Three Generations of Pediatric Care

At 6:00 one morning, I was playing tennis at our local athletic club a few months ago.  Sam, working at the front desk came running down onto the courts.  “There is an emergency and a woman on the phone says she needs your help.” I will be honest.  I panicked a little.  My husband was home asleep as were my four children.  My thoughts as I raced up two flights of stairs to reach the phone were “Could they be injured or in trouble?”

A young woman was crying and saying her mom was asking for me.  I still could not figure out who was on the phone.  Who knew I was here, at this time of the morning? “It’s Mary’s daughter.  I was still trying to piece this together in my brain.  Mary’s son was very sick, in a hospital, out of state.  Her mother kept saying I was the only one who could help.

Mary had been a co-worker of mine when I was a medical student 20 years ago.  She worked at our local health department where I conducted a study evaluating the benefit of home visiting services for children.  I had spent the summer of 1996 accompanying her on visits to homes in some of the most impoverished parts of my hometown.  More than a decade later, the program was cut due to lack of funding; I jumped at the chance to have her work at my office.  She had since returned to home visiting work in our community.

On the phone, Mary was sobbing to the point I could not understand her.  Her husband got on the phone and said their son, was very ill and lying in an ICU with kidney failure.  Their daughter-in-law had contacted them but could not relay the exact details of his illness.  “Please call the hospital and help us find out more, so we know what to do.”  I doubted I could help them; I did not think the hospital would even talk to me, but told them I would do my best.

I thought about their son’s chart in my office.  I had shredded it two weeks before; it had been more than a decade since I had last seen him and he was in his thirties now.  I take care of his son, Mary’s grandson, who is a young teenager.  I thought about what this loss would mean for my young patient as I dialed the number and asked to speak with the ICU nurse.  She came to the phone.  I explained that I had been her patient’s primary care physician many years ago and a family friend for two decades; I inquired as to his clinical status so I could inform the family.  She told me he was critically ill, they were doing everything they could to keep him alive.  She was not sure he was going to make it the next few hours, let alone days. 

I let her know I would relay the information to his parents and recommend they get on a plane.  “I am not sure they should be told he could die at any moment,” she replied.  I conveyed there was no one else better to relay that kind of message.  She wished me luck.  As I dialed Mary's number, my thoughts turned to my own brother who had died in an accident 8 years before.  I remember that phone call like it was yesterday and the crushing pain that followed when I was told the tragic news. I had watched my own parents lose their son.  I knew what this family may experience today, tomorrow, or next week. 

This was different; their son was alive and they still had a chance to see him.  Mary answered the phone.  “Your son is critically ill and may die today.  I am so very sorry.  The best thing I can tell you at this moment is to get on the first plane available and go see him.  I hope you have a chance to say goodbye, if that is what is to happen.”  They thanked me.  I was crying as I hung up the phone still sitting in the dark parking lot outside the tennis club.

Their son made it through and has a long road to recovery.  Hippocrates said, “Cure sometimes,
treat often, comfort always.”  As a small town pediatrician, I understand these words better than ever before.  Our job as physicians is not always to diagnose, treat, and cure.  It is also to ease the suffering of others and comfort them whenever we can. 

The relationships with families continue long after their children are grown up and become parents themselves.  More than a dozen parents in my practice were my patients as children and now their children are my patients as well.  Our role in the lives of the human beings for whom we have lovingly cared is a wonderful blessing, but also a grind on my heart.  It is a relationship I treasure. 

The True Value of Stomach Acid

To be completely honest, I have never worried much about exposing children to germs.  Children face so few threats from infection nowadays that it is beneficial for their immune systems to expose them to as many microbes as possible.  When parents ask about the necessity of hand sanitizer, my advice is that stomach acid takes care of almost everything a child may put in their mouth.  Let them eat something when it falls on the ground.  Washing their hands before they eat sounds like a good idea conceptually but may not makes a significant difference in their health because they are always sucking on their fingers anyway. 

We have one glass in the upstairs bathroom my children drink from after brushing their teeth, which makes this story about germs and the need for stomach acid all the more fitting. My second summer as a mom to four was physically exhausting; my children were 5, 4, 2 and fourteen months old.  We spent the day outside playing in the sun because that seemed like the best way to exhaust my young ones so they slept well when it is overwhelmingly hot. 

The evening routine went something like this:  4:30pm dinner, then clean up the kitchen, do dishes, and put away leftovers.  Baths were started by 5:30 or 6 pm and took about an hour from start to finish, including getting into pajamas, giving them fluoride, combing their hair, and brushing their teeth.  Barring any notable injuries or unforeseen events, we would then read bedtime stories, snuggle, and talk about our day as I tucked each one into bed.  The goal was to finish by 8pm, so I could read a few minutes by myself and go to sleep.

By this particular hot August evening, I was tired and especially thirsty.   Do you remember how thirsty you were when you were nursing your infant?  After baths, we were sitting on my bed getting ready to read stories.  I was nursing the baby and trying not to sweat too much in our house with no air conditioning.  My two year old daughter came in with a plastic glass full of cold water.  I took a sip and it was really good.  We finished the glass together and she went to get a refill.

I thought how great it was she was being so “helpful.”  She came back a second time with another full cup and all three children and I drank out of it.  When she returned for the third time, I realized I had not heard the faucet running in between trips and wondered from where she was getting the water.  This is one of those moments when you ask a question, knowing the answer right at that very instant.

“From the toilet,” she said.  The thoughts that went through my head at that moment cannot be repeated on the internet but suffice it to say I was speechless.   My kids all started laughing as they did not exactly understand why drinking water from the toilet is not a good idea.  If I had not been so tired, I might have panicked at the thought of what could happen to children who drink water from the toilet.

However, the reality of having four children in four years is you are so exhausted just getting through that day alone; nothing upsets you as long as no one is profusely bleeding.  Instead, you hope for the best and put them to bed anyway.  We all ended up fine and no one became ill, which lends some credibility to my theory about the value of stomach acid. Nevertheless, beware if your 2 year old brings you a cool glass of water on a hot day.  You might want to double check the water source before just blithely taking a sip.     

Autism Is Really a Disorder of Communication and Interaction

The numbers are staggering.  One child in 68 goes on to develop this disease; it is more common in boys.  We do not know the cause and are trying to find the best treatments but progress is slow.  The largest misperception about autism is it is NOT a behavior problem.  It is not something a parent has done wrong; there is no one to blame or judge. 

Autism, in plain and simple terms is a communication and interaction disorder.  Think about that for a few minutes.  Imagine not being able to communicate with your toddler and the frustration that entails.  Think about the way a newborn cries, then consoles in our arms, and smiles; that is interaction.  During that first year, so much communication goes on between a parent and child.  They push the spoon away when they are full.  They watch us clap, copy us, and begin clapping themselves.  Almost nothing in the world was better than that first laugh or giggle.   Then they wave, high five, and learn to “fist bump.”  On to their first words like hi, dada, mama, and ball.  Those single words at 15 months become short phrases by 2 years of age and then full on sentences by age 3.  What if things do not progress that way?

Let us go back to that 2 or 3 year old and flip our point of view.  Think about how hard it must be for that toddler, who cannot get the person he depends upon, to understand his needs. By 18 months of age, a child has a way of letting you know they are hungry, wet, tired, or sick.  They can even convey their moods by crossing their arms and stomping their feet.    Often, if a mother or father has a child with autism, it can be impossible to know what they are thinking, feeling, or trying to tell us.  Maybe they are screaming in public now because it involves more of those big people who do not communicate with them and they feel overwhelmed.  Can you imagine being hungry, uncomfortable, or ill and not being able to get your parent to understand?

I have watched many young autistic children in my office be most comfortable on their mother’s back in a carrier and the moment they are removed from that safe place, they literally fall apart.  They are terrified when being examined or weighed and measured.  Their tiny beautiful faces convey fear;  however, children with autism get ear infections, allergies, and the flu just like any other child yet they cannot tell me what is wrong.

I do not know what it is like to have autism, nor do I have experience raising an autistic child.   Watching these children grow and develop over the years becoming adolescents has been interesting.  Some develop their own way of communicating, especially when I have been caring for them their entire lives.  One of my favorite patients is a teenage girl with autism.  Her and I have never had a traditional conversation, but we definitely communicate.  I look forward to seeing her name on my schedule and she gets a huge grin on her face when I walk through the door.  She gives great hugs, ones that I treasure.   She knows me and has seen me for long enough to understand that I will not harm her.  We trust each other. 

On the other end of the spectrum, I have a teenage boy I take care of, who pretty much hates me.  When I walk in the room, he scowls and tells me his life is miserable and he detests coming to my office. He hates going to school even more, which provides some consolation. I would not exactly say I look forward to his visits, but do value and appreciate his honesty. He is communicating and trying to interact; he is trying to make a connection in his own way.

Social skills at a party might not be a gift of children with autism but they are often bright, capable and eager to learn.  Some of my kids are now attending college and moving toward adult careers.  It is hard to know what any one child will go on and do with their lives. I usually try to ask myself “Is this a future artist, computer programmer, engineer, or scientist who will find the cause of autism or possibly the cure?”

Most importantly, remember that a child diagnosed with a communication disorder at 15-18 months has overcome numerous hurdles and struggled with adversity many of us cannot comprehend.  So have their parents.  It just might change your perspective on things when you realize how much children with autism have to offer the world. 

If Amoxicillin Liquid Were Crack…

I would be totally, completely, and hopelessly addicted.  This past week, I find myself reflecting on my reasons for wanting to become a physician.  I think it had something to do with a tour of our local hospital when I was five.  However, it might have had more to do with my love affair with pink Amoxicillin liquid.

As the granddaughter of a General Practitioner and daughter of a Pediatrician, I had some unique experiences growing up. For instance, I was in the 6^th grade when I learned not EVERYONE gets a suppository up their rear end when they are vomiting.  I assumed it was something every mom bought at the local store, like cough medicine.

My best friend was absent from school and the following day I asked where she had been.  She had been vomiting so she stayed home.  I said “Oh you got a suppository to get better?”  She was puzzled and asked what that was.  I am sure you can picture what happened next; the look of astonishment on her face and the look of embarrassment on mine. 

Let me go back to where it all began:  the days when my dad would bring home antibiotic samples and leave them on the counter.  They were packaged in small little bottles containing one or two teaspoons of powder medication.  If the medicine turned pink when I added water, I had hit the Jackpot!  It was indeed Amoxicillin.  I remember the first taste of “antibiotic crack” like it was yesterday.  It was practically like sneaking dessert.  There were a handful of times I recall mixing up between 6 to 10 bottles and savoring every last drop.  I am certain I ingested more than the recommended dose for a child in one sitting, but who was keeping track?

This exposure to liquid Amoxicillin was buried in the recesses of my brain until my oldest son had his first ear infection when he was three.  Typical signs and symptoms including cough and runny nose for a week, then fever, and left sided ear pain.  The AAP recommends treating the first ear infection with Amoxicillin. I picked up the prescription from the pharmacy, went home, and opened up the bottle.  One whiff of that stuff and all those memories came flooding back.  It is amazing what our sense of smell can store in our brains. (For many, it is like inhaling the scent of your mother’s perfume and remembering your childhood, only a little different.)

After giving my son a teaspoon and tasting a few drops, it was love all over again.  It was almost as good as chocolate and it is just as delicious, pink, and heavenly as it was three decades ago.  My children love it too; they beg for more after each dose.  Not that I give it to them.  Maybe Amoxicillin addiction runs in families after all? 

Please understand this post is intended to be a little whimsical and not an endorsement to fill your children full of antibiotics, as judicious use of antibiotics is important and necessary.  Rather, it is a childhood story of survival in spite of a few episodes of Amoxicillin overdose. I would like to remind all of you to keep your medicines out of the reach of your little ones.

In truth, I might not have ended up becoming a doctor without my love of Amoxicillin. Do you think they would have accepted me to medical school if I had answered “why do you want to be a doctor” with the explanation of my love for liquid antibiotics?  Probably not.  It might be a good thing I did not remember all this until long after being accepted.    

Patients Are In My Mind and My Heart. #DoctorsDoCare

Physicians today are not held in the same high esteem as they used to be.  We are often portrayed as callous, intolerant, clutch-fisted, know-it-alls who schedule patients around our daily golf game.  (For the record, I do not play golf.)  Physicians are not skilled enough at public relations.  A few weeks ago, I got a brief glimpse of how people react when we reveal our warm and fuzzy side unexpectedly.

We are human beings; mothers and fathers, sisters and brothers, sons and daughters.  Like everyone else, we have bills to pay for homes, cars, and endless student loan debt.  Our days are stressful as we constantly juggle to keep up with the demands of life.  This should sound familiar to any adult reading this article. 

Recently, my husband and I attended an informational school meeting and ran into a mother whose children I see in my clinic.  She brought her 5 month old twins in a double stroller and wheeled it to the back of the room.  Just as the meeting began, the twins started fussing.  She picked one up and I walked toward her gesturing that I could hold the other baby.  She smiled, handed him over, and I enjoyed holding and nuzzling him throughout the one hour meeting. 

He cried here and there but overall consoled well in my arms.  About halfway through, he was talking and cooing at me, which melted my heart.  I love babies and their smell, smiles, and giggles; I treasured my time with this beautiful boy.  Seeing patients in public allows me a glimpse into their reality outside my office walls. 

As the meeting drew to a close, the learning specialist at the school approached us.  She stopped to talk with mom, admired her son, and asked how old he was.  Then she turned to me and inquired as to the age of my child?  I laughed and said, “They are the same age; they are twins.”  She looked surprised and confused (obviously she did not witness the hand-off.) 

The more interesting part occurred when mom said, “Yes, they are twins.  She is my pediatrician.”  The learning specialist was completely aghast, stunned, and speechless; her mouth dropped open in shock.  As she recovered, she said “Oh my word.  Really? (No lady.  We play this joke all the time on strangers.)  Are you serious?”  Clearly, she did not know what to say about this unexpected situation. 

Why is it unusual for a pediatrician to hold a little patient in public for a spell?  In actuality, it is probably not that rare, but the public perception of physicians makes it seem that way.  I love seeing my patients outside of my office.  She probably believed I was one of those nutty, hippy physicians… the kind that have conversations and close relationships with their patients. 

There is nothing extraordinary about this story other than it made me realize we need to be better at public relations.  When we establish connections with families we care for, those stories should be publicized.  I love my profession and am proud of what I do, and who I am.   

The “practice” of medicine can be extremely challenging.  We give patients our very best every day.  Doctors do care, but the human body manifests disease is very different ways.  No two patients are exactly alike (even twins), and sometimes we will stumble along the way as we try to solve your health dilemma. We need to be patient with one another and work together.

The public should know more about what goes on in the minds and hearts of physicians.  Please share this piece and start a “Doctors Do Care” Challenge.  If you are a physician, write a story about a patient who changed your life.  If you are a patient and a physician has improved your life in some way, please share your story with the same hashtag.  #doctorsdocare.   

The physician-patient relationship is and will always be the most powerful therapeutic force in medicine.  It is time we collectively harness it, document it, and start a movement.  #doctorsdocare.  I know there are many stories to be told and look forward to hearing them.  #medicinematters  #mydocrocks 

The Eyes Are Crossing? Is It Amblyopia?

Have you ever noticed someone’s eye darting off a different direction, even though they appear to be looking at you?  Over the past month, I have seen more than 10 cases where parents report “eyes crossing”, “one eye turning in”, or “one turning out.”  Seeing, hearing, touching, tasting, and smelling are very important for all human beings.  Something can go wrong with any one of these senses.  Vision is a crucial part of development for every child; however there are times when eyes do not work like they should.  This is known as amblyopia.

Amblyopia affects 2-5 out of every 100 children and is the most common cause of childhood visual impairment.  The American Academy of Pediatrics (AAP) recommends vision screening starting at 4 years of age to detect amblyopia early and allow successful treatment. Children reach visual maturity by 8 years old; the earlier poor vision is diagnosed and treated, the better chances are to avoid permanent vision loss. 

Children with amblyopia receive faulty images from the affected eye and their brain cannot “read” what they are visualizing.  Three main causes of amblyopia are strabismic, deprivational, and refractive.  The first is caused by eye misalignment:  eyes can cross in (esotropia) or out (exotropia).  A brain will ignore, or “turn off” the eye that is not straight and vision loss results. 

The second type develops when cataracts “deprive” an infant’s eyes of visual experience. Left untreated, their brains receive no visual input, then the eyes are unable to communicate with the brain resulting in permanent vision loss.  The “critical period” for visual interpretation in humans is birth to two years of age. 

The third type occurs when severe far-sightedness, near-sightedness, or astigmatism (blurry vision) are present. The brain realizes it is receiving ‘false’ information so it ignores the unclear images, resulting in vision loss in one or both eyes.  These difficulties may be invisible to parents, teachers, and even pediatricians because children cannot report blurry vision.  This kind of amblyopia in children is difficult to detect and may not be found until a child has a vision test.

Treatment of amblyopia is consistent use of glasses or contact lenses over a long period of time. Ideally, glasses should be worn from sun up until sundown.  The brain will learn to trust the corrected images it is receiving.  If glasses alone do not improve sight, then patching the “good eye” forces the brain to pay attention to the images of the weaker eye so vision becomes stronger. This is done through eye patches, eye drops, or a combination of the two.  For parents, enforcing the use of glasses or an eye patch can be challenging, however  kids usually adapt after an initial adjustment period once glasses become part of them.

The best outcome is achieved if treatment is started before age 8, however research has shown that children older than age 12 and some adults can show improvement in the affected eye. Children from 9 to 11 who wore an eye patch and performed vision therapy were four times more likely to show improvement than children with amblyopia who did not receive treatment.   A recent National Institutes of Health (NIH) study confirmed that SOME improvement in vision can even be attained with vision therapy in younger teenagers (through age 14).

If all the above do not correct the problem, eye muscle surgery involving loosening or tightening the muscles causing the eye to wander can be an option. Although it is an invasive measure, surgery is considered safe and effective and usually does not require an overnight hospital stay.

Everything we do in our daily lives involves reading.  Vision is extremely important to help a child function independently as an adult in society.  If you think your infant or child has crossing eyes, especially when they are tired, listen to your instinct and schedule an appointment with your pediatrician.  When amblyopia is overlooked a child loses optimal vision; they will struggle more than others around them for their entire lives. 

A Pediatrician Learned the Value of A Mother's Intuition

Medicine can wear down our hearts and souls.  My journey in pediatrics has been filled with many rewarding experiences but haunting ones as well, like this one from my third year of residency.  By that final year of training, I was no longer certain medicine was really the right choice for me.  I was struggling with the notion that after almost 11 years of education, the destination was not quite what I expected.  It was during this trying time I learned one of the most important lessons of my career:  the value of trusting a mother’s intuition. 

My patient was a 6 year old girl whose mother was sitting next to her bedside.  “Something is not right about my daughter; I would like you to do a blood count.”  I was not compassionate.  Frankly, I was so tired; I did not really care about her reasons for wanting the test.  “Ok”.  I left the room to check the computer for prior visits and a blood count had been done yesterday.  Yesterday, the result was normal.  I was incredulous.  I went relay the story and mother’s request to my attending at the time.  His answer was “do another one and release her once the result comes back the same as yesterday.” 

We were very busy that night.  I sighed, went back to the room, completed a cursory history and physical and let her know I would draw the blood.  I was probably short with her, condescending, and dismissive of her concerns.  I felt justified in thinking she was overprotective and could not possibly “know” what I knew as a physician.  Many years have passed since this experience.  I cannot recall the exact details of the history and physical but I do remember nothing seemed unusual.  In all fairness, that could have been my closed minded perspective getting in the way. 

An hour later, the lab called up to the ER with results.  “Leukemia”, the lab technician said.  My jaw and my heart hit the floor.  “What did you say?” I asked.  “Leukemia”, she repeated.  “How is that possible? The result of the smear was normal yesterday.”  She said, “We missed it, we went back and reviewed the previous smear and that was abnormal too.” 

I walked slowly back to that exam room and sat down with tears in my eyes and told this beautiful little girl and her mother that she had leukemia; the oncology team was going to admit her that night to begin the full evaluation and treatment process.  I felt terrible; not only for the diagnosis but also for how poorly I had treated this mother and her child.  She sighed and said she was relieved to finally know what was wrong with her daughter.  “I am so sorry.”  I was sorry for so many more things than I could say. 

I have always wished to have the opportunity for a do-over.  In my ideal replay, I would walk in and take an extensive history and physical, discuss a list of possible diagnoses with mom, and draw the child’s blood.  I would express compassion for her and tell her it was going to be alright.  Despite having ups and downs during those three years of internship and residency, I learned many invaluable lessons during those three years.  I wish I could thank this mother now.  She taught me the importance of listening to the person who knows their child best, their parent.  It is a lesson I have never forgotten.    #medicinematters #doctorsdocare

For the Love of Whole Milk

As a physician, I should be presenting oral arguments about the Constitution before the U.S. Supreme Court.  If you read the article below, you will probably agree with me by the time you finish.  But I digress.  Let me first discuss how school lunch guidelines were modified by “experts” to remove whole milk from the diet of school aged children. 

When I first went into practice, whole milk was the standard dietary recommendation for all children below the age of 5.  In my opinion, whole milk and other full fat foods (including real butter) will always be better for children, as they need fat for optimal growth and development.  However, childhood obesity has become a national epidemic.  Despite the cause of obesity being multi-factorial, reducing intake of whole fat dairy products was targeted to improve our diets. 

Full-fat dairy products contain more calories, so “experts” assumed avoiding them would reduce risk of obesity. However, when people reduce fat intake, they tend to replace it with sugar or carbohydrates, both of which have worse effects on insulin, diabetes risk, and weight gain overall.  Absolutely NO scientific evidence exists that people who consume low-fat dairy do better metabolically than those who eat whole-fat dairy.  Not one study ever demonstrated children benefit from skim dairy products versus whole fat dairy either.  So why exactly were “obesity experts” recommending low fat dairy?

In 2010, the President put together a Task Force on Child Obesity.  These so-called “experts” who reformed school lunch guidelines decided to offer only low-fat milk or skim chocolate milk (with its added sugars) at school and removed whole milk from the menu.  Guess what?  Not ONE member of the Obesity task force was an MD, let alone a pediatrician.  Five of the 9 members were lawyers! 

To be fair, many of the dietary modifications were based on a report from the National Academies' Institute of Medicine (IOM) in 2009 entitled School Meals: Building Blocks for Healthy Children.  There was one nutritional pediatrician involved.  Repeat.  The opinion of ONE pediatrician determined dietary recommendations for the entire nation of school-aged children. 

WIC and Head Start, responsible for supplying food to economically disadvantaged children in America, followed suit and withdrew whole milk as an option, allowing only low fat dairy products.  You might be surprised to hear Pediatricians are not setting WIC and Head Start policies either.  It sure is a good thing we have these lawyers/obesity experts out there on the front lines fighting childhood obesity one glass of skim chocolate milk at a time.

In a new study published in the journal Circulation, Dr. Dariush Mozaffarian and his colleagues reviewed blood samples from 3,333 adults in the Nurses’ Health Follow-up Study over 15 years. People with higher levels of byproducts from full-fat dairy had a 46% lower risk of getting diabetes during the study period compared to those with lower levels. In this particular study, the connection between full-fat dairy intake and lower diabetes risk remained strong independent of weight gain.

Another recent study published in the American Journal of Nutrition, analyzed the effects of full fat and low fat dairy on obesity and found that amongst 18,438 women in the Women’s Health Study; those who consumed the most high-fat dairy products lowered their risk of being overweight or obese by 8%.  Research suggests people who consume full-fat dairy weigh less and are less likely to develop diabetes, too. 

Now there IS convincing evidence whole fat dairy may help lower the risk of obesity and diabetes.  At the simplest level, fat increases satiety by slowing absorption of sugar, therefore regulating insulin and glucose release.  People ingesting higher fat may not feel as hungry and may have less craving for sugary foods.  But as a pediatrician, what could I possibly know about nutrition in children?

Having an MD after my name means I had to actually learn the biochemical mechanisms in the human body for breaking down carbohydrates, fat, and protein.  When “experts” began spouting off about low fat dairy products being better for children, most pediatricians knew they were probably wrong before they finished their sentences.  We are considered “experts” on the pediatric segment of the population.  Despite all those years of education, we could not do a thing to change WIC, Head Start, and federal school lunch guidelines. 

Who knew I needed to be a lawyer/obesity expert on the Childhood Obesity Task Force to really impact American children and their diet.  Hopefully, these scientific studies will help point the “obesity experts” in the right direction.  In the interim, it is high time this “physician/U.S. Constitution expert” presents oral arguments before the U.S. Supreme Court.  How well do I need to understand the subject anyway? 

Tried and True Advice for Picky Eaters

One of the most common questions a pediatrician can be asked is about picky eaters.  I have given my “picky eater” talk at least once every day for the last two weeks, so I decided to make this the next topic to cover.  Interestingly enough, this talk is the same for skinny kids as well as those who are overweight or obese (though I am not fond of that word.) 

To clarify, the following is my opinion based on my experience and is not evidence-based or scientifically proven.  It has helped many children who are overweight stabilize and “grow” into their proper weight and it helps underweight children eat more variety and volume.  It is safe and I have not had any children starve while on this plan.  Obviously, if you are going to take my advice then please use good old-fashioned common sense when applying the principles below. 

First and most important, the child needs to actually be hungry.  In all honesty, they need three solid meals per day.  They do not need a constant barrage of crackers in Ziploc bags, dried fruit, yogurt tubes, and those squeezable packages while on the go.  Snacking frequently causes cavities and prevents children from experiencing actual hunger, setting them up for weight difficulties in the future.  I tell parents if there is a long period of time between lunch and dinner than a small snack is acceptable but it should follow the rules below. 

Second, it needs to be an event.  This means turn off the TV or computer, hang up the phone, put down the electronic device and sit down at the table. Preferably have the entire family sitting at the table whenever possible.   Food should only be eaten sitting down, not while walking around at the park.  Eating is such an enjoyable experience that we should teach little ones early to focus and enjoy it, even if a meal is three bites for them. 

Third, children model the behavior they see, so we should be eating a wide variety of foods from all the food groups.  Personally, I am a fan of families eating red meat because the most common nutritional deficiency in the United States in children is iron-deficiency, which can lead to learning problems later in school.  If you can get other iron containing foods into your child instead of meat, then go for it.  Bottom line, variety and modeling are the take-home points. 

Fourth, do not let your picky eater drink their food.  Our house rule is half the meal has to be eaten before the milk is poured.  I had to learn this one watching mine down a glass of milk and say they were full a few times before I got with the program.  We only serve water at the start of meals to make sure they do get some variety and not just the OJ in the morning and milk for the other meals of the day. 

Fifth, if they plain do not like it and will not eat it you have two options.  Either they miss that meal and eat the next one or come up with what I call the “back-up food option.”  I developed this after my oldest refused dinner for three nights in a row.  You might not believe anything else I write after you read this next sentence, so prepare yourself, a confession is coming.  Our family “back-up” is a 100% beef, no nitrate hot dog.  At least you know I am completely honest right? 

My oldest ate this every night for more than nine months until one day he finally ate the spaghetti we made for the family dinner and the rest is history.  I tell most families to pick one neutral “back-up option” and all the children will know they either eat what you have served or they get the same thing all the time as the alternative.  Do not change the “back-up food” over time because the end goal is not to encourage them to choose it repeatedly.  Instead you would like them to get tired of it and eat something else.  It will happen, believe me. 

Sixth, understand that some children love pureed foods and want to eat them until they are three.  Some children dislike pureed foods from the get go and love smashed avocado, banana and steamed vegetables they can hold in their tiny hands.   Every child has diverse taste preference and chewing abilities at different ages.  That is absolutely acceptable and completely normal developmentally.  

Finally, we should talk about snacks.  A snack should consist of something natural of which they are not particularly fond (i.e. not crackers, which is the #1 favorite food of most picky eaters.)  My favorite recommendations are celery and peanut butter, carrot sticks and string cheese, or apple and yogurt.  It should always include something with protein.  Remember, it is still an event and they should not be able to walk around while eating it.  Also, there should be at least two hours between eating a snack and then serving a meal to allow them to become hungry again. 

In closing, I would like to say there will be times when they are growing rapidly and times they are not.  Remember, puberty is just around the corner and food will disappear right before your eyes.  Sometimes a meal will be everything you put on their plate or truly just three bites.  A child’s appetite changes daily as do their nutritional needs.    They are much better at eating when hungry and stopping when full than we are as adults.  Let them experience what it feels like to be hungry, enjoy their food, and then feel full.  It is one of the many important lessons we teach children.  Allow them to learn it. 

Immunizations Are About Trust and Science: My Alternative Vaccine Schedule

I confess that I am my children’s pediatrician.  I have given them every vaccination they have ever had and probably would not trust another physician to do it.   I endorse the vaccination schedule recommended by the American Academy of Pediatrics; I believe it is safe and prevents disease.  I completed medical school and three years of pediatric training that helped shape this belief.  I have seen death in children from polio, whooping cough, and pneumococcal meningitis. 

However, I believe in parent choice and do not believe in mandates when discussing healthcare.  Patients must have autonomy.  I use an alternative vaccination schedule when my vaccine-hesitant families request it. Mine evolved over time to complete most of the required vaccinations by the time a child is 2 years old.  It is not “evidence-based”, the catchphrase we use to say something is scientifically proven safe and effective.  However, it is rooted in something I value highly as a pediatrician – trust, open communication, and compromise. 

My patients and I have a difference of opinion sometimes, whether it is about immunizations, antibiotics, or discipline.  That does not mean we cannot or should not keep talking to each other.  There are a lot of people out there not vaccinating their children, who may be putting others at risk of contracting disease.  Guess what?  They love their children as much as I love mine and you love yours.  As a pediatrician, I am going to trust you are doing what you think is best for your children, even if I do not agree with your opinion.

Physicians think that convincing parents to vaccinate their children is mostly about science.  I am going to argue that deciding whether or not to vaccinate your child is also about trust.  Anytime we recommend treatment or perform a procedure, we are supposed to discuss the risks, benefits and, alternatives.  Why are primary care physicians not "allowed" to venture off the immunization schedule recommended by the AAP and CDC and at least, discuss alternatives?  We have boxed ourselves into a corner and not left much room for compromise.

We are talking about someone who is hesitant to hand over their 2 month old, 2 year old, or 10 year old for an immunization.  They have never seen diphtheria, tetanus, rubella, or measles.  They may never have held the hand of a child dying from preventable infectious disease.  Are we so far divided from these parents, we are unable to step back and see where they are coming from?

When I first went into practice, I accepted every non-vaccinating patient who walked through my door.  After practicing for 15 years in my hometown, I have learned there are two types on non-vaccinating families.  Those who want to build a trusting relationship with their primary care physician but are uncomfortable, hesitant, or unwilling to vaccinate.  They always hear me out as I do them.  We have trust and rapport.  I may not agree with their decision, but I respect these parents.  Some parents eventually do vaccinate and some do not, the point is we keep discussing it.  

Then there are non-vaccinating families who want to talk AT me and never WITH me.  Their brows furrow at the mention of vaccinations and their arms cross.  They call my office beforehand to remind me they do not want to discuss the subject at all during a well child exam.  It causes them too much distress.  It seems those parents are not interested in a trusting relationship with me or anyone else with an MD after their name, and that is alright. If there is no space for give and take conversation, there is little else I can offer to them.  

Some parents trust movie stars who oppose immunizations more than they trust their family doctor or pediatrician.  I know that is hard for a health care provider to accept, but it is true.  Times have changed and people do not look only to physicians for answers like they used to, nor should they.  Maybe there are things we, in primary care, could do better.  Maybe we could stop shoving science down parents’ throats and try a spoonful of compassion and communication to the help the medicine go down.

Welcome to MommyDoc

I am a mom of four and pediatrician who has been in practice for 15 years in the town in which I was born and raised.  MommyDoc is a blog where moms, physicians, or other health care clinicians can come to read articles about pediatric topics.  

As a mom and pediatrician, MommyDoc, is about the trials and tribulations of doing both jobs on a daily basis.  I share stories about patients (with their permission) who have taught me important life lessons, keep you up to date with new pediatric information, and share my own thoughts from time to time.  My father and I are in practice together. 

Our practice is unconventional in that we still use paper charts (meaningful use be darned) and have known many of our families for two or three generations.  I know every child and most of their parents by first name and always stop to say hello when I see them in public.  For me, pediatrics is a calling.  I love children and helping make their lives more comfortable.

I love my own children, who are often seen in the office helping comfort little ones receiving immunizations or just talking with my families.  It is a very special place to work everyday and I treasure the opportunity to continue practicing for many years to come. 

My general philosophies are that a parent knows their own child best; so always listening to them is a rule by which I live.  My goal is to have parents be more confident when they walk out of my office than when they entered. 
   

I hope you enjoy this journey with me.  There will be some anecdotes about my own children along the way, some opinions thrown in here and there, and parenting experience "from the trenches".