. I charted her on a growth chart and my calculations showed a ten year old child who is 50 lbs is less than the 3rd percentile for her wt. Put another way, she is the average weight of a 7 year old. Given that she is on ADHD meds this may be the reason and if she otherwise looked healthy, it would be reasonable to not undergo other specific testing at this time. But if she’s sick a lot, she may be having other medical issues and would warrant a check up with her doctor. What labs need to be checked will be tailored to your child’s
specific situation and symptoms.

For now I would go back to your pediatrician and really talk with them. Bring up your concerns. Often when I have a family come in and express a deep concern, I will order labs even if I think everything is okay. I find it’s worth it to under go the tests for peace of mind. If the labs are normal you can assume it’s just the meds. You can then focus on giving her high calorie foods, medication holidays and returning for follow ups to monitor her growth. If your doctor isn’t comfortable managing the ADHD or poor weight gain, she can be referred to a behavioral specialist and a nutritionist for management.

Please see my other article on Tips on Mealtime and Your Underweight Child.

Best of luck to you,

Sheila Cason MD