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Helen Dandurand (Host): Welcome back to the Well Within Reach podcast. I'm your host, Helen Dandurand. And today, I'm going to be joined by Dr. Federico Herrera, Riverside pediatrician, to talk about well-child visits in the first year of life.

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Host: And we are back with Dr. Herrera. Thanks for joining me today.

Dr. Federico Herrera: My pleasure. Thank you for having me here.

Host: Of course. So, we were just chatting that this is your second podcast or really third, because we did an English and Spanish version of your last podcast. But could you start for anyone who maybe hadn't heard those episodes by telling us a little about yourself?

Dr. Federico Herrera: Absolutely. I was born and raised in Argentina. I did my medicine school back in Argentina as well. I've been in the U.S. for a little bit over 17 years. I had my first 15 years of practice back in Chicago. And about two years ago, I moved down here in Kankakee County, living in Bourbonnais, and I'm loving it.

Host: Great. Great. How many years did you say you've been with Riverside?

Dr. Federico Herrera: Almost two years now. Time flies.

Host: Great. At our peds office. So, we're going to jump in on the topic of the well-child visits. So, why are well-child visits so important In the first year of life?

Dr. Federico Herrera: The most important part of the first year of life is that pretty much everything about growth and development. So, we want to ensure that patients, our little babies, are growing adequately, not just physically checking weight, length and impressing footprints, but also making sure that their neurodevelopment is appropriate as they grow visit by visit. So, we want to ensure that they are very good and ideally as pinpoint on the appointments when they're supposed to come. There's always a little bit of cushion in between appointments plus minus a week or so. But the more accurate they are to come to their appointments that are set, the better understanding of what is expected and, with the questions, appropriately answering those questions for parents.

Host: Because, you know, babies change so much month to month, even week to week in the first, you know, amount of time when they're first born. So, it's definitely important to be on track with those, and kind of catch those changes and developments, right?

Dr. Federico Herrera: Absolutely. Yeah. Everything happens in a blink of an eye.

Host: Yeah. So, can you walk us through the general schedule of well-child visits in the first year, like when they happen and kind of what's covered at each one?

Dr. Federico Herrera: The American Academy of Pediatrics recommends a newborn visit, which should happen within the first five days after discharge from the hospital. Of course, sometimes they stay a little bit, a few more days, a little bit less, but within five days of discharge. Then, the next recommended appointment is at one month, then two months, then four months, and six months, then nine months, and then 12 months.

Host: Okay. What are some key developmental milestones that you're looking at in these early visits?

Dr. Federico Herrera: The first thing we do when they get all the vitals taken, of course, we do the heart rate, respiratory rate. We don't regularly do blood pressures unless they're preemies. All preemies should have their blood pressure checked in every single visit, and temperature, of course. But then, we do measures that are extremely important. We do the growth, which measure growth by doing height, length, which they're not standing yet; weight and head circumference. And then, neurodevelopmentally speaking, we want to ensure that they are meeting their milestones that you may have heard of or read a nywhere, pretty much all over the internet. They're progressively moving forward from doing tummy time, lifting their head, lifting their chest, supporting their body weight, where they're doing tummy time with their arms, then slowly doing the sitting, then slowly doing this pulling to stand up, then remaining standing up by themselves, and then slowly walking.

And all those, of course, again, it's a cushion. This is an expected amount of development where we expect that certain appointment. But of course, plus minus, again a few weeks is always a cushion. It's a range of normality. And that's also important to know because a lot of parents come and compare, which comparing is good. But the problem in comparing could be good or it could be not so good. It's always good because it brings the parents the doubt and the questions about, "Oh, my kid is not doing this yet. My nephew, my niece, a friend already was walking by the age of nine months, which is early." But then, always we say, "Oh no, you know what? This is normal." It's most commonly frequently seen that this patient may be walking by eight, twelve months, for example. But then, we have a cushion over the end that some kids are much earlier, nine, 10 months, and some kids are a little more on the later part up to 15 months. So, always knowing that there's a range of normality when to expect this milestones can give a lot of peace of mind for parents as well.

Host: Yeah, that makes a lot of sense. And typically, especially for maybe first time parents, when they come in, do you kind of supply them with when they should be expecting to see those things? Or do you recommend they kind of find that at a certain resource, like the ages and things?

Dr. Federico Herrera: Resources are all over the internet is where to find them. That is extremely important. The one that we as pediatricians use the most is called Bright Futures, but there's a lot of literature that can be found all over the internet as long as any information that you take from the internet is supported by the American Academy of Pediatrics. That's going to be reliable information on every visit when they come to see us. We always try to supply information about development as well, that it was expected at that appointment. And through my assessment and plan, I always try to put things that if they're already at that milestone achieved, then of course great. And what is expected for the next appointment. And if they're not yet, of course, we need to do like more encouraging to do some practice, some exercise with the little babies to achieve them. And of course, if we see they're falling way behind, then, in that case, of course, there's other referrals, things we can do to make sure that the patients don't fall behind.

Host: That's great. So, you're saying you put those notes normally in their myChart so they can look back. They don't have to be writing things down with their hands are full. They can look back and see what you say. Awesome. So, those were kind of some of the things, and I didn't hear you mention at all vaccines, but I know those are a big part of the first year. Could you explain what parents might expect in terms of immunizations and why they're critical?

Dr. Federico Herrera: So, immunizations are extremely important. It's a hard topic to address. Hard from the sense that there's a lot of, again, as I was saying before, a lot of information out there and there's good information and there's not so good information. So whenever we try to do any kind of research related to any topic in medicine, this particular subject being vaccines, it's always extremely important to make sure that the data we're getting from the internet is There's a substantial amount of information coming from reliable sources. I know there's a lot of blocks, which are awesome because there's a lot of parents sharing their experiences. But also at the same time, I always made the same kind of analogy when you go to a restaurant and there's 10 people didn't like the restaurant, maybe nine or 10 people will leave a bad review. When people like the restaurant, maybe two or three will leave a good review. It's always going to be about the critic or the review, or the comments that are left is extremely important.

So, going back to vaccines per se, it's extremely important when vaccines are starting to be not addressed or not being given appropriately. Of course, things happen as we recently actually have very close experience. A few months ago, actually, almost a year ago now, what happened in Texas. Then, when we stopped vaccinating, it only takes one outbreak of a virus that could be preventable and drastic things happens.

And I think even that sad episode proved that vaccination helps. Over the course of the last year, when they tracked all the measles outbreaks throughout the United States, 96% of the patients that actually were diagnosed with measles were unvaccinated. And the two fatalities that, at least as per my memory, I can remember that happened in Texas, both were unvaccinated as well. So, I'm not trying to say that being dramatic, but vaccines make a difference.

We are lucky that most of the patients get vaccines. So, that gives us what is called a cocooning effect, meaning they're having a lot of people vaccinating around you, somebody just cannot get vaccinated. For example, in particular situations like patients that are immunosuppressed by vaccinating everybody around them, that patient has an indirect protection, but not a hundred percent protection. So, always having a thorough discussion about vaccines, why we do vaccines, when we do vaccines, and not just the simple "Oh, so they don't get sick." There are more things to bear in mind, the reality of the complications, including death as part of the complications of some of common infections that thankfully we don't see them anymore.

And that's where my background comes, I think, like valuable to where I come from, Argentina, being a third world country. Yes, main city where I did my studies was Bueno Aires, which is a first world city, but then the rest of the country sadly is not. The accessibility of vaccines is not always there. And sadly, I had the opportunity of seeing patients with very common infections that could have been prevented and what can happen.

Host: So, you've got the experience.

Dr. Federico Herrera: I had the experience, first hands on experience of seeing how bad can those infections that could have been prevented could happen. And I always address vaccines in a nonjudgmental way. I have substantial amount of parents that they decline some vaccines. And I never criticize, I never look them with a weird eye or judge them in any way. But I always want to make sure that whenever they decline a particular vaccine, they make sure that they do a knowledgeable declining of the vaccine. Knowing that if you're declining, then it's just not that they're not going to get the infection, that's it. That it can happen, all the subsequent problems and that they're aware that whenever they say no, it's just not to a poke. It is not no to the poke, but all the subsequent, again, problems that may arise because of saying no to the vaccine.

Host: Absolutely. So, that's really great. I mean, that you're so supportive, you know, that is a choice, but that you're educating to the best of your ability, kind of what that means. So that is very important. And so, that also happens during these well-child visits. Is that correct?

Dr. Federico Herrera: Oh yeah. Every single well-child visit. And even if they say no to a vaccine today. On the next well-child visit, I will revise that again and again and again and again until they're 21 years old, which our first policy in Riverside, that's until when we see pediatric patients in our clinic, and then they can make their own decision after that. But I will not be pushy, just mindful of, "Hey, you did not get this vaccine. How about now? What do you think about it? Do you read anything else? Any more questions?" Try to go over and over and over.

I know a lot of parents, but after X amount of time, they may change their mind or they may have an experience with somebody around them, or sadly their own experience with an illness, and then they say, "Oh, you were right," and they start getting the vaccine. So, not try to convince. Ideally, try to make sure that they make a knowledgeable decision, and hopefully by getting more reliable information, they realize that, "Oh yeah, that makes sense," and hopefully changing their mind.

Host: Yeah. Great. Well, we are going to take a quick break to talk about primary care at Riverside.

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And we are back with Dr. Herrera. So, what kinds of questions or concerns do you typically see that parents will bring up during these visits? And what do you wish maybe more parents would even ask about?

Dr. Federico Herrera: The first question I always get from the newborn to the optional second week of life appointment to the first month, even maybe the two months still is breastfeeding concerns. If they're breastfeeding enough, if they're producing enough milk. So, I do personally spend a lot of time doing lactation consultation to my moms or if they opt to add or not do breastfeeding breast milk and they go straightforward for formula, the different types of formula, what each of those formulas, what do they mean? There's normal formulas, partially hydrolyzed formula, fully hydrolyzed formulas, amino acid formula. There's alternatives to soy, goat milk. And all of them are valid. There's a specific one for each patient, depending on what the problem is to start with.

Then, usually, I try to address each appointment with the most common questions I've been getting over the last 15 years. For example, I always say the same thing at four months. Four months, we start seeing the teething concerns. Not that maybe teething will start at four months, but we start seeing drooling, the patient gnawing on everything, they want to bite everything.

And the second concern, they're much more aware, they're already starting to sit up. So when the family's having dinner or lunch, any kind of meal, the baby looks at the meal and is already tempted, "nom-nom", looking for that meal. But the official recommendation is to not start meals until six months. So, addressing, doing what is called anticipatory guidance. We see signs of that where patients may be going through, but not quite there yet. So, addressing them on a timely manner so we prevent problems. Again, in this case, feeding-wise, it's not that they cannot be fed at four months. It's not that the patient's not able to be fed food or puree, but the immune system is not fully developed. So, the main concern with starting too early, for example, will be gastrointestinal infections.

And then, as they grow older, again, typical questions say, "Oh, my kid is not sitting yet," and maybe they're not doing the right way of positioning the patient, where patient starts sitting doing the tripod, which is showing the patient to put their hands in front of them so they can support with the hands first. And then, when they start sitting, showing like what is called the parachute when they fall to one side, to put the hand on one side or the other side to avoiding falling. Always preventing, when they're practicing sitting down, making sure they put a nice cushion behind them. So just in case they go backwards, they don't hit their head. And then, with some kind of same process, with standing up and start walking. We start cruising and then walking. Those are the most common things. When should my kid be standing? When should my kid be sitting? When should they be pulling? When should they be cruising? When should we start feedings?

Feeding's a big one as well. "Oh, I want to start feedings. How should I start feedings?" And there's a lot of trends going on out there as well. So, I'm not against trends. It's just to be careful to address it with your provider. What, for example, right now is very big out there, lead weaning. I'm not against it, but we have to be very cautious when we do that type of feeding, which is pretty much feeding the baby everything that parents are eating. Be very conscious that their swallowing reflex may not be the best one, and it may actually post a risk towards choking. So when you do those, maybe be careful of what you are offering, how much. Make sure to always consult your pediatrician when you're trying to do something that is outside of what American Academy of Pediatrics recommends to see what we can accommodate that to the patient without contradicting parents, but making sure it's a safe way of addressing that problem.

Host: Yeah. That's great. Maybe we could do another episode coming up here quick about feeding and feeding children. That'd be a good one.

Dr. Federico Herrera: That's a very interesting subject.

Host: Yeah, absolutely. Okay. But yeah, so it sounds like you and pediatricians are such a wealth of knowledge and any question you have, they can be sure that you could have the answer or find the answer to it and feel good about that. So, how do you feel like these visits help build kind of this long-term relationship between families and provider?

Dr. Federico Herrera: So, I guess the most important part about those well-child visits, not just, again, as we were saying before, assessing patients' development, growth, also understanding how the parents think through different visits. of course, everybody's different. And that's one thing I always say, I will never criticize what happens in your house. Everybody has their own way of raising their kids. There's not a perfect book that I could tell my parents, "Hey, this is the perfect book to refer to raise a perfect kid. We were all raised differently, culturally different situations. And I think they're all somewhat acceptable. Of course, there's limits to it. But overall, there's no right or wrong. I always tell them the same thing.

So by understanding what the parents are saying, why they're saying what they're saying, what happened or what is their habit of feelings, again, going back to feelings, making sure that we understand where they're coming from, it makes us understand what could happen, and then having thorough conversations. In my case, I have a benefit of like being here for almost close to 20 years. So, I know the culture here in the United States. But also being Latino, I have a lot of background towards the Latino community as well. So, understanding both sides of the coin, it gives a lot more thorough understanding, more thorough explanation of what things parents can do and how to adjust recommendations that we usually give with the background that that patient may have.

And then, of course, giving the parents the freedom of ask me anything, I always tell him the same thing. There's not such a thing as a crazy, silly question. I'd rather you get everything out of your chest. So by the time you go home, you don't get that, "Oh, I should have asked this." Make sure that you ask every single question. And then, also, that gives trust for the parent that, "Hey, this guy or this lady is listening to me." And that will give us a better, again, understanding relationship and through their every appointment, years. I've been doing this already-- now that I've seen patients growing up all the way into adulthood and start seeing their babies, that's amazing when that happens. And that is beautiful, that they trust you so much that not only you took care of them all through adolescence. And now, when they have a baby on their own, you start seeing them. That's beautiful.

Host: And you could build those relationships and ask those questions and feel comfortable. That's great. What would you give as some tips for new parents to help them prepare for well-child visits, especially if, like I said, it's their first baby.

Dr. Federico Herrera: So, first doing research before the baby's born. In this case, within Riverside, when they go to OB-GYN, they do all the obstetrics, doing their pregnancy checkups, they can already start looking to what pediatricians or family medicine doctors are available that will be able to see their kids, know what is again their background, how many years experience, what are their particular areas of interest in knowing there's a family history of certain illnesses. Knowing that that particular pediatrician has experience or particular interest in those Subjects may actually like give you more peace of mind that not that other pediatricians or other family medicine doctors will not address them, but having more experience in that particular subject will give you maybe a peace of mind that, "Okay, he understands or she understands what we're going through."

My case, I have three boys, my middle one and my youngest one have autism and ADHD. So, my particular area of interest, which that was my first podcast about autism, is something that is very high there on my priority list. The same thing with ADHD. To be honest, all mental health status. But of course, I can address everything. But those areas in particular are very fun to me so that I know that when I talk to a parent that has a patient with ADHD or autism, I take it not just professionally, but also personally, my experiences going through that.

And knowing that, again, in my case, I know what it feels to have a son with autism. It gives me a little bit of an advantage towards understanding what the parents are going through. and I always say the same thing, just to clarify, I will not change the world for my kids right now. There's nothing different I would've done. My kids taught me to be a better pediatrician since they were born with every single step of the way, the three of them. The oldest one's Federico, the middle one, Nathaniel the youngest one, Tobias, they made me a much better pediatrician.

Host: That's great. It's good to do that research and see what specialties that that pediatrician or provider can provide to you. And also, just kind of preference-wise, you know, gender, if you have anything like that, just seeing who's available and what's in the community, because you'll be spending a lot of time with that person as you get going in the first year.

Dr. Federico Herrera: Actually, you just mentioned and I completely forgot. Of course, I'm Federico, I'm a guy, he, him. And oftentimes, thankfully not a lot of times, but through adolescence, through when they're going through puberty, I have some female patients that they may not feel comfortable doing a checkup with a male pediatrician when the patient is female. And I always tell the parents the same thing, i've seen patients for 10 years and they were super comfortable with me. But when going through puberty, they feel a little bit overwhelmed, they're like, "Uh," that's another thing I do want to address, particularly talking about how important is wellness checkups.

One thing that is extremely important to do yearly is genital checkup. And I know that's maybe a taboo subject, that sometimes it is taken that way, but it shouldn't. So, always, before I do any checkup, I need to let them know, "Hey, part of the wellness checkup is I need to check, make sure that the chest is normal, that the genital down there looks normal." And if I see already there's some resistance towards the patient letting me do that, I never, ever, ever will push, force push, to get a physical done if the patient is not comfortable. So, addressing to parents, in my case, saying, "Hey, she doesn't feel comfortable with me. I'm perfectly fine. I don't take it personally."

In our clinic here at the Atrium in Bradley, I work together with Dr. San Gabriel. She's a female doctor. We work together. We have our own panel of patients, but we also can see each other's patients. As I was saying before, we have areas of a particular interest. Dr. San Gabriel sometimes refer patients with me that have autism, ADHD, depression, anxiety, DMDD. And then sometimes have female patients that don't feel comfortable doing a checkup, and we refer those patients to Dr. San Gabriel so she can take care of them. We work as a team. And that's a good thing about the beautiful work in our clinic, the setting we are working right now working as a team, understanding that, "Hey, we don't own the patients." We can always see each other's patients. So, the patient also feels comfortable that, "Hey, Dr. San Gabriel saw you," but I'm aware that she saw you. I know what is going on. It's not that I forget about you.

Host: That's great well, is there anything else that you would like to add today about the well visits, or do you feel like we covered it all?

Dr. Federico Herrera: Overall, the thing like knowing that there's a sequence of wellness checkups during the first year of life, that those are the ones that are supported and recommended by the American Academy of Pediatrics. Of course, at any given point, we can see them more in between, either other concerns, not just from my side, but from the parents' side as well. And one more little thing I always say, we always welcome families to the appointment. We know that parents have to work, mom has to work, dad has to work. So, grandparents, uncles, aunties are involved in the care and raising of that child. So, hearing from them as well as their concern is extremely important as well.

Host: Great. Well, that's so good to know. Well, thank you so much for being here today, Dr. Herrera.

Dr. Federico Herrera: Oh, it was my pleasure. Thank you for having me.

Host: Of course, Anne. Thank you listeners for tuning into the Well Within Reach podcast brought to you by Riverside Healthcare. For more information, visit riversidehealthcare.org.