Cruel Kids and Tribalism

I just read of a newspaper story (which I'll discuss below) which triggered two related memories from my childhood.

Memory #1: I grew up in a nice middle class neighborhood in Detroit, with cozy houses, fenced in backyards, and close neighbors. I rode my bike all around the area with freedom and had a gaggle of kids to play with. Except Billie Wiggins, with whom I never associated. He lived about five houses away, but it might as well have been on the moon. Billie talked funny, said incomprehensible things, acted eccentrically, even looked bizarre in an ill-defined, clumsy, overweight way. In retrospect, I'm pretty sure he was moderately autistic, but at the time "weirdo" was as far as I got.

Memory #2: In my elementary school, Fred had a huge, oddly shaped head. He walked with a tentative, shuffling gait and looked so fragile I thought he could break at any second. Worse, once he had a two minute seizure in my 3rd grade class, which terrified me and everyone else, although we never discussed it. When he walked by, some of my friends would taunt him: "Here comes Fred with the light bulb head." Needless to say, Fred was no pal of mine. Even being seen talking to him was inconceivable. He was not my kind and I didn't want anyone to think he was.

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In my defense, I wasn't overtly mean to Billie or to Fred. But - to my eternal shame - neither was I at all friendly. Never did I tell my friends to cool it with the cruel taunts. Never did I attempt to get to know either of them. Never did I empathize with the hell they were going through.

I was, after all, a kid and - let's be clear-eyed about this - kids can be incredibly cruel. Differences in others are inherently threatening, mandating excommunication from the tribe of peers, to be avoided at all costs, lest you too be perceived as weird and banished. It is such peer culture (not peer pressure) that rules the world.

But, I wonder now, where were the adults? Why didn't my parents talk to me about Billie and force me to go visit with him and his parents to dispel my fears and fantasies? Why didn't my teachers inform us about the nature of Fred's seizure and disability, and put an end to our cruel taunts?

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These two childhood memories came to mind as I read of an incident in a school in Florida. Seems that a teacher organized a vote by the 5 year olds in her kindergarten class on whether to expel a child who was a pain in the butt and frankly weird. (You can read the whole sorry story here.)

Big surprise, the class voted 14-2 to kick the kid out. Aside from how breathtakingly cruel and boneheaded it was to give 5 year olds the right to vote (hey, why not let 5 year olds vote on what kind of meals they want, on what their bedtime should be, on whether their little sisters should be sent to prison), the teacher gave voice to and supported the children's meaner prejudices, and allowed them to rule the day.

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To be sure, we all have within us the capacity for such cruelty. But so too do we all have nobler instincts, like generosity and empathy. Which of these warring instincts will develop and flourish as we mature has everything to do with the adults and teachers in our lives.

If you encourage me to despise the Billies and the Freds of the world, if you teach me that all such others belong to another species altogether and are therefore deserving of only our contempt, then that early human instinct for hating those outside our group enlarges and fuels the horrific headlines which we read every day, in which humans are not murdered, but cleansed from the earth, like a lowly germ.

In my view, tribalism is a great scourge. The problem is not so much that we identify with and adhere to groups with similar interests or beliefs (I, for one, am currently a member of the Detroit Pistons' tribe), it's that those who are not in our affiliative group are accorded sub-human status and, as such, are fair game to exploit, to taunt, to banish, to diminish, to cleanse.

In our shrinking global village, we see the destructive effects of tribalism all around us and can ill afford not to treat all humans as members of our same tribe, worthy of our respect and consideration. If we are to transcend our baser instincts, that lesson needs to start early and often, taught by parents and teachers, taught by you and me.

Related Topics:

• WebMD Video: Bullying - Going From Victim to Survivor
• How to Stand Up to a Bully's Mom

Technorati Tags: Alex Barton, Wendy Portillo, tribalism, discrimination, bullying, autism

Kids, Clowns, and the Age of Innocence

"Can't sleep. Clown will eat me!"
- Bart Simpson

Snap quiz: Kids love clowns. Right?

Not so fast. According to a study published in January in Nursing Standard (a British journal), it's quite the opposite. I'm happy to report (for reasons I'll explain) that kids actually loathe clowns. 240 hospitalized kids (ages 4-16 years) were asked if they appreciated the obligatory visits by clowns to cheer them up. The authors were surprised to find "that clowns are universally disliked by children. Some found them quite frightening and unknowable."

What a relief! I have always found them to be so, but as a sensitive, child-loving pediatrician, have felt it politically incorrect to voice my prejudice. Until now.

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I vividly remember the following internal monologue when I was about seven years old and a clown insistently tried to amuse me at the Michigan State Fair: "Omygod. What manner of creature is this? What is his little game? What does he want from me? Why he is so in my face? How have I come to live in world where beings like this exist? Get me out of here. Dad, save me. This guy is scaring me!"

Turns out that - unbeknown to me - I'm part of the great silent majority who abominates clowns (we'll deal with mimes and Patch Adams at another time), and who holds in great suspicion the motives and mental health of many who put on red noses and oversized shoes to "cheer up" the children.

So I'm glad I don't like clowns, because if I liked clowns I would want to see them and I don't like clowns.

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Author's message
To me, this whole clown debacle makes an important point: we adults just don't understand kids. We think of their lives as blissful and carefree, living large and loving clowns. But of course they are far more complicated than that, often wracked with anxieties and insecurities and feelings of powerlessness, mystified at the workings of the world and easily undone.

With our adult projections, we naively assume that all children love clowns (to the point we even inflict them on hospitalized kids). Which is why I love this study. Someone finally had the good sense to actually talk to and ask the kids themselves what they like and why. We need to do a lot more of that.


Related Topics:

• WebMD Video: Patient Friendly Hospital
• Counterpoint - WebMD Video: Big Apple Circus Cheers Up Sick Kids

Technorati Tags: clowns, pediatrics, health and wellness

Raise a bilingual 21st century child

In my previous blog I railed against trying to create super-kids and the uselessness of hoping some simple early stimulation will enhance any of your child's long term capacities. But that doesn't mean that some interventions might not be useful, as long as you recognize that in order to be of benefit, they will need to be continued for a long time, often at least up until adolescence.

So here's my #1 suggestion for extra experiences and learning that will benefit your 21st century child: raise your child to be bilingual at an early age.

Some of the advantages of being bilingual are obvious: knowing a second language will be a huge advantage in competing for jobs in our flat world. Plus, a second language provides a more complex understanding of other countries and cultures.

Additionally, there is some evidence that learning a second language early in life confers other advantages: more of the brain's firepower is devoted to language, there may be a better ability to deal with distractions, it certainly makes it easier to learn a 3rd language, it improves attentional and spatial abilities in the elderly, it may benefit some aspects of memory, and there is improved creativity in using language.

The potential downside? Really, myths aside (such as, "bilingualism confuses kids", "bilingualism causes language delays"), there is none. Plus, you don't need to be a superstar to become bilingual. Pretty much any child without a language disability can do so with ease. And the sooner the process begins, the better.

Of course, raising a bilingual child is easy if English is not your primary language. You can and should just speak your native tongue at home from the start. Don't worry, between peers and school and the media, your child will learn accent-free English just fine.

But it's not so easy if you, like most of us hopeless Americans, are a monoglot (the wonderful term for a single language speaker that vaguely sounds like an insult). Here's what won't work: having a foreign nanny for a few years or teaching sign language at 9 months without continuing your child's immersion in that language.
You'll have to pick a language to which your child can continue to be exposed (hopefully for at least 5 hours/week), the earlier the better, for many years.

(All things being equal, I'd vote for usually choosing Spanish since so much of the U.S will be Latino by the time your child is an adult + so he can travel with ease all over Central and South America and Spain + he can order a chile relleno and know what is actually in it).

Admittedly this will take dedication on your part. Find non-English speaking families with kids who can play with your child. Learn the new language together. Watch the international TV programs in the chosen language. Most importantly, try to find a school for your child that teaches a second language from the start. If you can afford a private language school, do it.

If you can pull it off, of all the extra stimulation and experiences you may be considering for your child, becoming bilingual is, in my opinion, the most enriching one and the skill for which long term benefits are likely to be greatest.

In my next blog, I'll opine about my #2 best extra thing to do with your child.

Related Blog Entries:

• Your 21st century child: Raise a book lover
• Your 21st century child: Raise a lover of science
  

Technorati Tags: 21st century child, pediatrics, bilingual, education

Raising your 21st century child: How to make a super-kid

You've got to love raising a child in the 21st century. All you have to do is to listen to all of us experts and you can't help but to raise a brainiac. It's a snap. Here's how:

• First you need to play Mozart all the time so she will develop exceptional musical and motor skills.
• Be sure to place a scientifically correct mobile over her crib to enhance visual abilities.
• Play her Baby Einstein and Sesame Street videos, which will promote her brain development and make her smarter than she would have been otherwise.
• Teach her baby sign language, so she can communicate sooner and have a better language capacity.
• How could I forget Baby Van Gogh to make your little artist have a better sense of color.
• Of course, be certain your child doesn't go without the latest and greatest new educational toys.
• Make sure she watches the new cable kiddy network which will only have content to enhance her development.

Follow my advice and she's sure to end up, like all the kids in Lake Wobegone, above average...perhaps even a genius.

You may have already sensed my true feelings about all this early stimulation and the claims that you can enhance your child's capacities with a few bells and whistles early on. This whole cottage (and very profitable) industry is, in my opinion, totally misguided. Here's why:

1) None of this short term stimulation works in the long run. There is, alas, no "immunization" to enhance brain development, no short-lived early experiences that will improve long-term skills. The little research that has been done shows that, yes, perhaps you can artificially improve one skill or another while if you focus on it, but these effects do not endure as your child gets older, unless you keep it up. Extra Gymboree may give your toddler's gross motor skills a boost, but it won't make him Michael Jordan. In fact, it won't even make him any better than other kids his age who were 'deprived' of this early experience, unless you continue it throughout his childhood. Baby sign language is awful cute and may enhance early communication, but so what? Unless you are fluent in sign language and will continue to teach your child this second language for the next decade, it's not going to confer any long-term benefits.

2) Psychologists have a great term: "the ordinary expectable environment." By this they mean the typical environment experienced by human kids which, over evolutionary history, has proved plenty stimulating for brain growth.

When experts talk about enhancing brain development, many quote a scientific study done on laboratory rats. It showed their brains to be more complex if they were raised in an extra stimulating environment (whatever that means for a rat!), compared to those raised with no extra stimulation. "Complex environments make complex brains", we are told.

Fair enough, but what isn't usually mentioned is that wild rats have the most "complex" brains of all. Apparently, if you're a rat, just fending for yourself in the real world is the best "stimulation" for brain development. Remember Einstein's parents didn't bombard him with extra stimulation as an infant. In fact, the poor guy didn't even get to watch Baby Einstein, he was just raised in an ordinary environment. Imagine how smart he could have been!

3) It's a set-up for disappointment as a parent. The upper limit of your child's capacities is constrained by who and what she is (mostly via her genetic heritage). All the extra stimulation in the world isn't going to make your child an Einstein or a Mozart or a Michael Jordan. (While I'm at it, you should know your ability to change his/her personality isn't all that great either.)

So if you need a super kid - one who conforms to your fantasy of what the perfect child should be - in order to be happy with him/her then, alas, unless you luck out, there's plenty of trouble ahead when you face the disappointment of the unique kind of person your child turns out to be (often in spite of, instead of because of, your best efforts to change or "improve" her).

Go ahead and buy fancy educational toys, teach your infant to sign for her bottle, play a nice Mozart sonata at bed time. But do it because it's fun, because you and she enjoy it, and not because you need/want her to be the next Van Gogh or to raise her IQ by 10 points.

And don't feel guilty if, instead of bombarding her with some extra stimulation, you spend your time just having a good time together. As a parent, loving your child up and fostering her emotional development with a positive, nurturing relationship should trump everything else on your priority list.

Having said that, in my next blogs I want to make 3 suggestions (a little blog suspense: can you guess what they are?) for you to consider in trying to raise a happy and successful 21st-century child (this is above the most important part of what you do: loving and nurturing him/her and accepting, understanding, respecting and supporting her for who she is, not who you want her to be).

Related Blog Entries:

• Raise a bilingual 21st century child
• Your 21st century child: Raise a book lover
• Your 21st century child: Raise a lover of science
  

Technorati Tags: Baby Einstein, baby sign language, parenting, child development

Sibling relationships

Sibling relationships are a hot topic. The 7/10/06 cover of Time magazine reads "How your siblings make you who you are." Of course, for those of you with more than one child, it's likely to be high on your parenting agenda, media attention or not.

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When I was in training as a fellow in behavioral and developmental pediatrics with T. Berry Brazelton, I was asked to see parents who had been determined to prevent their two year old, Petunia, from resenting their new baby.

"We don't understand it," they confessed. "We've done everything the books advised to avoid sibling rivalry. We frequently talked about the new baby in mommy's belly, which we encouraged Petunia to lovingly stroke. We assured Petunia we would love her as much as ever and explained how wonderful it would for her to have a new playmate. Soon after delivery, we allowed her to hold her baby brother, Gregory. The doll she took home from the hospital was bigger than the baby! Petunia was allowed to help feed and diaper Gregory. When he was asleep, we gave her extra 'just you and me' quality time together."

Sound familiar?

Two months later, following the appearance of inexplicable scratch marks on Gregory's face, Petunia was seen lobbing her Cabbage Patch doll into his crib and was quite adamant that the time had surely come for Gregory to go back the hospital, "where he belonged". That's when her distraught parents sought help from the great Dr. Brazelton (alas, they had to settle for a very green Dr. P).

As Petunia's parents learned, sibling rivalry is inevitable. To help her parents understand why this is so, I asked them to picture this scenario:

Without asking your permission, one day your husband/wife/partner comes home with a new man/women, saying: "Hi honey, this is Rachel/Freddie. S/he is going to live with you and me now. Sure, s/he'll be getting lots of my love and attention, but don't you worry: I love you just as much as always! This is just a wonderful addition to our family! Hey, why don't you look happy!?"

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Time magazine's certainty aside (to be fair and balanced, see their alternative viewpoint to mine), the importance of sibling relationships in "making us who we are" is still hotly debated.

Here's the key issue: Of course sibling relationships are important within the home. Do siblings get along? Who is dominant? Whom does mom love best? What behaviors get you more attention and energy and affection from your parents, compared to your siblings? All this is pretty obvious.

But think back to when you were a kid: how similar was the way you interacted with your siblings within the home, as opposed to how you interacted with others outside the home?

Most of us (thankfully) behave and feel very differently with our parents and siblings than we do in the "real world." It's called "code switching" - we adapt our behaviors to succeed in new circumstances. We toddle off to school and quickly learn, for example, that those behaviors that were so endearing to our parents and allowed us to get along with (or manipulate) our siblings may not be good ways to make and maintain friends outside the home. Maybe I am mean to my little sister, but that behavior isn't going to make me very popular with my peers. I may have been under my big brother's thumb at home, but I can be a leader among my new friends.

(Incidentally, you may have thought that Frank Sulloway's 1996 Born to Rebel proved being a first-born made you more likely to be ambitious, domineering, conservative and aggressive, while later borns are more likely to be rebellious, open to new ideas, and agreeable. If this were correct, then sibling relationships are indeed a major force in"making us who we are." Alas, the findings in his book - at least to my mind - have been debunked, decimated really (e.g., by Judith Rich Harris in her new book No Two Alike or here).

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There is one important reason the research in this area remains muddled: Genetic effects are rarely taken into account. Sure, you may be cooperative and positive with your brothers and sisters, and subsequently with your relationships outside the home. But is that because you had good early sibling relationships in the home or because you had the disposition to be a cooperative and cheerful person in any setting? If you are a peace-maker, is it because you were the middle child or because of your pacifistic nature? Correlation of child and adult relationships does not mean cause-and-effect. And there is plenty of data showing how different we are in our relationships inside and outside the home.

So it's still up for debate. I have to say, in thinking about my own history and having watched a ton of kids grow up in a ton of families, I'm more on the side of the "code-switching" hypothesis: that we often behave very differently in different settings to get our needs for status and affection and affiliation met. Yes, our siblings "make us who we are" inside the home and in our relationships with them, but their impact on us outside the home is much more limited than Time magazine implies.

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As I often ask: Is that good news or bad news for you parents, you who are conscientiously investing so much time and effort to teach your unruly kids how to get along with each other? Does this mean that your efforts don't matter?

I think it's good news and, yes, how you handle your kids' relationships with each other matters a lot - although perhaps not in the way you imagine.

Of course, as a parent, you make a huge difference in how things go in your home. You can try to be fair with your motley crew of kids as best you can, to show them pretty equal affection (even if you don't always feel that way), to teach them to generally work out their sibling conflicts on their own without your choosing sides, to treat and respect them as individuals, to recognize each one's strengths and weaknesses without constantly comparing them to one another.

These efforts will have been critical - once the early inevitable rivalries and disputes are past - in how they come to interact with and feel about each other. It will enable them to grow up with wonderful memories and stories and lessons and values from the positive family relationships you are working so hard to foster. And this will serve to enable them (hopefully) to establish close and enduring sibling relationships which, at their best, can be one of the deepest and most beautiful relationships of our adult lives. That's a lot of power and importance in my book.

But if you hope by being the "perfect" parent (not that there has ever been one), you can avoid any sibling rivalry or conflicts, or that by enhancing sibling relationships you will have a major impact on your children's eventual personality and status and relationships outside the home, you may be disappointed. Khalil Gibran (1883-1931) the Persian poet said it best in his book The Prophet:

Your children are not your children.
They are the sons and daughters of Life's longing for itself.
They came through you but not from you.
And though they are with you yet they belong not to you.
You may give them your love but not your thoughts,
For they have their own thoughts.
You may house their bodies but not their souls,
For their souls dwell in the house of tomorrow, which you cannot visit,
not even in your dreams.
You may strive to be like them, but seek not to make them like you,
For life goes not backward nor tarries with yesterday.
You are the bows from which your children as living arrows are sent forth.

Related Topics: 6 Ways to De-Stress at the Dinner Table, Heart Disease in Sibling Doubles Your Risk

Technorati Tags: sibling rivalry, genetics, family relationships

Frequent infections: Normal or a sign of weak immunity?

Q: Dr. Parker, our kindergarten age child seems to have had more colds/infections this year. Since Sept., she has had probably 7 colds or infections (sore throats, fevers, coughs, stomach virus, etc.). She had blood work done at the end of December and it was normal. She has has seen her pedi, who has checked her and given her meds which cleared up her issues.

My wife says that kids this age will be sick with this stuff often while I feel that she is sick too often and something bad could be the cause. Or child is otherwise active and enjoys school and such. Am I overreacting? A what point does a parent say, OK, I demand more tests?


A: I'm betting that, yes, you are overreacting and that these are just the normal extra infections contracted by kids who are exposed to a bunch of other kids, Here's when we worry that what you describe could be due to a weak immune system or some other problem:

1. The infections are unexpectedly severe - meaning they last a lot longer than expected and/or the symptoms are especially nasty.



2. The infections are unusual - they occur in unlikely areas or are caused by unusual germs.



3. Frequent severe infections have been a problem most of the child's life.



4. The child has other signs of a chronic illness - poor growth, low energy in between bouts of infection.

None of which seems to be the case with your gal.

The good news? There is evidence that the more infections you get as a child, the stronger your immune system as an older child and adult (practice makes perfect!).

Tools to Try

• Flu Shot Video
• Cold & Flu Quiz

Reading aloud to your child

Dr. P's favorite quote of the week

"You have brains in your head.

You have feet in your shoes.

You can steer yourself any direction you choose.

You're on your own.

And you know what you know.

And YOU are the one who'll decide where to go. "

- Dr. Seuss, Oh, the Places You'll Go! (1990)

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"You make 'em <[children], I amuse 'em."

- Dr. Seuss (aka Theodor Seuss Geisel)

Dr. P comments

Of all the gifts you can give your children, a lifelong love of books and reading has to be high on the top 10 list.

Give your little infant a nice cardboard book to chew. Start reading books aloud to him/her well before s/he has a clue what the book is about. What s/he will learn is to associate books with closeness to you and with warmth and love and interesting visual displays and expressive language. Baby Einstein can't hold a candle to reading aloud in promoting infant brain development!

As s/he becomes a toddler, the content of the book becomes more interesting and s/he will delight in reading the same thing over and over and over... Books are a great way to end the day and, as your child gets older, you may even become interested in a compelling 'chapter 'book' that is read aloud every night.

Bottom line: It's never to early to promote a love of books, which will lead to a love of reading. Aside from the early benefits of promoting attachment and language and active learning (unlike the passivity of watching TV), what a gift as an adult to be able to enjoy a wonderful book!

Related Topics: Communicating With Your Child, Pull the Plug on Television

Tags: reading, books, childcare, babycare, WebMD

Cleanliness and asthma

Dr. P's Pediatric Journal Club

The study
These Dutch researchers measured levels of dust and bacterial and fungal toxins (potential "allergens") on the living room floors of 700 three-year-olds with allergic moms.

• They classified exposure to these allergens as low, moderate, or high.
• They then followed the kids for 4 years, looking for the development of doctor-diagnosed asthma and allergies.

What the study found

• Children with high exposure to dust and mold at 3 months were significantly less likely to have developed persistent wheezing by four years of age.
• Children with high exposure at 3 months were less likely to wheeze occasionally, but this outcome was not as pronounced (and not statistically significant).
• Children with high exposure at 3 months had lower allergic antibodies (IgE) to one of the fungi.
  

Dr. P comments.
Why do farmers' kids have fewer allergies and asthma? Why has the prevalence of allergies and asthma increased, even as we conquer ever more infectious diseases? This study adds to the mounting evidence that the exposure early in life to a very clean environment (low on dust and various bacterial and fungal toxins) may play a role.

Here's the theory: The newborn immune system is tolerant and non-allergic to most anything (which is why it sometimes does such a lousy job of fighting off infection). When it is exposed to the usual allergy-causing antigens (such as dust and mold and dogs and cats), the immune system and allergens become lifelong buddies: a long-lasting acceptance and tolerance between them develops.

On the other hand, when an allergy-prone infant is raised in a very clean - almost sterile - environment, the immune system remains unfamiliar with these allergens. Then, when exposed later on, it reacts to them as it would to any alien invader, triggering allergies and/or asthma.

What does this mean?
Sloppy parents of the world stand tall! Your kids may have fewer allergies than will those of your hyper-sanitary peers!

Even if there is a family history of allergies and/or asthma, I think it's too early to actually recommend a little extra dust and mold in your baby's bedroom. But I do hope this information will help parents to overcome their messiness/germ phobia and free you to lighten up on obsessively trying to 'sterilize' your infant's world from all germs and dirt and crud.

Hey, life is messy. This study suggests that maybe that's not such a bad thing after all!

A caveat from Dr. P: It may be true that early exposure to mold and dust and cats, for example, will prevent allergies to them later on (in an already susceptible child). However, once that allergy has been established, the horse is out of the barn: cleanliness and even catlessness, etc. are then very important to prevent significant symptoms.

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Article cited
"Does early indoor microbial exposure reduce the risk of asthma?
The Prevention and Incidence of Asthma and Mite Allergy birth cohort study"
Douwes J, et al. Journal of Allergy and Clinical Immunology, April 2006.

Related Topics: New Clue to Development of Asthma, WebMD Video: Pets & Allergies

Technorati Tags: allergies, asthma, early childhood asthma

Q & A: Mosquitoes and your kids They're baaaaack!

Q: Every summer it's the same worry. My 4 year old has severe reactions to bug bites and I'm terrified she'll catch West Nile Virus or encephalitis or who know what? Help!

A: Good question! As the hazy lazy crazy days of summer approach, let's devise our plan for attacking this expectable challenge from an oncoming horde of despicable creepy-crawlies.

Fortunately, we have good ways to address your concerns, which I will summarize here (and have discussed in more detail in an earlier blog post here)


Dr. P's Top 10 Strategies to Banish the Creepy Crawlies of Summer:

1. Don't panic! Don't be overly paranoid. Don't let your fears ruin the fun of summer for you and your kids.



2. Take prudent precautions. Remember that the odds of contracting a serious disease from a bug bite are very very slim - and vanishingly small if you take proper preventive precautions.



3. Prevention, prevention, prevention! Once a bite has happened, there is little to be done except to treat whatever symptoms might arise. The trick is to prevent the bite in the first place.



4. Have your child wear long sleeves and long pants when possible.



5. Apply bug repellent to clothing and exposed skin.
   


6. Bug repellents with Deet are the most effective. They are safe to use on children over 2 months of age. Pick the lowest concentration that will get the job done for as long as you need.



7. Newer repellents that are likely effective include picaridin and oil of lemon eucalyptus (although they have is less long-term safety data). Feel free to try these and see if they work as well.



8. Wash off the repellent after coming indoors.



9. Take environmental precautions. Look for mosquito breeding grounds in still water around your house. Be sure your screens are intact. Use mosquito netting around strollers, beds.



10. Stay abreast of any reported transmittable infectious diseases in your area. Call your doctor if you are concerned your child may have one.

Here's to a healthy, safe, and fun summer - that most magical of childhood times!

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For more info on bug repellents, go to the CDC website.

Tools to Try

• First Aid Center
• Slideshow: Bad Bugs
• Tips for Mosquito Control in the Yard

Give that baby a pacifier!

OK you blogsters, you want real controversy, people coming to blows, marriages in shambles, World War III? Let's talk pacifiers.

Here's my contention:
Every human infant on the planet should be offered a pacifier.

Aside from my copious stock options in binky companies, here's why:

There is pretty good (but perhaps not quite definitive) research to show that infants who suck on a pacifier have a significantly lower risk (perhaps as much as 45-90% less, depending on the study) of dying from Sudden Infant Death Syndrome (SIDS). (Yes, thumb-sucking also had a protective effect in at least one study, perhaps a 50% decrease).

The reasons for this association are not clear (especially since we really don't know what causes SIDS in the first place). Some wonder if the pacifier changes the airway in an important way, perhaps by moving the tongue forward or keeping the mouth open. Others speculate the sucking reflex stimulates the brain so it doesn't 'forget' to breathe or to sleep too deeply.

Who knows? (Really, who cares if it does the job?)

But them's fighting words. There are vociferous opponents - haters, really - of pacifiers, mostly because of the concern that their use will interfere with the initiation of breast feeding (although studies generally do not support this) or hasten weaning (which a few studies do suggest). Also pacifier use is associated with a small increase in ear infections in the first year.

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Soooooo, let's take stock: on the one hand, potentially less time breast feeding and/or ear infections, on the other decreased risk of DEATH. Really, is this a tough call?

Even the conservative American Academy of Pediatrics recommends the use of pacifiers for the first 12 months or so, with the following provisos:

• A bottle-fed baby can be offered a pacifier right away.
• Wait until breast feeding is well established to offer the pacifier (remember peak of SIDS is not until 2-4 months of age).
• Use it for all sleep and nap times.
• No need to keep putting it back in the mouth should it fall out.
• Don't use sweeteners on the nipple.
• Keep them clean!

The nice things about a pacifier (which the British call a "dummy", perhaps because it was first used only by the lower classes) is that you can get rid of it whenever you want (unlike the thumb). Since dental misalignment is not a concern for 4-5 years, you have plenty of time to decide when you are ready to face your infant/toddler's wrath at its banishment.

I only wish there were other as simple, effective, inexpensive and relatively risk-free public health interventions! Maggie Simpson has got it right. Power to the Pacie!

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Articles cited:
Do pacifiers reduce the risk of sudden infant death syndrome? A meta-analysis.
Hauk F, et al. Pediatrics, October 10, 2005.


Use of a dummy (pacifier) during sleep and risk of sudden infant death syndrome: population-based case-control study.
Li D, et al. British Medical Journal. December, 2005.

Related Topics: Nutrition During Breastfeeding, Infant Formula, Parkinson's Tie Probed

Technorati Tags: pacifiers, infant care, pediatrics, SIDS

Dr. P's Butt Balm

Dr. P's Butt Balm for persistent diaper rash due to irritation

If you are certain your baby's persistent red yucky diaper rash is due to irritation (and not, for example, from a bacterial infection) and the usual over-the-counter creams haven't done the trick and you are at your wit's end and your baby is uncomfortable, not to worry. Try using Dr. P's Butt Balm.

Here's how to make it and use it:

• Thoroughly mix together 1/4 zinc oxide with 3/4 A&D (or similar) ointment. If yeast is present, you can mix in 1/4 yeast cream (like Nystatin) and decrease A&D.

• Apply liberally.

• The key is not to completely wipe off the butt balm with each diaper change!


• Wipe the top layer off.
  
• If the bottom thin layer on the skin is clean, leave it on and apply more over it.
• If the balm on the skin is soiled, use an oil filled cotton swab to gently wipe it off before applying a new layer.

Dr. P's Pearl: When you need to clean the balm completely off the skin, always use a cotton swab with oil. Gently wipe the balm away (sometimes the balm is sticky and wiping it off too hard irritates the skin).

Good luck! Let me know on my message board if you try and if it works!

Related Topics: Diaper Rash, Diapers and Other Baby Gear

Tags: butt,balm,rash,childcare,babycare,webmd

Breast-feed or else

In August, 2003, the U.S Department of Health and Human Services launched its Breast-Feeding Awareness Campaign to increase public understanding of the extraordinary benefits of human milk. (Details of this commendable effort here).

That's great. No one doubts that breast milk - refined by mother nature over a few million years of evolution - is the perfect food to nourish a human infant. The evidence is compelling: human milk lowers the risk of early infections and SIDS, and may provide long term benefits with reduced allergies, obesity and risk of various other diseases. Let's take "breast is best" as a given.

But how far should we go to encourage moms to breast-feed? Or, more precisely, how far should we go to discourage moms not to breast-feed. Here's where the controversy lies, fueled by a recent article in the New York Times (from which I shamelessly stole the title of this blog).

What controversy? Have a look at this spot which has been aired on TV.

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Hmmm... What do you think? Realistic, tough-love way to get across the risks of not breast-feeding? Justifiable scare tactics, given what we know? Isn't a little parental guilt-tripping a small price to promote infant health?

To help you better understand the benefits and risks, let's take a closer look at one of the many studies, in this case breast-feeding's protective effect on early respiratory infections.* This study showed (and the headlines trumpeted) that breast-feeding cut the incidence of respiratory infections in the vulnerable first month of life about in half.

Sounds impressive. It is impressive. But let's dig deeper and put the findings in perspective:

1. The protective effect, curiously, was true only for girls; breast-feeding didn't seem to provide protection for boys.
2. Breathing infections occurred in 241 of 13,224 (1.8%) infants in the first month of life. Put another way, 98% of the infants did not contract a respiratory infection, regardless of whether or not they breast-fed. So, yes, breast-feeding conferred an advantage, but the odds are great that an infant will be fine either way. An important benefit, to be sure (every little bit helps when it comes to prevention!), but not exactly the same as not riding a bucking bronco in the third trimester, is it?
   

On top of that, is it fair to scold those who decide not to breast-feed (or do so for a short time) when we as a society are unsupportive of breast-feeding moms? Very few companies, for example, have a designated area where a working mom can express her breast milk or have on-site child care. And, anyway, we weirdo Americans think it's obscene for a mom to breast-feed her infant in public. Perhaps working to change corporate America's practices and American attitudes towards openly breast-feeding would be a better use of our efforts.

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One of the scourges of 21st century pediatrics, in my view, is its incessant parent-bashing (anyway, most of you parents are plenty good at feeling guilty about your parental "shortcomings" without my help). Parenting is a tough and complicated business, almost all of you are conscientiously doing your best, and kids are resilient. Sure, breast-feeding is best and if you can do so, great. But if you don't, odds are still that your child will be just fine - unless, that is, you feel so anxious and guilty about it that it ruins your emotional well-being and undermines your relationship with your little one.

Promote the benefits of breast-feeding? By all means. Beat moms over the head who decide not to? It's not fair. It's not justified. It stinks.

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* Study cited
"Reduced risk of neonatal respiratory infections among breastfed girls but not boys." Pediatrics: Oct., 2003
http://pediatrics.aappublications.org/cgi/content/full/112/4/e303

Related Topics: Is Guilt Getting the Best of You?, Breastfeeding 101: A Mother's Guide

Technorati Tags: infant care, breastfeeding

Was your baby jaundiced? Are you worried? Good news!

Dr. P's Journal Club

As you loyal readers know, one of my goals with this blog is to help you to be informed consumers of medical literature and pediatric advice. Admittedly, it can be confusing and a daunting task for those of you with little training or appreciation of the scientific method, but it's worth the effort.

Here's another example of how new scientific evidence changes practice. Even if your newborn wasn't jaundiced, watch how yesterdays' state-of-the-art becomes today's out-of-date pediatric care.

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When I was just starting out in my pediatric training, I was taught to obsessively follow bilirubin levels in healthy, full-term newborns because "levels over 20 could cause brain damage."

As a result, we would occasionally perform "exchange transfusions" on healthy, full-term babies (taking out the baby's jaundiced blood and re-infusing blood from a donor, in order to keep the levels below 20). I well remember many an exhausting all-nighter, extracting via a large IV an infant's blood and reinfusing new blood. Out goes the bad blood, in goes the good blood, over and over again. This laborious task took hours, side effects were not rare, and I was a bleary-eyed basket case the next day.

As it turns out, there wasn't a lot of evidence to support this practice but, as often happens, "better safe than sorry" sometimes prevailed and it was pretty much considered the state-of-the-art. (But not everyone. In 1983 a famous and wonderful pediatrician named Frank Oski coined the term "vigintiphobia," meaning "fear of the number 20", to poke fun at what he concluded - correctly, as it turned out - to be an unwarranted phobia.)

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The study:

• 140 healthy but jaundiced, full-term infants born in 1995-1998 were followed over time.
• 130 had bilirubin levels between 25-20, and 10 had levels greater than 30.
• They were compared to infants born at the same hospital without jaundice (a valid study almost always has a "control" group, i.e., a healthy comparison group).

What the study found:

• None suffered brain damage ("kernicterus").
• Follow-up neuro-developmental testing two years later or more showed no significant differences between the jaundiced and the control group.
• Parents did not report greater behavioral problems or concerns in their formerly jaundiced toddlers.
• This information does not imply that jaundice can never cause long term developmental trouble in healthy, full-term newborns, just that the levels most babies experience (less than 30) don't appear to.

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Dr P Comments
I wanted to familiarize you with this study to:

1. Show how pediatric practice changes in the face of new data.
2. For those of you whose pediatric providers have not kept up with the latest evidence and still suffer from vitiginophobia and who, as a result, needlessly scared the bejesus out of you in the process.
3. For you parents who have never shaken that fear and still wonder if their child's newborn jaundice could lead (as has caused) some developmental or behavioral problems in your child.

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Two caveats from Dr. P:

• Remember, this evidence applies to full-term healthy infants. Premies and seriously ill newborns are another story.
• It will be important to follow these kids as they get older to be sure nothing subtle shows up later on (for example at school age).

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Study cited: "Outcomes among newborns with total serum bilirubin levels of 25 mg per deciliter or more." Newman T., et al. New England Journal of Medicine. May 4, 2006.

Related Topics: Newborn Growth & Development: Common Concerns, Understanding Newborn Jaundice

Technorati Tags: newborn, jaundice, bilirubin

Why isn't my baby talking?

Q: "My baby is 13 months old and not talking at all. He hears sounds because I'll tap on a table and he looks, but he won't say any words, just noises. Should I worry?"

A: Is there anything more thrilling than when a baby first starts talking? It's a brilliant developmental advance. Think about it. Your baby has learned that a sound -- which is, after all, nothing more than waves in the air stimulating the eardrum and the ear nerves -- actually means something. She's learned that this noise actually stands for this person or thing I love so much. The first word marks the beginning of the ability to think symbolically. It marks the beginning of what sets us humans most apart from all other animals on the planet.

The first word is, in short, a miracle!

Of course, that's also why parents tend to worry so much when their baby may be a little slow in talking. So for all of you whose infant still isn't saying any meaningful words at 13 months, here's some reassurance and here's some advice.

First, the reassurance.

There is tremendous variability in when children say their first meaningful words. (Note the emphasis on meaningful. Just saying "dada" doesn't count unless the word really represents and refers to that guy who is such a big part of the baby's life.) Some say their first words at nine months; other perfectly normal kids don't do so until as late as 18 months. And, by the way, if there's no problem otherwise, early or slightly later language is not a sign of how smart your infant is going to be.

Now, the advice.

Although it's too early to worry and your baby's probably OK, you (and/or your pediatric provider) need to remain alert to the possibility of a potential problem. Here are seven questions to ask yourself:

• Does he understand the meaning of single words (e.g. "where's mommy?" "NO!" "give me ...")?


• Is he making a lot of different sounds with a lot of expression to them?


• Could there be a hearing problem?


• Is he developing normally in other areas?


• Is he being spoken to a lot? Is someone reading to him every day?


• Is he exposed to any significant family (or other) stress?


• Is there a family history of slow language?

Reassuring answers to these questions are, well, reassuring. In such a case, a real problem is unlikely and, if I were your pediatrician,I'd say that it would be OK to wait another three to five months before an evaluation would be necessary.

But if you are not reassured, by all means talk to your pediatric provider about how best to keep an eye on yourchild's language development and whether an evaluation by a speech language therapist or other child development specialist would be helpful.

Tools to Try

• Slideshow: Toddler Milestones
• Slideshow: Baby Milestones

Sibling Rivalry

Q: I have a 3 1/2-year-old son who is jealous of his 4-month-old sibling. The signs include bedwetting, baby talk, and fits of rage in which he demands that I give him something by screaming "DO IT RIGHT NOW!" How do I make this transition smoother for him?"

A: Picture this scenario: Your partner comes home tonight with another woman in tow. He says to you:"Honey, I've brought home this new woman to live with us. Isn't that great? Isn't she cute? She's going to take a lot of my time and attention. But don't worry, I love you as much as I always have. I just thought our cozy little family needed expanding."

From his point of view, that's exactly what has happened to your little guy. He was quite content to be king of the hill and can see no earthly reason for your needing another child. So sibling rivalry and a sense of having been betrayed are inevitable in these circumstances. But all the attention in the world won't erase what the stunning change in his circumstance means to him.

That's not to say that his mixed feelings are bad.

Firstborns have had to learn to deal with this dethronement since the first mom had her second child. I think that as children learn to cope with that rivalry, they are learning to deal with stress, learning that they can be loved and valued even if there is competition for parental attention, and that there are better and worse ways to express one's ambivalence toward a sibling. They also learn to care for a person smaller and more helpless than themselves. They learn what it means to be a family. It's a great opportunity for learning important lessons, even if it's a bit painful at times.

So if you can't convince him at this stage that it's wonderful to have a little sister, there are tricks of the trade to make his road a little easier:

• Frequently reassure him how much you love him.


• Be sympathetic to his regressions and tantrums. Tell him you know he's having a hard time being a big brother and that's OK.


• Try to make some "special time" available to him every day where just the two of you are together and "the baby can't come."


• If he's interested, give him a new teddy or toy to take care of, "Just like Mommy is taking care of the new baby."


• Involve him as much as possible in the care of his new sibling. Ask his advice: "The baby's crying! What should we do?" Allow him to feed the baby a little or assist in changing.


• Don't accept bad manners, even if you're sympathetic to his plight. Tell him your expectations for his behavior.


• Appeal to his desire to move on developmentally. Emphasize to him how he's the "big boy" now and his sibling needs his instruction and guidance, as do you.

Sibling rivalry almost always resolves in a positive, constructive way and represents a wonderful opportunity for emotional growth for your oldest. Although it can be a bumpy ride, the end result is usually siblings who have learned to love and care for each other, a lesson that extends far beyond the family as they get older.

Tools to Try

• WebMD Video: Preparing Siblings For a New Baby
• Ages 2-5: What to Expect

My Toddler Stutters. Is this normal?

Q: Our 2 1/2-year-old son began stuttering about two weeks ago. Up until that time he really had no problem speaking at all. He has quite an extensive vocabulary and speaks in full sentences. Help!"
A: >I'm pretty sure your child has "transient dysfluency of childhood." Wait, don't be nervous! It's just a fancy name for a common stuttering problem that goes away.

Transient dysfluency (temporary stuttering) is typically seen in 2- to 4-year-olds. They usually are very verbal and often advanced for their years. The dysfluency results from their talking abilities going faster than the language centers of their brain. It's as if their brain can't catch up to their motor mouth, so it slows things down by repeating sounds over and over (i.e. by stuttering).

Stuttering is probably, at least in part, an inborn, genetic problem. There are lots of theories, but nobody really knows what causes it. Boys are about three times more likely to stutter than girls. When it comes to developmental issues, boys always get the short end of the stick!

Once your little guy's brain catches up to his mouth, the stuttering will disappear. In the meantime, Iwouldn't make a big deal out of it. He's too young to be very bothered by the stuttering, and if you get anxious about it, so will he, which may just make it worse. Continue to talk to him in a nice, slow, relaxed way and patiently wait for him to make his points. The odds are very good he'll outgrow it in less than a year.

So I wouldn't worry if I were you, but while I'm on the subject, let's discuss when a parent should begin to worry about a child's stuttering, which is seen in 1% of school-aged children.

Personally, I usually don't worry about stuttering unless it's still happening after the age of 4 years. Here are some things that would lead me to bring a child to a speech-language therapist's attention:

• The child is very bothered and upset by the stuttering.


• The stuttering occurs in all situations, not just when the child is excited or nervous.


• The child seems to be struggling to get the words out, with an increase in the pitch of his/her voice.


• The repetitions are very frequent and very long.


• There are frequent prolongations or blockages of words and sounds.


• The child avoids saying certain difficult words.

We've all known people who stutter and we all know how hard it can be for the stutterer. The good news is:

1. Most kids get better.


2. Speech therapy helps. If you have any concerns about your child's dysfluency, talk to your pediatric provider or find a good speech-language pathologist (the Stuttering Foundation of America can recommend one).

Tools to Try

• WebMD Video: Treating Kids Who Stutter
• Conquering Fear of Public Speaking

Should my child have his tonsils out?

Q: My child has persistent strep throat and my pediatrician says his tonsils should be removed. I'm not sure I agree. What's your opinion?

A: Not so long ago a child had a couple of strep throats and WHACK! … his tonsils or adenoids (or both) were unceremoniously removed, with all the ice cream s/he could eat as meager compensation.

Times have changed and for good reason. We now believe the tonsils play a role in how the immune system functions (though we're not exactly sure what that is). So we're loath to lop out what Mother Nature has so carefully provided. Also, scientific studies have shown only modest benefits for tonsillectomies in preventing future strepthroats. Finally, although generally quite safe, any surgical procedure has some risks, so there better be good reasons to do it. [It gets a little confusing. Remember the tonsils are lymphoid tissue at the back of the throat; the adenoids are higher up, behind the nasal passages. There are different criteria for taking out the adenoids (e.g., heavy snoring with obstruction of breathing during sleep, frequent ear infections, swallowing problems, etc.) which I'm not going to address here. Sometimes you just take out the tonsils, sometimes just the adenoids, sometimes both.]

The studies aren't en