Ask the Experts

Written by Various authors

Our Experts on Finding a Family Physician, Gestational Diabetes and  Daycare

Our August Experts

Oliver Kharraz, MD, is the co-founder of ZocDoc, a service allowing patients to find nearby doctors. For more information, visit www.ZocDoc.com.

Lori Walker, RD, CDE, is a Registered Dietitian and Certified Diabetes Educator based in Orange County. For more information, visit www.LoriWalkernutrition.com.

Cynthia Baker, PhD, is a licensed Psychologist and co-founder of SoCal Moms Connect. For more information, visit www.socalmomsconnect.com.

What's Up, Doc?

Q (Family): My family just recently relocated to Orange County and we need to find a good family physician. Where do I begin the search and what information should I focus on?

A: Finding a great local doctor who accepts your insurance and can see you at a convenient time is a daunting problem. In the Los Angeles/Orange County area, it takes an average of over 24 days for patients to see a doctor after making an appointment. Unacceptable! As a doctor and a father myself, I fully understand the importance of not just finding an appointment, but discovering doctors who will take the best care of you and your family.

One of the most important factors is the quality of the relationship between you and your doctor: trust, clear communication, and respect should be a given. Asking your friends and contacts for recommendations can be a great first step if you tend to "connect" to the same people. If you want to broaden the set of suggestions, read reviews of doctors online. Make sure you're reading verified reviews on a reputable site because this means that the patient writing the review actually saw that doctor. Bear in mind that on some review sites only the most satisfied and least satisfied patients take the time to seek out the website and write a review. Services that solicit reviews from all patients allow you to get a more representative sense of the real experience of seeing that doctor. It's important to keep in mind that one doctor isn't necessarily better than another doctor. Different patients value different things, and you should read the reviews to find out if the doctor behaves in a way that would make you feel comfortable.

While it sounds obvious, it is important to pick a doctor who literally speaks your language. This usually isn't a problem when your native language is English or you are embedded in your community, but websites will frequently provide you information about language skills, which help you consider all your choices.

Of course, you also want to pick a doctor who is well qualified for your needs. Make sure you know a doctor's education and credentials by speaking to the doctor's office or researching online. Your primary care doctor can usually refer you to the type of specialist you need, if any. If you want to go to the specialist directly, make sure you pick the right one for your problems. Some doctors have a more specialized practice. For example, some orthopedic surgeons will only see you for shoulder problems, but not your hip, and vice versa.

The last piece of the puzzle is to find out if any of the doctors accept your insurance and see new patients. Insurance companies' websites or review sites can be a great way to find this information online. Once you've chosen a doctor, make sure that the opening hours work well with your schedule, or save yourself time by booking an appointment online.

In order to get the most out of the experience of seeing the doctor there are a few things you can do to prepare. In any situation, a list of questions you want to ask is very useful. If you educate yourself prior to the visit with the doctor by reading about your symptoms on reputable websites, don't hesitate to ask why the doctor thinks you have one condition instead of another one. It is important for you to trust the recommendations you are getting so you will follow them fully (rather than skipping the tedious parts). If you are going for more than a routine checkup, it can be a good idea to keep track of your problems, when do they occur, what are the triggers for your symptoms, what exactly do you experience, has anyone in your family or your other contacts experienced something similar? If you take more medications than you can remember, bring them with you; the same goes for your medical history.

When you finally see the doctor, he or she will frequently guide the discussion. You should make sure that by the end of your visit, you have answers to all of your questions, you understand what the doctor said, and you know what the next steps are. If you can't remember the instructions on how to use the drug, device, etc. ask your doctor to write it down for you.

After the visit, consider writing down what you learned so you can refer to it later. Also, if you can, write a review on the web. It will help others choose a doctor. -Dr. Oliver Kharraz

Gestational Diabetes

Q (Pregnancy): I recently learned that there is a type of diabetes that only occurs when a woman is pregnant. What is gestational diabetes and who is at risk for getting it?

A: Gestational diabetes occurs in approximately 7 percent of all U.S. pregnancies each year. When a pregnant woman begins to experience high blood sugars or insulin resistance during her pregnancy she is diagnosed with gestational diabetes (GDM).

Who is at risk? Women are more likely to develop gestational diabetes if they:

• Are over the age of 25
• Have previously given birth to a baby weighing more than 9 pounds
• Are Hispanic/Latina, African American, or Asian/Pacific Islander
• Have previously had Gestational Diabetes
• Have a strong family history of diabetes (parents, grandparents, or siblings)
• Have a pre-pregnancy body mass index greater than 30

Diagnosis All pregnant women should take an oral glucose tolerance test (OGTT) between weeks 24 and 28 of their pregnancy. The OGTT should be taken after a woman has been fasting for at least 8 hours. After the healthcare provider takes the woman's fasting blood sugar, she will be asked to drink a quickly digested, sugary beverage. This test will evaluate how well a woman's insulin responds after drinking this beverage. The medical staff will then check the woman's blood sugar every hour for three hours. If it is determined that her blood sugar is high on more than two occasions, she will be diagnosed with gestational diabetes.

GDM and Your Baby If blood sugars remain high during the last weeks of the pregnancy, there are several problems that can occur. Potential problems for the baby include:

• Increased risk of stillbirth
• A high birth weight
• Breathing difficulty
• Low blood sugar (hypoglycemia) after delivery
• Increased risk of becoming obese and developing diabetes or heart disease

Management and Treatment Upon diagnosis, a woman will be instructed to check her blood sugar at least four times per day. Usually she will be asked to check her sugars in the morning before eating, which is considered a fasting measurement, and also an hour after eating her breakfast, lunch, and dinner meals. This will give insight as to how well controlled the blood sugars are and whether she is consuming the appropriate amount of carbohydrates at each meal.

Many women with GDM can control their blood sugars with diet alone. A healthy, balanced diet is extremely important in order to control blood sugars and provide the nutrients your growing baby requires. Your doctor will recommend you meet with a Registered Dietitian that specializes in diabetes to help create a specialized meal plan for the remainder of your pregnancy. Your meal plan will require spreading the carbohydrates you consume evenly throughout the day between three meals and two to three snacks. It is also advised to avoid sugary or sweet foods because these foods can digest very quickly and cause blood sugar levels to spike, especially if they are consumed in the morning.

Regular physical activity is also important for a woman with GDM. Exercise can improve the effectiveness of a woman's natural insulin to help lower blood sugar. The best time to exercise is immediately following a meal when blood sugar levels are at their peak. It is recommended that you exercise at least 20 minutes four times per week.

It is important to understand that blood sugars often become more difficult to control as a woman gets closer to her due date. This is a common occurrence since the placenta will make more pregnancy hormones as the pregnancy progresses. If this is the case, you may also need to use insulin, which would be prescribed by a specialist, usually a Perinatologist.

Will Gestational Diabetes go away after the baby is born? After delivery, your blood sugar should return to normal. The doctor will check your blood sugar after delivery and then 6 to 12 months following your child's birth. If your blood sugar remains normal, you should continue to have your fasting blood sugar checked at least once every 3 years. Unfortunately, women who have had GDM have a 50 percent chance of developing type 2 diabetes within 5 to 15 years after delivery.

In order for a woman to lower her risk of developing type 2 diabetes, she should achieve a healthy body weight as soon as possible after giving birth. One strategy is to breastfeed your newborn, ideally for up to 2 years. Not only will this reduce your risk of developing diabetes by over 50 percent, but your child will also be 20 to 50 percent less likely to become overweight as an adult. Additional prevention strategies include exercising at least 30 minutes on most days of the week and following a well-balanced eating plan. -Lori Walker

Care-ful Considerations

Q (Infant): My husband and I are struggling with the decision of whether I should go back to work now or stay at home longer with our 9-month-old baby. What's best for our baby? And if I decide to go back to work, how do we find the right childcare for her?  

A: In my private practice, I often work with young couples dealing with the stresses and joys related to the transitions in parenthood. One of the many important decisions to be made during this time is whether Mom (or Dad) should continue to stay home with the baby after a few months maternity (or paternity) leave.
 
There's no definitive "right" answer. Some research indicates that high quality daycare can have a more positive impact on a child's cognitive and social development compared to staying at home with mom or dad. However, those effects "wash out" if children spend more than 35 hours a week in childcare, and we see even poorer social and cognitive development in children who receive low quality care.
 
Given this, how can parents decide? As part of the decision making process, I encourage parents to consider what will make them - the parents - happiest and most fulfilled. The reason for parents to consider their own happiness is this: research indicates that parental depression has a significant negative impact on a child's psychological functioning and social, emotional, and cognitive development. In short, having happy, fulfilled parents increases the chances that a child will develop in happy and healthy ways.

While 62 percent of children in California under age 5 are in at least part-time childcare, only 1 in 7 childcare programs provides high quality care that promotes healthy development and learning. Therefore, if parents decide that they both want or need to go back to work, they must make a concerted effort to find high quality childcare that fits their budget and other needs. Here are some useful tips to help.
 
The first step is finding programs to visit. Start by asking friends, family and neighbors for recommendations. You can also look online for programs near you. Call each facility that interests you and schedule a visit. To limit distraction, do not take your child with you on your initial visit. Be sure to take a notepad and paper.
 
A few key questions to ask during your visit:

Is the approach and philosophy of the program related to child development? For infants and toddlers the focus should be on helping the children develop trust and feel safe in the world, while preschoolers should be learning through play and exploration.  Also, ask what they do when an infant cries for an extended period and they "have tried everything." Ideally you should also see caretakers using slings or carriers to keep the babies close physically.

What is the caregiver to child ratio? For infant care, look for the caregiver to baby ratio to be 1 to 4 or better. For two-year-olds, state regulations require a 1-caregiver-to-12 children ratio but can you really imagine one adult caring for 12 2-year-olds?

What are the caregivers doing to engage the children? Observe the classroom for at least an hour. You want to see caregivers on the floor interacting - playing, reading, smiling and talking - with the babies (rather than to each other).There should be no television in the infant, toddler or preschool rooms.

Is the facility clean and does it have adequate space? The facility must be clean, and caregivers should frequently wash their hands. An infant room should have a no-shoes-inside policy, and ideally toys should be cleaned twice a day and rinsed off, not just sprayed and wiped. Infants also need a quiet and clean space to feed and nap.

What is their policy on parents observing the children? The facility should have an open door policy, and ideally observation rooms should be available for parents to watch their child at any time without caregivers knowing (i.e. one-way mirrors).

What is the staff turnover rate? Low staff turnover illustrates staff are happy in their positions. Your child will benefit from the regular rhythm and routine of consistent caregivers. Ask the director how she supports staff to reduce burnout and retain good employees.

Is the program accredited and does the staff have credentials and continuing education requirements? Look for a center approved by the National Association for the Education of Young Children, which demonstrates the program is dedicated to providing high quality care. Staff should be knowledgeable about infant development and attachment, and continuing education should be required.

How do the caregivers communicate with the parents? You want to know how and when caregivers communicate with parents about routine matters (e.g., what did she eat for lunch, how did he sleep today) and non-routine issues (e.g., sleeping habits, developmental concerns)?

What is the curriculum for "older children?" During your visit, ask to see the older child rooms. Since your child will likely continue on you want to see that the ratios stay low and that the teachers are continuing to support your child's development.

Once you have selected a program, try to ease into the new routine. Start back to work part time if possible. Also, consider flexing your schedule to limit the use of the childcare to 35 hours a week or less. For example, you can go into work early while your spouse drops off and then you can pick up while your spouse works later into the day. Such "flexing" will limit the childcare day to 6-8 hours instead of the more typical 8-10 hours. Those few extra hours of mommy and daddy time are really beneficial to parents and babies alike.{jcomments on}

Give your family time to adjust to the new routine and expect some difficult days initially. After 3 months evaluate how well the program is meeting your needs. And, of course, always observe your baby to make certain she is thriving as expected. Good luck! - Dr. Cynthia Baker