Healthy Children

Passing of an Expert & Friend

2009-04-13T15:00:00.007-04:00

It's with great sadness that we announce that Dr. Steven Parker died unexpectedly this morning. Dr. Parker was an example of the passionate practitioner who brings not only knowledge but care to patients and readers. As WebMD’s expert pediatrician, he provided information and support to countless expectant and new parents. Our hearts go out to his wife, Karen, his family and friends. You can share your messages of condolence and support here.

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Who Are Your Children's Role Models?

2009-02-12T07:00:00.006-05:00

I am shocked - shocked! - that Michael Phelps smoked dope at a fraternity party. Who does he think he is? Doesn't he know he is a role model to our kids? I wanted my kids to be him and then he goes and pulls this stunt!?

Actually, what I am really shocked about is the ridiculous brouhaha this has generated. Let's face it, his behavior is not at all unusual for his age (in the only phrase from George W that I've appropriated: "When I was young and foolish, I was young and foolish."). Of all his potential misdeeds, this seems a minor transgression indeed.

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And, anyway, who says he is (or should be) a "role model"? The dictionary defines a role model as "a person whose behavior, example, or success is or can be emulated by others, especially by younger people."

Let's face it folks, your kids have no chance of becoming Michael Phelps, unless they too have a body like a torpedo, outsized hands and feet like a pizza pie, the wherewithal to swim for 13 hours a day, 7 days a week, a coach who will devote his life to their success, etc.

I work in the inner-city of Boston. Who are the role models of many of the kids I see? Mostly rappers and basketball players. Yet the odds of actually making it in life as one of those is zero. It's completely unrealistic and misguided in its values and what they can accomplish in life. Why their heroic 6th grade math teacher is never mentioned is a source of great sadness to me because, with some hard work and motivation for school success, they could actually become that math teacher.

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Here‘s where you parents come in. Much like talking to your kids about what's on TV and what values it promotes, so too do you need to address this question of what kind of people we admire in life and why.

Sure, Michael Phelps did a very cool thing and loves his mother, but what about someone who has devoted her life to helping others, someone who started a successful small local company, someone who is really smart and worked hard in school to succeed, someone who teaches.

You get the idea. If you don't push for alternative role models, who will? Surely not the media who are financially committed to hawking celebrities as the royalty of our culture.

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I want to close this screed on a scary note.

I do know with 100% certainty at least one or two people who, no matter what, will surely serve as important role models in your kids' lives. That would his/her parents. Yes I am talking about you!

Many parents think they are teaching their kids by their discipline methods or rules of the house, etc. But we humans - and that includes your kids (at least most of the time) - learn mainly from what is called "incidental learning," that is, learning on the fly, learning by observing and interpreting and making meaning of what is going on around them all the time.

Be afraid, be very afraid: your kids are observing you and eventually will judge what kind of a role model you are based on how you behave, your relationships with others, how loving and caring you are, and how mean and selfish.

Some of you lucky ones will be 100% positive role models for your kids (don't count on it), some will be 100% negative (I hope not), but most of you will be a mix of good and bad, with some traits that your kids will want to emulate and carry on to the next generation and some that your kids will reject and be glad not to pass on to their kids.

So the next time you are thinking about Michael Phelps and his bong, better to think of your own behavior and what lessons your kids are deriving from it day after day, year after year, generation after generation.

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Faith Healing and Children

2009-01-22T12:03:00.009-05:00

Some stories just break your heart on every level, like this tragic one. But most don't also make you so mad you could spit. Here's what happened:

Kara Neumann, 11 years old, was getting progressively, inexorably sicker. Despite a powerful thirst and hunger, she seemed to be wasting away to nothing. Over time she was becoming weaker and weaker. Despite nutritious food, she continued to fail. Eventually she was too weak to get out of bed. She became confused, then lethargic, then comatose. Then she died.

Many of you probably recognize the classic symptoms of untreated diabetes and diabetic ketoacidosis. It's an easy diagnosis to make and, had she been properly diagnosed, she would have been treated with fluids and insulin, and gone on to have a nice long life.

But that is not what happened. Instead, her pious parents - who strongly believed that only God and prayer can and should heal - never brought her to medical attention, even as they profoundly and urgently and continuously and lovingly prayed for her recovery.

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Now the state of Wisconsin is prosecuting the parents for "reckless endangerment." Each .faces up to 25 years in prison. Apparently, the critical legal issue is whether the parents knew it was a "life-threatening" condition (really, how could they not?). Their lawyers contend the state is unjustly violating their right to religious freedom.

To put this in context: Over 300 children (that we know of) have died in the past 25 years because of medical neglect due to parental religious beliefs.

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On two occasions during my pediatric training, I cared for Jehovah's Witness kids who required major surgery. Turns out this was a fairly common event and we knew just what to do. Parents were informed that surgery could only be done with the option of a blood transfusion if needed. They refused. We then went to a local judge and got a court order / permission to transfuse blood if need be. Surgery went ahead.

I have to say, on both occasions I got the impression the parents were relieved to cede authority to us to save their child's life. They didn't have to violate their religious percepts - after all, Dr. P was the one who would go to hell if blood products were administered! But neither did they have to worry that their child would die for want of blood.

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What's your take on this? Isn't this a free country? Wasn't it founded on religious freedom? How can we then deny parents their right to practice their religion in the way they choose? How dare the state intervene into the lives of families in such an intrusive way?

Here's my view. As an adult you have the right to believe anything you want and, as long as those beliefs don't impinge on the rights or well-being of others, you have the right to freely act on those beliefs. You can act against your own self interest, even do things that are clearly self-destructive. That is your right, boneheaded as you might be.

But you do not have the right to use those values and beliefs to harm a child - especially your own - who cannot decide for herself. You do not, for example, have the right to impose cruel physical punishment, even if your beliefs dictate you should do so. You do not have the right to have your child avoid all educational programs in the hope of isolating her from the temptations and misguided beliefs of this wicked world.

And, most assuredly, you do not have the right to endanger her health and well-being and very life to conform with your beliefs.

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In short, as a parent you have the right to make a martyr of yourself, but you do not have the right to make martyrs of your kids.

I feel bad for Kara's parents. I really do. They have lost a child - the very worst thing that can happen in this life, At the same time, if I'm honest, I want to throttle them for their reckless, stubborn abandonment of their ever weakening child. Jail or no, now they will have to live with the awful knowledge that her death was their fault.

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Read the entire New York Times' article, Trials for Parents Who Chose Faith Over Medicine.

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When Your Child has the Misery

2009-01-15T07:30:00.002-05:00

It's a sight sure to pierce the very heart of any parent.

Your little bundle of joy, Pookie, is sick: snorting, spewing, coughing, miserable. She looks up at you with those big, limpid, trusting, bleary, red eyes: What's wrong with me, Mommy? Help me! Fix it!

Then, when miraculous relief is not forthcoming, reproach: Why aren't you making me feel better? Why are you letting me down when I love and trust you so? What kind of a Mommy are you?

The urge is overwhelming: Don't just stand there, do something!

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But what, exactly?

How about a cold medicine? Whoops, no go. Cough and cold preparations are no longer prescribed for children under 4 years because of rare but potential significant side effects. And, to be honest, they never did work well anyway. Scratch the cold medicines.

How about good old Tylenol or Motrin? Well, no. They are only useful for pain and fever, neither of which Pookie has. They wouldn't do anything useful (except to give the illusion of doing something to make things better).

I've got it! Good old Vapo Rub! Great idea. Except, as you probably just read, there was a recent case report of a problem with an 18 month old infant who was hypersensitive to camphor oil and had breathing problems because of its administration under her nose. Plus, the stuff is pretty useless, except to stink up the joint.

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Here's the sad, hard, inconvenient truth: there are some negative experiences in life from which you will be unable to protect your kids - the misery of a bad cold being one of them. The desire to do something - anything - is strong but, as we've learned, that can sometimes lead to side effects that are far worse than the 'disease'.

As physicians, we take the vow: "First do no harm." That goes for you parents also.

Actually, I'm not convinced this is even bad news. Like all of us, children need to learn to cope with adversity, to feel lousy but then to endure the misery and emerge unscathed, perhaps even stronger, on the other side. That successful sense of mastery will serve your child well when other adversity strikes (as it inevitably will) and she instinctively knows: I will get through this OK!

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But there is an even more important lesson that is often learned: the magical healing love and support of wonderful caregivers. Perhaps Mom was ineffectual at making it better right away but, during my miseries, she provided me with a powerful, comforting cocoon of warmth, of support, of care, of love.

When we ourselves have the misery, who among us - no matter what our age or station in life - doesn't ache for Mommy to soothe a fevered brow and offer hot soup and a knowing hug and a sympathetic gaze, just as she so memorably and lovingly did all those years ago.

For many, the tender ministrations of our parents during illness is one of the most enduring and beautiful and powerful of our childhood memories. Be sure your kids have a bunch of them and you will, in fact, have really done something of earthshaking importance during their misery, something that far transcends the quick fix of an ineffectual medication, something that cuts to the heart of a parent's love.

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Dr. P's Top 10 Pediatric Stories of 2008

2009-01-05T10:00:00.008-05:00

Is it possible another year has passed? Here, in no particular order, are 10 pediatrics stories that caught my eye in 2008:

1. New recommendations for lipid screening and treatment in kids.
Perhaps in response to the epidemic of childhood obesity, the American Academy of Pediatrics has significantly revised its recommendations on the screening and treatment of kids for high cholesterol and blood lipid (fat) levels.

Basically they are recommending that your pediatric provider order blood tests for these levels starting at age 2 years, and then every 3-5 years thereafter if you have a positive family history for high lipid levels or early heart disease, or if such history is unknown, or if your child is overweight. That turns out to be a majority of kids!

However, what has generated a lot of controvery was their recommendation that - if diet and exercise fail to lower the levels to an acceptable range – cholesterol and lipid-lowering medications be used in children, as early as age 8 years. As you might guess, I have an opinion on this New Cholesterol Guidelines for Kids. Stay tuned for where all this goes in the next few years.

2. Cough and cold medicines get the axe for infants and toddlers.
I've long contended that cough medicine is essentially useless and cold medications are not much better. What I wasn't aware of until this year were the numerous incidents of these over the counter cough and cold preparations causing harm to infants and toddlers (often due to giving too high a dose. After all, "If a little is good, a lot is better", right?). Here are my appreciative comments on this change: The FDA and OTC Cold Medications for Infants.

So it's now no longer recommended to use any of these medications for children under two years of age. Stick to old stand-bys: a humidifier/vaporizer, elevating the head of the bed, honey after age one year for cough and, of course, chicken soup and TLC.

3. New ways to lower the risk of SIDS
Earlier in the year I alerted you to a study showing that pacifier use seems to significantly cut the risk of Sudden Infant Death Syndrome (SIDS). Now comes another potential low-tech way to decrease the risk even more: running a fan in the bedroom. In this study, a fan in the bedroom seemed to also cut the risk of SIDS by 70% (perhaps because it prevents the baby from sleeping too deeply).

So now the list on how to decrease the risk of SIDS includes "back to sleep", pacifiers, a fan in the bedroom, not too soft mattresses, no dolls in the crib, not too hot a temperature in the bedroom, and, I'm sure, more to come. I so would love to see the last of SIDS in the world. It is such a cruel event.

4. Probiotic "friendly" bacteria safe in pregnancy and for infants
It's always nice when research confirms what you have been preaching. In 2007, despite scant evidence, I came out for giving infants and kids "friendly" probiotic bacteria under certain circumstances.

This year another study showed that feeding normal infants these bacteria was safe and also seemed to increase resistance to respiratory infections during the first 2 years of life! During the 6-month intervention, antibiotics were prescribed less often than in the placebo group (23% vs 28%) and respiratory infections occurred less frequently in the friendly bacteria group.

5. Honey is the best cough medicine.
OK, if cough medicine is useless, does anything help? A neat little study this year showed that good old buckwheat honey did help in children over 1 year of age. Try it.

6. Eating breakfast reduces weight gain in adolescents
Could my (and everyone else's) mother have been right? Is breakfast the "most important meal of the day"? I don't know about that, but a recent study did show that adolescents who eat breakfast aren't nearly as overweight as those who skip breakfast. The reasons for this association are not clear.

Given this study and others showing children who have breakfast are better able to concentrate at school, let's go with mom on this one: have a good breakfast! (Timlin MT et al. Breakfast eating and weight change in a 5-year prospective analysis of adolescents: Project EAT (Eating Among Teens). Pediatrics 2008 Mar; 121:e638.

7. On the road to a malaria vaccine
I hate mosquitoes, but for the wrong reasons No doubt, so do you. The most important reason to loathe mosquitoes is their transmission of malaria, arguably the worst disease on the planet. Every year over 500 million people contract malaria and 1-3 million die, the majority of whom are children in sub-Saharan Africa.

But just a few weeks ago, a vaccine with about 50% efficacy to prevent malaria (not great but much better than anything else) was reported. You know how much I love vaccines. Now it looks like we may soon be getting the upper hand on banishing this horrid disease from the lives of the world's poorest children.

8. Stem cells created from normal skin cells
2008 was a great year for stem cell research. Two research teams were able to take skin cells from patients suffering from a variety of diseases and reprogram them into stem cells. This may avoid the need to use the controversial embryonic stem cells all together.

The newly created stem cells can hopefully then be induced to assume new identities and serve as major tools for understanding how diseases arise and develop. Eventually, when scientists master cellular reprogramming so that it is more finely controlled, efficient and safe, patients may someday be treated with healthy versions of their own cells.

9. Five-in-one vaccine developed
The first "five in one" vaccine ("Pentacel" - diphtheria, tetanus, pertussis, polio, hemophilus influenza) has been developed. This means fewer shots and less cost. And, yes, combination vaccines have been shown to be just as effective and no more prone to serious side effects than the single, double or triple vaccines were.

Pentacel still has to be administered in four separate doses, three times between the ages of 2 and 6 months, then again between 15 and 18 months - but it cuts down by 30% on the 23 injections toddlers under 18 months normally receive.

10. Prenatal maternal blood test for Down Syndrome
A new genetic test may be able to pick up Down syndrome in the fetus with a simple blood sample from the mom-to-be. Because small amounts of fetal DNA enter the mother's blood stream, the test is designed to detect abnormally elevated levels of chromosome 21 in the mother's blood, which would indicate a baby with the syndrome. This would be a far less invasive and safer way to diagnose this common parental concern.

11. Enjoy your kids! All the best from Dr. P for a happy and fulfilling 2009 for you and your family!

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PROJECT GOOD HEART 2008: Teaching Your Kids the True Spirit of the Holidays

2008-12-10T10:03:00.005-05:00

Somehow, not only Christmas, but all year through,
The joy that you give to others is the joy that comes back to you.
And the more you spend in blessing the poor and lonely and sad,
The more of the heart's possessing returns to you glad.

- John Greenleaf Whittier

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As if you needed more proof that economic times for families are tough and likely to get tougher, consider this: in this 2008 holiday season, the average American consumer plans to spend about 1/2 of what they spent last year ($431 versus $816) on gifts (that still totals about $100 billion dollars nationwide).

Your kids will be, of course, still excited to get their presents, which are - let's face it - pretty much the meaning of Christmas and Chanukah for most of them (and most of us).

I'm no Grinch, but what if each of us were to donate to charity a mere 10% of our intended expenditures on presents? That would amount to $10 billion dollars. And what might that teach our kids?

That's why I'd like to encourage you to sign on to our PROJECT GOOD HEART, in which you donate to a charity (of your child's choice) the money that you would have spent on one of his/her presents.

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Here's how PROJECT GOOD HEART works:

Explain to your kids (over the age of 5-6 years or so) that instead of one gift you would have given them, they are to chose a charity to donate whatever dollars that present would have cost.

Talk about the reasons charities exist and why empathy towards people less fortunate is a family value ("Remember when we saw those people on TV who lost their homes?").

Discuss with them the various kinds of charities and how they help those less advantaged in many ways.

Ask them what kind of help they would like to give: for food? shelter? medicine? toys? books? For kids their age? needy families? victims of disasters or war? the poor? endangered animals? the environment?

Encourage them to put themselves in another's shoes: "If our family was unlucky and lost a lot of the things we now have or we were victims of a storm or a war, how would you want others to help us?"

Guide the discussion: "Sure, Billy, buying a lot of Twinkies for a homeless family is a great idea and would make them happy for a short minute, but can you think of other ways to help them?"

But, remember, in the end, it's their donation and their charity. Let them choose.

On Christmas or Chanukah, give them a Project Good Heart card (you can print the logo above) that says, "X dollars donated by Billy to the ABC charity, where it will be used to ___. Thanks, Billy!"

Perhaps, one day, when the latest toy is rusting in the basement, your kids will remember their charitable gifts as having best taught them the true spirit of the holidays.

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The fragrance always stays in the hand that gives the rose.
- Hada Bejar

HAPPY HOLIDAYS FROM DR. P

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PROJECT GOOD HEART logo by my colleague, friend and collaborator on PROJECT GOOD HEART, Jack Maypole, MD.

If you'd like some information and guidance on worthwhile charities, here are some good web sites to guide your discussion and help make a choice:

** Read about some families' experiences with PROJECT GOOD HEART from last year. I'd love to hear from you about what your family does and learns from PROJECT GOOD HEART 2008.

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Let Them Eat Cake!

2008-11-17T15:15:00.006-05:00

Billy sits in his 3rd grade classroom, happily munching on double Dutch chocolate cake with creme frosting.

Suddenly the door to the classroom is kicked open. Five policemen rush into the classroom and surround Billy. "Kid, we have a report you brought a toxic substance into the school and, even worse, are inciting other children to ingest it, much to their peril."

Billy starts crying, "But it's my favorite cake and it's my 8th birthday and I brought enough for everybody.'

"Sorry, kid. We will have your cake analyzed at great taxpayer expense, but clearly you have violated the new statute of the State of California's school nutritional standards which forbids any snacks during the school day containing more than 35% sugar by weight or 35% of their calories from fat or more than 10% of their calories from saturated fats. Kid, it's the slammer for you. The good news is that you can eat all the cake you want in jail!"

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OK, I made up this scenario, which hasn't taken place - at least not yet. But the law and its standards are real. I learned of it in a newpaper article about school bake sales being banned in California (http://www.nytimes.com/2008/11/10/us/10bake.html?_r=2&ref=health&oref=slogin&oref=slogin).

Should you have a mistrust of agents of the government getting it right, here is exhibit #1,098,765. First, start with an excellent idea: food offered to kids while at school should be healthy, low in saturated fats and junk food and refined sugar, high in nutrition and fiber, etc.

So far so, good. The initiatives to make school breakfasts and lunches healthy are truly laudable. Banning soda and other junk drinks - instead offering only water and 100% juices - is the right thing to do. Trying to teach proper nutrition and eating habits is an appropriate role for schools where, after all, kids are eating 1-2 meals / day.

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But, as often happens, the well-meaning authorities don't know where to stop. Banning cake sales? Does anyone believe that by banning bake sales from the premises, children will come to abhor cake and ice cream and all junk food, and live happily ever after in tofu & bok choy heaven?

Not me. Let's deconstruct the article:

Misstatement #1:

Banning junk food from schools "will do for junk food what smoking bans and taxes did for cigarettes." Forgive me, but what a dumb analogy. There is no inborn pleasure or motivation to smoke, but there certainly is to eat and for foods high in fats and sugar to be especially appealing. If the goal is to make kids hate cake and ice cream, lots of luck fighting city hall. In fact, I'd argue that, in the long run, prohibition only increases their allure, so that the deprived child may even want it more than s/he would have otherwise.

Misstatement #2:
"You're teaching them eating habits for life." I have to say, there is no good research relating early eating habits to those in later life (except in extreme cases). Having watched a lot of kids grow up for a long time, I'm quite skeptical of this truism. The reason to promote healthy eating habits is to keep your kids and their arteries healthy, at least for the 18 years or so in which they are (sort of) in your clutches.

Misstatement #3:

"I don't think all celebrations need to be around food." It is this attitude which led to the described "Healthy Halloween vegetable platter" for kindergartners, a "celebration" which must have bordered on child abuse in my book.

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A decade ago, when I was co-authoring Dr. Spock's book, he came out strongly against cow's milk for kids over age 2 years. It was a major bone of contention between Dr. Spock and me (guess who won). Aside from there being little to no credible evidence to ban milk from the diets of children, the idea of a childhood without ice cream was unthinkable to me.

I can't help but believe that - aside from legitimate health concerns - the zealots are in some way anti-pleasure meanies (much like H. L Mencken's definition of puritanism: "The haunting fear that someone, somewhere, may be happy."). The answer is to teach moderation and smaller portion size, not a blanket prohibition of some of life's great delights - cake, ice cream and, yes, even the occasional Twinkie.

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A Cure for Infantile Cerebral Palsy?

2008-11-04T07:00:00.003-05:00

While researching my previous post on the pros and cons of banking your baby's cord blood, I happened upon the stories of two infants whose cerebral palsy seemed to improve after they received an injection of their cord blood stem cells. (Amazing Recovery Attributed to Cord Blood; Girl's Own Cord Blood Gives Her Parents Hope

The stories were as dramatic as they were heartrending. Each told of almost miraculous improvement following the experimental treatment: the utterance of the first word, more awareness of surroundings, improved muscle strength, and (for me, most touching of all) parents reporting: "He also began to laugh at about a week after the infusion. He never laughed before; he would just kind of screech."

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These stories could not help but fill me with great hope. Could cord blood stem cell injections actually improve a previously 'incurable' condition like cerebral palsy? It would literally be a dream come true, especially for a developmental pediatrician like me.

Yet, despite these compelling stories, I still opted not to recommend privately banking your baby's cord blood. Why not? Shouldn't these tales seal the deal and mandate, if you can afford it, that you privately bank your baby's cord blood for a rainy day?

The problem is - as I have learned from long experience - often the most compelling story doesn't withstand close scrutiny and turns out to be a false lead, a flash-in-the-pan, offering unjustified hope to despondent families or, even worse, a way for true-believer charlatans to make a buck off parents desperate to find a cure for their child.

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Let me explain further why in this case I refused to jump on the bandwagon:

Usually, only positive stories are publicized. Infants for whom the stem cells did nothing don't make it to the media's radar screen, so you never read about them. That's why you always need to ask, when hearing of miraculous cures "How many kids did this not work for?"

It could have been a coincidence. Yes, it sounds like these two children benefited, but do we really know it was from the stem cells? That can only be proved by scientific studies showing it was due to the injection (and not something else that happened around the same time).

The "placebo effect" has to be considered. If we think and pray something will help, we tend to interpret what happens in a positive light. Believing is seeing. That's why the improvement needs to be documented, not just by hopeful parents, but by objective observers who may not even know if the child received the treatment or not.

The progress, even if real, could be short-lived. Are these children continuing to improve? Have they regressed and lost any of the initial skills? Only studying them over time will tell.

We need to watch for negative side-effects that only show up later. Sure, we think one's own stem cells should be trouble-free, but until it is put to the test, we don't really know. First, do no harm.

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So, call me a Grinch, but until there is a published, peer-reviewed, proper scientific study, I'm reserving judgment and not allowing these stories to change my attitudes.

I know this caution drives some parents crazy or even makes them angry with me, but alas, I'm old enough to have been through about 100 "cures" for autism which, despite their compelling stories at the time, never panned out and only led to more heartache and expense.

From where I sit, it is an egregious sin to offer families false hope that is cruelly dashed over time, rather than impatiently but prudently waiting for the scientific evidence to come in.

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Should You 'Bank' Your Newborn's Cord Blood?

2008-10-27T15:30:00.003-04:00

As if life weren't complicated enough, many expectant parents are now being confronted with a wrenching question: to bank or not to bank? If you haven't dealt with this question, let me explain.

Turns out that the umbilical cord blood has a goodly store of stem cells, those magical immature cells which can reconstitute a bone marrow as part of transplant treatment (e.g., for leukemia, sickle cell or some metabolic diseases). To date close to 7,000 umbilical cord transplants have been successfully performed, with excellent results.

Or perhaps one day they might be cajoled into transforming into any manner of needed tissues - nerve cells, skin, intestines, ears. The medical community is justifiably excited about the potential for these cells to be used in the future to cure a variety of diseases.

So the idea is to "bank" (meaning, freeze) these cells from the cord blood and save them for a rainy day when they might be needed to work their magic.

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There are two kind of cord blood banks: public banks that, following a thorough screening process, make your baby's stem cells available to anyone who is luckily a match and might need it.

And there are private, for-profit banks that store the cells specifically for your baby or for a family member. The cost is about $1,000-$1,500 for the initial procedure and then about $100-150 / year to keep it on ice.

Perhaps you read about or were offered these options when you had your baby. The private bank is an appealing idea. If, someday in the future, your infant (or a close relative) were to contract a disease that required a transplant, a perfect (or close to perfect) match could be obtained. Who would not, for a mere few thousand dollars, want to protect their child from some future catastrophe with such "biological insurance"?

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Not me. Here's why:

The odds of the cells actually being useful some day are very very low - variously estimated at 1 in 1,000 (the odds of dying in a fire), up to 1 in 80,000 (the odds of dying from lightning strike), to 1 in 200,000 (the odds of dying from an asteroid hitting you).

It's expensive.

It's not clear how effective the stem cells might be after being frozen for a very long period of time.

By the time they might be needed, other ways to derive stem cells from our bodies may exist, so the newborn stem cells would not even be necessary.

If the cells are to be used to cure a genetic disease, these same cells will contain the genetic defect and may not be appropriate treatment.

What happens if the banking company goes out of business?

On the plus side:

It makes sense to do so when there is a sibling with a medical condition that could benefit from a stem cell transplant.

Who knows what advances in the future might render these stored cells useful to your now adult or aged baby?

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Dr. P Opines
Banking cord blood is akin to purchasing lightning insurance. Sure, it's not impossible it might be helpful some day, but really the odds are very slim.

And, if let's say one in 50,000 infants will actually benefit from doing so, that leaves 49,999 cord blood specimens languishing in the freezer, making a profit for the freezing company, when they potentially could have been used as a match for a needy fellow human.

About 4,000,000 babies are born each year in the U.S. whose precious cord blood is discarded with the garbage. If parents agreed to bank their cord blood in public banks, the chances of everyone - including your family members - finding a much needed match someday would greatly increase. It's an example of doing something for the greater good that also benefits the individual.

So I vote NO to private banking (except for the immediate benefit of an ill family member). Instead, take the $3,000 you would have spent and invest it over the next 18 years to pay for your baby's college education, for which, I hope, the odds are much better than someday needing a stem cell transplant.

And a big YES to public banking of your baby's precious cord blood, as precious a gift as s/he may ever give.

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If you are interested in donating your baby's cord blood to a public bank and for heartwarming stories of how such donations have helped others, check out National Marrow Donor Program: Donate Cord Blood.

For the position of the American Academy of Pediatrics on this, see Cord Blood Banking for Potential Future Transplantation

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Got Vitamin D?

2008-10-13T12:41:00.018-04:00

Vitamin D is the new vitamin du jour. This week, the American Academy of Pediatrics Committee on Nutrition doubled its recommended intake of vitamin D from 200 to 400 IUs (international units)/day.

Why the change? I wrote about this 2 years ago (Vitamin D, Infants and Teenagers) and, as far as I can tell, it's not because there have been any new important studies.

Rather, it has just gotten clearer that vitamin D is good stuff; that when taken in infancy and childhood it promotes strong bones lasting into adulthood; that it may play a role in preventing such nasty adult diseases as diabetes and cancer; that it may bolster the immune system; and that it can lower the rate of hip fractures in the elderly (yes, Lord willing, some day your little one will be an old coot). Not bad for a long ignored vitamin!

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At the same time, low vitamin D levels have been documented in about 40% of infants, children, and teenagers. Why?

It's well established that breast milk often doesn't contain enough vitamin D to meet these requirements. This can be especially problematic in the dark winter months and with dark skinned infants (whose skin pigment repels the sunlight needed to make vitamin D in the body).

To ingest the new recommended amount of vitamin D, a child would have to drink about a quart of vitamin D-enriched milk a day (or, to reprise an old childhood nightmare, a teaspoon of cod liver oil). Lots of luck!

Most teenagers aren't getting nearly enough vitamin D and there is reasonable evidence that adult bone hardness is related to vitamin D and calcium intake during the growth spurt of puberty.

People with darker skin or those who take their doctor's advice and avoid direct sun exposure, also can't make enough vitamin D (it's estimated you need 10-15 minutes of direct exposure without sunscreen a few days per week to do so - much more if your skin is dark).

In fact, many argue that 400 IUs is still too low a dose for older kids. I think they are right: it really doesn't make sense that the recommendation is 400 IUs / day for everybody, whether you are a 6 pound baby or a 160 pound teenager. My guess is that in a few years they will bump up the recommendations for bigger kids, so stay tuned.

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FAQs: What to make of these new guidelines?

Should I give my child vitamin D supplements?
Consult your pediatric provider about this, but I vote yes to 400 IUs /day, unless it's clear your child is getting enough through his/her diet and/or sun exposure (or unless s/he needs more due to a chronic disease or medication).

What if my infant is breast fed?
Then it's all the more important to add a daily supplement of vitamin D to avoid the problems associated with inadequate intake and poor sunlight exposure.

What if my baby is formula fed?
In that case there is no need to supplement since all formulas sold in the United States contain extra vitamin D.

How will I know if my baby might have rickets?
Rickets - due to inadequate vitamin D over a long time - causes soft bones. Mostly it is seen in dark-skinned, breast-fed babies with little direct sun exposure who are not taking supplemental vitamins. Rickets is diagnosed by an X-ray, at which time there may be excessive bowing of the legs and/or swelling of the wrists and ankles.

Should I give more than the recommended 400 IUs?
Vitamin D is great stuff, but there is an important catch: Too much can be harmful. Unlike vitamin C which is just peed out if taken in excess, vitamin D is stored in our fat tissues. Too much can lead to an overdose and serious medical problems, so it's important to strike the right balance. 400 IUs may still be too little in older kids and teenagers but, until we know more, I'd err on the side of too little, rather than too much.

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Dr. P's Bottom Line
I think vitamin D supplementation is a good idea for infants, children, and teenagers. 400 IUs extra/day appears safe and may have important short-term and long-term benefits for your child. I say, go for it!

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A "Minute Clinic" Visit for Your Kids?

2008-10-06T08:00:00.007-04:00

Is there a 'minute clinic' in your area? One just opened in mine.

Housed in a CVS pharmacy or Target or Wal-Mart or Albertsons, these are health care dispensaries staffed by nurse practitioners and physician's assistants intended to care for minor, self-limited medical issues (like ear infections, strep throat, skin rashes and vaccinations).

Hmm... Let's see, I'll get some school supplies, milk and, while we are at it, have that pesky rash looked at. "You're sick. We're quick!" is their motto. Apparently there's gold in them thar hills. Consider:

25 states already have such clinics.

No less than Wal-Mart has gotten into the act. They currently have about 75 clinics in 12 states and plan to open thousands more in-store medical clinics in the next 5 years.

Is this good idea? Have you or will you take your kids to a minute clinic?

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Here, as I see it, are the pros and cons. On the positive side:

Patients can be seen promptly, without an appointment. No muss, no fuss.

The charge is generally only about $50, much less than an emergency room or primary care doctor's visit.

Most use electronic medical records so there can be access to previous visits at any site.

Most parents are capable of distinguishing a minor illness from a potentially more serious one, as are the health professionals who are seeing them.

On the worrisome side:

The providers don't really know your child. What if there are some complicating medical concerns they should, but don't, know about?

Sometimes parents underestimate the nature and severity of the symptoms. Will the minute clinic, for example, be able to pick up early and subtle signs of meningitis?

There is no physician oversight on-site. What happens if the child is too sick to be seen or there is some mysterious complication?

Care is fragmented. Will your primary care provider ever even know about the multiple diagnosed ear infections?

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Alas, I can't find any good studies assessing the quality and appropriateness of the care delivered at such places. Of course, most of the time, things will go well. Most illnesses are self-limited and kids get better no matter what we do or don't do. It's our dirty little pediatric secret.

The real question is this: how often will the rare, but much more serious illness be missed? And what will be the effect of this further fragmentation of care on the general well-being of our kids?

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You may be surprised to hear I'm not necessarily opposed to minute clinics, as long as there are quality safeguards and oversights in place.

I think parents should have choices when it comes to their child's health care. Lord knows emergencies rooms are often an expensive, endless nightmare. I can see why you might want your child checked out quickly and inexpensively, instead of waiting in my office for an hour, only to be told "it's probably just a virus. Nothing to do." I can see why uninsured families might make use of this service, in lieu of more expensive health care services.

Also. it will be interesting to see how insurance companies deal with minute clinics. Sure, the price is right, but if your child was not sick enough to see a doctor, perhaps she was not sick enough to warrant reimbursable medical care and perhaps these clinics will make it too easy to seek care for trivial complaints and, they may reason, perhaps we shouldn't pay at all. Stay tuned for Blue Cross vs.Wal-Mart battle of the titans on pay per view.

I'm sure some of you are making or will make use of this convenient form of acute health care. On the other hand, some of you may want the comfort of seeing someone who knows your child, someone whom you trust, and someone who is more likely to pick up the unexpected, unusual cause of the symptoms. In such cases, the wait and expense of seeing someone like me will be worth it. It will be (and should be) your call.

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Have any of you used a minute clinic? What was your experience? If not, would you use one for your children? Inquiring minds want to know.

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Dr. Parker's FAQs

2008-10-01T14:44:00.000-04:00

Are Temper Tantrums Dangerous?

How can I get my child to take medicine?

My child bites other children! What should I do?

My child's growth is slower than the chart! What do I do?

My Toddler Stutters. Is this normal?

Potty Training Blues?

Reflux or Not?

Should my child have his tonsils out?

Sibling Rivalry

Should I worry about my picky eater?

When should my baby eat solid food?

When should I switch to cow's milk?

Why isn't my baby talking?

Autistic Kids: Who Should Pay?

2008-09-29T15:04:00.004-04:00

It's a war you can see coming, a war where there are no bad guys, a war that breaks your heart, a war for which you will be asked to chose sides . For the latest volley, see this article from the Boston Globe: Push on for Insurers to Share Autism Cost.

Watch this war heat up between two titans - the health insurance industry and the educational system. It's a border war. At issue is where to find the immense resources needed to pay for therapeutic services for autistic children.

You can see how the stage has been set for this looming battle:

The numbers are huge. Currently it's estimated that about one in 160 (or about 560,000) children in the U.S. are autistic.

Everyone agrees that the treatment of autism should begin as early as possible (sometimes as early as age 2 years) and that it needs to be intensive (say, 25 hours/week).

Let's do the math. The American Institute of Research estimates the annual cost to educate an autistic child in public school is between $15,900 and $21,700. (The average annual cost for a students in public education is $7,600. If we say $17,000 a year per autistic student, that means the annual cost for educating 560,000 autistic kids would be more than $9 billion a year.

No exactly chump change, even in these outrageous times (hey, how about an autism bail-out?). So who should pay?

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What the School System Says:

We can't pay for this. We have a small lump of dollars to educate all of America's children. Every dollar spent on special education means one dollar less to educate typical children. We know that if they are to be helped at all, autistic children require intensive services (physical therapy, occupational therapy, speech therapy, applied behavioral analysis, to name a few). We simply can't afford it, or else we'll have to cut educational funding a lot for the vast majority of children.

Anyway, this is a medical problem, caused by a neurobiological problem. As such, it falls well within the purview of health insurance (just as mental health issues do).

Health insurance must pay the lion's share.

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What the Health Insurance Industry Says:

This is not a medical problem. The treatments are primarily educational, not medical. We pay for medically necessary care, not, for example, basic skills training. Sure, we'll pay for 60 days of physical/occupational therapy to rehabilitate an injured patient, but not daily therapy to educate a developmentally disabled child for 20 years. Additionally it's always unclear how much of these therapies are needed. Is 4 hours of speech therapy enough? Of course, more is better, but how much is enough? There is simply no good scientific evidence for the efficacy of almost all of the autism therapies. The treatment plan is therefore a decision best left to the child's teachers, who know him and his individualized needs.

The educational system must pay the lion's share.

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So, Who's Right?
First, it pains me that we even need to have this discussion. SOMEONE needs to pay for the intensive treatment. One clear measure of worth as a society is how we care for our most disadvantaged, needy citizens. And autistic children and their families are right up there. But who wants to pony up for the billions needed? Imagine how you would feel if you were the parent of an autistic child and couldn't provide the recommended therapies for your child because of the lack of money. That should never happen but - hello! - it does every day. It's shameful that we as a society still haven't (and likely won't) agree to provide the requisite services for these children and their families.

OK, so most agree that we need to pay for the therapy of autistic children and that it will cost a lot. Someone has to pay.

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Some states have entered the fray and passed laws mandating that health insurance companies foot much of the bill (see, for example, Pennsylvania which makes the insurance companies liable for up to $36,000 year in treatment expenses!).

One way or another, as the insurance and educational titans duke it out, you may asked to pay a share, either through increased health insurance rates or increased property taxes for schools. So again I ask:

Who should pay?

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Dr. P Weighs In:
I have to say (and to my own surprise), I am on the side of the health insurance companies on this one. I think autism is primary an educational, not a medical challenge. The wonderful autism teachers and therapists - not insurance companies - are in the best position to decide the nature and intensity of the interventions. They should be given the resources - through their own special educational systems - to provide those therapies without being in the terrible bind of robbing those dollars from much-needed services for typical and even gifted children.

The bad guy here is our woefully under-funded educational system and how we chose (or chose not to) fund it (property taxes - don't get me started). It's a non-system bound brother against brother, where if one wins, the other loses.

Frankly, I'm guessing that if there were adequate resources, the school systems would agree with me, as would most parents. Their current position of looking to health insurance is purely pragmatic and strategic - because that's where the money is and because, unlike the school system, health insurance companies can simply raise their rates and do not need to ask for a vote of the people to do so (which is usually rejected by disgruntled and older property owners).

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What About Now?
As this gets sorted out (if it ever will), parents of autistic children will remain in the untenable position of scrambling to get services paid for. Here are some questions to ask your health insurance as you advocate for your child's needs:

What are the individual and family out-of-pocket deductibles before 100% reimbursement begins?

How many visits per specialty (i.e. PT, OT, Speech) does the insurance allow per year for in-network and out-of-network providers mental health coverage?

Most children with autism need physical, occupational, speech, psychological, feeding, social and behavioral (ABA) therapies. How well does your insurance company cover these therapies?

What about coverage of supplies and equipment (e.g., augmentative communication devices.

The squeaky wheel. If you feel you have the right to insurance coverage based on your policy, and you are running into problems getting that coverage, resubmit and even consider filing a grievance.

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It's so sad to me that we are even having this discussion and that part of my job is to help parents learn to game the insurance and educational systems to get their children the therapies they need and deserve. A she-bear advocate is, alas, what is usually needed.

Paying for this should be a no-brainer and not our current dysfunctional system where desperate parents are pitted against beleaguered, underfunded special education systems and recalcitrant health insurance companies. But here, alas, we are and, until such time this gets settled, likely to remain so.

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Is Your Baby's Bottle Safe?

2008-09-15T17:36:00.004-04:00

DR. P UPDATE:
I wrote this only 4 months ago, but things are changing fast and, although I haven't really changed my position (that is, be a little paranoid), I thought a timely update was in order

Since May, 2008:

Many more manufacturers are promoting BPA-free bottles and containers, so they are much easier to find and lower in cost.

The good news: On 8/14/08 the FDA again came down on the side of the safety of the chemical BPA and concluded that, despite a paucity of good research, "an adequate margin of safety exists for BPA at current levels of exposure from food contact uses." Not to worry!

The bad news: A few weeks ago (9/08), the federal National Toxicology Program said it has "some concern for effects on the brain, behavior, and prostate gland in fetuses, infants, and children at current human exposures to BPA." Worry!

Two reputable federal agencies still duking it out in public! It's quite dramatic and unprecedented. But what is a parent or a doctor to believe and what should we do? Be confused! Be concerned!

Mindful of this controversy, the FDA is holding public hearings on 9/16/08, which I (and I hope you) will follow with interest.

Here's my original post, slightly updated, with my take on how to handle this quandary:

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It's a haunting image.

A beautiful infant gazes up at her mother with unblinking eyes, blissfully sucking on a bottle, absorbing both life-sustaining nutrition and her mother's love. Then, as in a bad horror movie, this idyllic scene takes a nasty turn and the bottle is unexpectedly shown to be evil, with poison seeping into the trusting baby's mouth.

By now you have read about the controversy about bisphenol-A (BPA), which is used to make plastic durable and shiny. BPA has been shown to be in the bodies of 90% of Americans and there is little doubt how it got there: trace amounts leach out of the polycarbonate plastic and into our milk and canned foods. But is BPA harmful?

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I've done my due diligence in researching this important question and can confidently report to you: the definitive returns are not yet in and it's just not clear and no one really knows.

On one side, in 2007 the FDA wrote it has "confidence that no safety concern exists for BPA in regulated food contact materials. Furthermore, the FDA has determined that the use of polycarbonate-based baby bottles and BPA-based epoxy coated cans used to hold infant formula is safe."

Others beg to differ, albeit with weak evidence and mostly on theoretical grounds. While everyone agrees that BPA has negative effects on laboratory animals, what isn't known is whether humans - especially very young humans - might be more (or less) susceptible to those effects. For that reason, the National Toxicology Program (part of the U.S. Department of Health and Human Services) recently disagreed with the FDA: "The possibility that bisphenol-A may alter human development cannot be dismissed."

And so - as often is the case - we are left to decide what to do with incomplete and conflicting evidence. Perhaps the small amounts of these compounds in our bodies will turn out to be harmless. Or perhaps not. Or perhaps we are focusing on the wrong chemicals, and it's really some new, as yet unrecognized, environmental exposure that will prove to be the real bad guy.

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Now that I've made you both paranoid and confused (my specialty), where do we go from here? The easy answer, of course, is to say: if the risks are unknown, why not just eliminate them altogether and protect our kids from even the remote possibility of harm?

I have to admit, I often subscribe to this view. But I also worry that hysteria about something that may prove to be non-toxic could lead to problems of its own (the all important "Law of Unintended Consequences"). Like what? Perhaps a spate of glass bottle injuries. Or the introduction of a new kind of super-duper material for baby bottles that, in 20 years, will be shown to be bad news.

Still, on this one it seems prudent to play it safe. After all, what is the downside of going green? So here's my advice:

Avoid polycarbonate bottles containing BPA and phthalates by using glass bottles.

When picking bottle liners or plastic containers, use polypropylene/polyethylene (#5 plastic which is opaque), not hard, shiny or tinted (#7) polycarbonate plastic.

Look for "BPA-free" and "Phthalate-free" on cans and bottles. You'll be seeing this more now that consumers are demanding it.

Avoid plastic/vinyl teethers for your infant to chew on.

Avoid heating foods in plastic containers (which may increase the leaching of the BPA). Instead, use glass or ceramic containers.

Wash all plastic containers with a sponge, by hand, with a mild dishwashing soap (not in the dishwasher and not with an abrasive sponge which scratches the plastic off).

Learn how to read the "ingredients" of plastics. No-nos include abbreviations such DBP and DEP (phthalates sometimes found in shampoos and baby powders!), DEHP, DMP. DEHP. Look for #5 (polyethylene) and avoid #7 (polycarbonate) when you can

Avoid using any plastic bottles with cracks or cloudiness.

Choose foods packaged in cardboard "brick" cartons. When you can, eat fresh, locally-grown foods in season and save the canned foods for convenience or emergencies

Can your own fruits and vegetables in safe glass jars.

Will this extra caution prove to be helpful?. Really, I have no idea. But, at this stage of the game, it seems a reasonable bet to make and, as we say in the trade, it wouldn't hurt.

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Technorati Tags: bisphenol A, BPA, polycarbonate, plastic bottles, baby bottles

Should We Lower the Drinking Age?

2008-09-03T13:11:00.010-04:00

When I was a lad of 17, I went off to college from a state (Michigan) where the drinking age was 21 years, to a state (New York) where it was 18. (A national drinking age of 21 was not established until 1984.) One of my first official academic acts was to go to Theodore Zinck's, a local bar, and get totally drunk (for the first time) on sloe gin fizzes. All these years later, coming within 10 feet of this drink makes me nauseated by its cloying, sickly sweet aroma.

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I recently read of a new bid to lower the drinking age from 21 to 18 years. Lest you think this initiative came from some dizzy 18-year-olds, it is sponsored by 100 very sober college presidents. They contend that the higher drinking age actually increases binge drinking on campus.

I have to say, I was startled by their proposal which, at first blush, makes no sense. But because teen drinking is so worrisome and so important, and because these are smart thoughtful people, I decided to probe a little deeper, see how I felt about it and then, of course, report back to you.

Certainly, there is much common ground on this issue. Everyone agrees that binge drinking is an epidemic - often a lethal one - in our youths. Everyone agrees that anything that will cut down on mortality and morbidity and suffering due to drinking should be a national priority. Could lowering the drinking age help?

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The Problem
Be afraid. Be very afraid:

40% of college students report drinking in a way that would qualify them as having a symptom of alcohol dependence.

500,000 college students/year suffer some drinking-related injury.

1,700 college students die each year from drinking-related injuries.

In my experience, a major reason for these startling statistics is that teens don't just have a glass of wine or two. Instead, they head for oblivion in a hurry, guzzling so quickly they are drunk literally before they know it. Then it's a perfect storm of an astronomical blood alcohol level coupled with a pre-existing sense of invulnerability and bad judgment. The recipe for lethal accidents is complete.

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So Why Lower the Drinking Age?
Here are some of the arguments for lowering the drinking age:

Adults over 18 years can vote, marry, sign contracts, serve on juries, and enlist in the military. How can we as a society then tell them they are not mature enough to have a beer?

Some studies suggest that a higher drinking age barely reduces underage consumption. Worse, those under-aged youths who do drink are much more likely to do so behind closed doors and drink to excess in the short time they have access to alcohol.

The higher drinking age gives alcohol the allure of "forbidden fruit" and serves as a badge of rebellion against adult authority.

There were few differences in the incidence of drinking problems in colleges where the drinking age was 18 versus 21 years.

The bottom line is, according to the president of Johns Hopkins College: "Kids are going to drink whether it's legal or not. We'd at least be able to have a more open dialogue with students about drinking, as opposed to this sham where people don't want to talk about it because it's a violation of the law."

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The Other Side
Of course, many beg to differ - most notably Mothers Against Drunk Driving. They contend:

After the National Minimum Purchase Age act of 1984, an estimated 1,000 lives were saved in 1987. From 1975 - 1996, the estimated number of lives saved reached nearly 17,000. (These numbers are hotly disputed and often attributed to reasons other than the higher drinking age).

Raising the drinking age has decreased the number of DWI arrests, youth suicides, marijuana use, crime, and alcohol consumption by youth.

The 1978 National Study of Adolescent Drinking Behavior found that 10-12th graders in states with lower drinking ages drank significantly more, were less likely to abstain from alcohol, and were drunk more often than students in states with a drinking age of 21.

(I'm really not doing justice to the either side here. For more details, see this collection of links presenting both sides of the argument from Santa Fe Community College.)

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So Who's Right?
To be honest, I don't know. I find the evidence confusing.

I don't have a dog in this fight. If lowering the drinking age will prevent alcohol-associated morbidity and mortality, sign me up. And if it increases same, I'm agin' it. Perhaps, the issue will be clearer over time as new studies emerge.

Since I'm ambivalent, my take is that the estimable college presidents have not made a persuasive case for lowering the drinking age. I'm open to their arguments, but remain unconvinced that, all told, fewer college kids and other youths will be harmed with a lower drinking age. And I worry that more will be.

So, for now, I vote no for lowering the drinking age to 18.

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Actually, Is the Drinking Age Besides the Point?
I suspect not much would change either way with a lower drinking age. Perhaps a more important cause of the problem is that (unlike sex ed) we don't try to educate our youths about responsible drinking at any age.

And that, moms and dads, I'm putting on you. Most parents put their heads in the sand and assume that their lovely teen is not drinking (dream on!) and ignore talking about it, lest it be interpreted that you are condoning their drinking.

What I do think would help is parent-driven education/counseling on responsible drinking. We could, for example, try to teach our boneheaded youths that, if abstinence fails (as it usually does):

Never drink just for the sake of drinking, to appear cool or as a game or contest.

Know when and how to say "when," even if your friends are not behaving responsibly.

Don't drink on an empty stomach. Eat both before and while drinking.

Drink slowly; know your limits and what it takes for you to be drunk. Don't aim to get drunk!
Never, ever drive if you have been drinking. Never, ever allow yourself to be driven by a pal who has been drinking.

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Looking back, I wonder if I would still have gotten drunk quite so soon after my college arrival had the legal drinking age been 21 instead of 18. I have to say, I don't think it would have made a difference. I was going to achieve that rite of adulthood with my new pals, come what may.

In retrospect, I only wish I had gotten some counseling on how to handle this new temptation/responsibility (such as don't get drunk on sloe gin, go for single malt scotch) before that ill-fated night I went to Theodore Zinck's and headed for oblivion on the sloe gin express. Fortunately, I survived the experience. Alas, not all teens are so lucky.

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Technorati Tags: drinking age, teens, alcohol, college, binge drinking, health and wellness

Dr. P's 2008 Top 10 Back-To-School Tips

2008-08-22T12:30:00.004-04:00

"BACK TO SCHOOL" - 3 words certain to fill your children's hearts with despair and yours with joy. As an annual rite of passage, it's a good time to take stock: How can you help your kids to make this school year academically productive, socially fulfilling, and safe as can be?

Here, in no particular order, are my top 10 suggestions. Feel free to share your own.

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1. Get organized! Plaster a monthly/yearly school calendar on the refrigerator to highlight upcoming events, deadlines, etc. Figure out and agree on morning routines: when to get up, bathroom rules and time, getting dressed, eating a decent breakfast, etc. in a "no nagging required / no whining allowed" environment.

2. Talk things over. Arrange a "planned discussion" with each of your kids to talk about academic goals for this year. Is there anything she is particularly anxious about? Be sure you include your expectations for performance - just make sure they are appropriate (if perhaps a tad high) and fair, linked to his/her talents and potential. If she's a brainiac, then good grades are reasonable to expect. If an average student, don't set the bar so high she is sure to fail. Remind her that what you really expect is for her to try hard and do her best, no matter what her final grades may be. Discuss expectations for completing homework. Construct positive (hopefully) self-fulfilling prophecies about the year. Reassure her that a lot of kids are anxious at the first day of school, but you know she'll handle this just fine, as she usually does. Remind her about the good things that happened last year.

3. Talk some more. What are his/her social goals? Is he looking to make new friends? How might he best accomplish that? What might be some of the social challenges this year? Ask about what's important for social status in school this year (it changes on a dime). What kind of clothes, shoes, backpacks, hair styles are in? It's important to give this some sort of adult perspective but - make no mistake - social status is very important to all of us and your kids are no exception. So don't belittle their feelings and desire to fit in, rather help them to achieve that within the values and aesthetics and monetary constraints of your family. Allow him/her to pick his/her own school supplies and clothes, but within an agreed-upon budget and your veto power in extreme circumstances (like too-sexy clothing). Click on the above image to read the very funny Onion parody of necessary school supplies.

4. Discuss and rehearse walking to school safety. Have your c hild walk (with or without adult supervision, depending on his age) to school if possible. It's great low-tech exercise and a wonderful time to socialize with friends in the great outdoors. Find a couple of reliable pals to walk with each day. Review pedestrian safety. Take a rehearsal walk or two, noting potential dangers along the way. Find a direct, safe route with the maximum crossing guard support. Be sure she always crosses at a crosswalk (or at least a corner). Be sure she understands to look for a green light and walk sign. Be sure she knows to stop at the curb, look left and then right and then left again (unless you're British), and listen while crossing all streets. Beware parked cars or other obstacles blocking vision of the street.

5. Go over appropriate response to strangers. Role play: What if a nice stranger came up to you and asked to help him to look for his poor, sad, missing dog? What if he offers you a ride on a rainy day? How about some candy, little girl? Does it matter what he or she looks like? You don't want to make your kids abduction-fearful, just stranger-wise.

6. If your child is taking a bus, the biggest danger is getting on and off. Go for a bus ride together and show him how to wait at the curb 10 giant steps away from the bus for the driver to stop, how to be in clear view of the driver at all times (don't walk behind the bus!), how to be very careful and make sure all oncoming cars have stopped and the driver has signaled it OK to cross. Be sure to pick a safe spot in the neighborhood for boarding and exiting the bus. Go over your expectations for conduct on the bus. Encourage him to feel safe to discuss any bad experiences on the bus (like bullying or teasing).

7. Don't overdo the weight in the backpack! Don't let your child tote more than 10-15% of his/her body weight in the backpack. Encourage him/her to wear both shoulder straps (to evenly distribute the weight) and to keep the straps tight, so the weight rests against the mid and lower back. Buy a lightweight (but of course, very cool-looking) backpack with padded shoulders, padded back and waist strap so that the bottom of the pack sits a few inches above the back of the waist. Teach your child to pack the heaviest items in the center. Encourage him/her to lighten the load in the school locker during the day. In a pinch, rolling backpacks are catching on (but are tough in the snow).

8. Go over potential bullying experiences with your child. Remind him this happens, but is mean and unacceptable and not to be encouraged. Tell him/her if it happens to talk, walk and squawk. TALK: tell the bully you don't like what s/he has done and that it isn't nice or fair, and WALK: Walk away. Bullies like victims who are passive and come back for more, and SQUAWK: Tell the teachers or parents. Bullies prefer kids who keep silent so they can go about their nasty business without consequences. As a parent, get the school involved in teaching about bullying.

9. Mention the unmentionable: toileting in school (if you don't who will?). For a surprising number of kids this is the most anxiety-provoking part of the school day. In great discomfort, they'll hold it all in rather than face what might await them in the bathroom. Remind them you expect them to ask to go in school whenever they need to go, and to tell the teacher or you if there are any problems in the bathroom. Role play what they might do if someone makes fun of them or offers a cigarette (or worse) in the bathroom.

10 . Whoops, can't think of a #10, so I'll resort to my usual:

Enjoy your kids! Enjoy the ride!
Some day soon you'll wonder how it all went by so fast and why you didn't appreciate it more as it was happening.

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Technorati Tags: back to school, safety, pediatrics, health and wellness

Mixed Martial Arts for Children

2008-08-11T15:22:00.014-04:00

Maybe it's just me.

In a favorite cartoon of mine, a school-aged child innocently asks his father: "Dad, when was it you realized you weren't studly any more?"

I am getting longer in the tooth and am decidedly not studly any more (let's leave aside the question: was I ever studly?). As I have gotten older, I've happily groused in this blog against many of the newer developments for today's youth: their music, social web sites, text messaging 24/7, early introduction to sex, drugs and rock and roll, etc.

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So, as I prepare to rant about yet another 21st century social "advancement" for kids, I really do wonder: Maybe it's me. Am I just getting old and out of it and reflexively intolerant of most things new, like my parents before me who were horrified as I wandered around barefoot listening to the Rolling Stones?

So do Dr. P a favor. Look at this and tell me what you think: Outside the Lines: MMA...For Kids

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"Mixed martial arts" (MMA) is one of the fastest growing "sports" in the U.S.

The Ultimate Fighting Championship - hugely popular on cable TV - defines MMA as "an intense and evolving combat sport in which competitors use interdisciplinary forms of fighting that include jiu jitsu, judo, karate, boxing, kickboxing, wrestling and others to their strategic and tactical advantage in a supervised match...with commission approved definitions and rules for striking (blows with the hands, feet, knees or elbows) and grappling (submission, choke holds, throws or take downs)."

The goal is as simple as it is primeval: to make the other guy (or gal) "tap out" because of pain or being successfully choked or temporarily disabled. Rules include: "No head butting or kicking to the downed opponent. No knees to the head of a downed opponent. No downward point of the elbow strikes. No strikes to the spine or the back of the head. No groin or throat strikes." (Well that's reassuring!)

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You can probably guess how I feel about this mayhem in the guise of sport. For the life of me I don't get why viewers plunk down so much money to watch humans brutally hurting one another. But that's me. I suppose if consenting adults want to watch and participate...

But when MMA is being taught to kids as young as 6 years old, that's a different ballgame and we have to ask ourselves: what is it really teaching and is this a good thing for kids?

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Frankly. every aspect of this sorry saga horrifies me, but none more than the sight of young children being encouraged and rewarded for punching, kicking, twisting the limbs, and otherwise physically attacking one another. Of course, the risk of significant injury is worrisome, but more so is what MMA might be teaching participating children:

You must learn how to hurt and physically prevail in life.

Guile, intelligence, strategy, mastery of fine motor skills, are not relevant to succeed in this "sport," (or in life); mostly it's just the greater will to beat up the other guy.

Unlike other martial arts (like karate), the goal is to inflict pain on the other guy, rather than to master a discipline.
By regularly physically hurting others, might not a child become more and more desensitized to doing so?

It glorifies street fighting violence.

Of all the many things to teach your kids, this is among the top? Teach your kids to be bilingual, to play a musical instrument, to love science, to play a competitive sport, to participate in a cause. But teach them how to beat the stuffing out of another human...???

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You tell me: is this whole MMA thing another small step backward for civilization as we know it, or is Dr. P just too unstudly to get it?

Related Topics:

Technorati Tags: mixed martial arts, MMA, Ultimate Fighting Championship, UFC, children, pediatrics

New Cholesterol Guidelines for Kids

2008-07-07T08:24:00.061-04:00

The lure!........................ The bad guy?........................ The problem.

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On 7/7/08, the American Academy of Pediatrics issued new guidelines for monitoring and treating children with high blood cholesterol levels.* The stakes couldn't be higher. At issue is whether we pediatricians and parents can prevent long term cardiovascular disease in our children by detecting high cholesterol levels early on and by promptly intervening to lower those levels.

The problem is (as I will discuss), the scientific returns are not in as yet, so this is an open question about which you should keep current and discuss with your pediatrician. Because it's so important, I've read the guidelines very carefully. As your faithful cyber-pedi (or am I your pedi robo-cop?), I wanted to share my thoughts.

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First, what do the guidelines recommend?

Most importantly, a healthy diet and increased physical activity for all children, including low-fat dairy products for all children over two years of age.

Low-fat dairy products for children 12 - 24 months who are overweight.

Screening (a fasting lipid profile) - starting at age 2 years and then every 3-5 years - for all children and adolescents with a family history of high cholesterol / high fat levels or early cardiovascular disease.

Screening for all children whose family history is unknown or who are overweight, have high blood pressure, or diabetes.

Weight management should be the primary treatment for overweight kids with high lipid levels.

For patients 8 years and older with an LDL concentration greater than 190 mg/dL (or 160 mg/dL with a family history of early heart disease or two additional risk factors present; or 130 mg/dL if diabetes is present), medications should be considered.

(LDL = low density lipoprotein = the bad guy cholesterol that appears to clog up the works, as opposed to HDL = high density lipoprotein = the good guy cholesterol that protects against atherosclerosis).

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What I like about the guidelines:

The prevention of adult diseases during childhood is one of our great challenges. These guidelines reinforce that vital pediatric mission.

It makes sense to me to aggressively intervene with children who already show signs of disease (diabetes, metabolic syndrome) or who are at great risk by virtue of genetics.

The emphasis on a low animal fat, high fiber diet will serve to improve the health of all humans (see my blogs on this favorite subject of mine: Overweight toddler, overweight teen? Dr. P's 8 steps to a healthier family ).

I like being given the OK to put chubby one year-olds on low fat milk products.

My concerns about the guidelines:

I wish they had put more emphasis on fitness, i.e., more exercise for our kids (see my blog: Your teen's physical fitness). Even an overweight child can and should be physically fit, just as even a skinny child can be an unrepentant couch potato.

Since we know that artery clogging atherosclerosis begins in childhood, it makes sense to intervene early. But, in fact, we don't really know whether lowering cholesterol levels in childhood will, in any significant way, prevent long term cardiovascular disease. Since that is the case, our interventions should at least "do no harm".

The potential short-term and long-term consequences of using cholesterol-lowering agents during childhood simply aren't known. Just because they appear to be safe in old fogies like me doesn't mean that they couldn't have some sort of unanticipated effect on the growing, changing child's body (especially since cholesterol and fatty acids are essential building blocka for many organs, including the brain).

For that reason - and until long term studies are done and we know more - unless the risks seem especially high, I'm still not going to recommend medications for my healthy pediatric patients with high cholesterol levels.

I worry about you all needlessly obsessing about a high cholesterol level in your otherwise healthy, happy, active child, especially since we don't really know what it will mean for your child over time.

I worry (hey, I worry a lot!) about the loss of a carefree childhood. As I wrote in my old blog: What is lost from childhood when the glorious taste of a hot fudge sundae is confounded by the worry that it is causing blood vessel sludge?

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Dr. P's bottom line: Unless your child has one of the risk factors listed above, don't worry about their cholesterol 'number'. Worry instead about their general fitness and nutritional well-being. Feed them a healthy, low animal fat, low junk food, high fiber diet, make sure they get plenty of exercise, and you'll be doing a superb job.

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* "Lipid Screening and Cardiovascular Health in Childhood"
Daniels S, Greer F and the Committee on Nutrition

Related Topics:

Technorati Tags: pediatrics, childrens health, cholesterol, healthy diet, exercise

A Ticket For Poor Kids

2008-06-30T11:11:00.004-04:00

Sometimes the best ideas are the simplest.

I just read an inspiring article in my hometown newspaper. It has provided me with renewed hope that, if only we mustered sufficient political will, we could successfully solve one of our most important social challenges: How to improve the academic performance of poor kids?

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I regard childhood poverty as the single greatest public health menace facing our children. Like most public health threats, we have some good (albeit imperfect) solutions.

After working with inner-city children for almost a quarter of a century (ouch!), I've come to believe that the best ticket out of poverty, the ticket that allows economically disadvantaged kids to become productive members of society, the ticket to their personal fulfillment, is educational success (by that I mean at least finishing high school and, better still, going on to higher level education or training).

How can we achieve this noble but daunting goal, especially given the myriad reasons almost half of poor kids never complete high school: their underfunded, overcrowded schools, parents who neither demand nor expect school success, the myriad psychosocial issues they are dealing with, the unsafe neighborhoods, a peer culture that demeans 'brainiacs', the learned hopelessness... Pick your poisons.

One can become depressed by the intractable complexity of academic failure. It's easy to throw up your hands and declare it hopeless: let's just invest in more police, bigger prisons and unemployment benefits!

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The newspaper article was about the "Say Yes to Education" project, the brainchild of a smart, caring, rich guy named George Weiss. It started over 20 years ago when, while giving a talk to a class of 6th graders in a Philadelphia inner-city school, he made the following promise: "I will pay your college tuition if you graduate high school." In the article, a 25 year old man discusses how Weiss made this same pledge to him when he was in 2nd grade and how it changed his life and the lives of the majority of his classmates.

How simple and how brilliant! Of course we need to improve our public schools. But what about enhancing a child's learning by raising her own internal motivation and aspirations? Mr. Weiss' pledge gave the students (and, of course, their parents) - at an early age - the hope and the inspiration and, most importantly, the means to attain their dreams of making it in this hard world.

The success of this simple strategy has been replicated over and over in the last two decades and gives lie to the perceived hopelessness of the situation. For you evidence wonks (I hope there are a few of you out there), below is an outcome graph you can click on (better still, go to their website, from which it is taken) showing that about 75% graduate high school (compared to the average of about 55% of economically disadvantaged kids), and about 1/2 of those continue beyond a high school education.

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Feeling down in these trying times? For an inspirational pick-me-up and for instructive lessons, do yourself a favor and go the Say Yes To Education website and read about this fabulous project which now provides children with not only the promise of college, but health care and educational supports along the way.

I can't help but wonder, why aren't our federal and state departments of education following their lead? I can think of a lot of worse (and few better) ways to spend my tax dollars.

Related Topics:

Technorati Tags: children, education, poverty, Say Yes to Education

Preventing allergies: When to introduce solid foods

2008-06-21T07:17:00.000-04:00

Dr. P's Pediatric Journal Club

The study
Data on 2,612 German infants was gathered from birth as part of an ongoing study looking at when solid food was first introduced and the development of allergies by two years of age.

What the study found

Waiting until after 6 months of age to start solid foods did not have a protective effect on the development of eczema ("atopic dermatitis") or other recognized allergies at age 2 years.
Waiting until 4 months of age to introduce solid foods may or may not have had a protective effect on the development of allergies. The data were not clear.

Dr. P comments
My WebMD Message Board is filled with parents who are agonizing about what, when and how to introduce solid foods to their infants. It's also filled with a ton of different opinions - "I fed my baby cereal at 2 months and she is fine!"... "Hold off until she is past 6 months or she will have allergies!" ... "My pediatrician says that 4 months is OK, but only cereal!" The only similarity between the varying opinions is that each side is 100% certain that their way is the right way!

Whenever there is such diversity in parents' and pediatricians' advice, you can bet it's because kids do fine almost no matter what the parents do, and because there isn't much scientific evidence to guide us one way or the other. (Interestingly, these are often the parenting issues about which the various camps feel most passionately.)

As the authors of this study state: "Scientific evidence supporting a delayed solid food introduction for the prevention of atopic diseases [allergies] is scarce, inconsistent, and based on a few studies only." This study helps by demonstrating there to be no benefit in waiting for more than 6 months, and suggesting that it's still up for grabs whether there is really a benefit in waiting 4 months.

Truth be told, this is a common scenario for pediatricians: often there is insufficient scientific evidence to strongly recommend one practice over another. So we essentially fly by the seat of our pants and make our best judgment based on meager evidence and our experience, and wait for definitive research to clarify the issue.

So here's my seat-of-the-pants advice on starting solid foods:

Hold off the introducing solid foods until 4-6 months. (Remember that cereal does not increase sleeping through the night!)
Introduce one new food every few days, so if there is a digestive problem or apparent allergic reaction, you will know what may have caused it.
Always be sure the texture of the food is such that your baby doesn't cough and sputter when it is introduced.
Introduce the small amount of the new food when your baby is hungry - before, not after, he has had her milk. Then gradually increase the amount.
Don't let "neophobia" (fear of new foods) discourage you. Even if your infant doesn't take well to some (or all!) solid foods, never try to force feed him. Remember that milk alone can serve the baby's nutritional needs until at least 6 months. Gently and cheerfully reintroduce the hated taste/texture at another time.
Most importantly: keep meal time fun and pleasant for all. In the long run, that's much more important than whether your bundle of joy eats his broccoli or not. More than anything else, emotional warmth and support at mealtime is what promotes a love of eating in the child and makes family meals a joy.

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Article cited:
"Timing of solid food introduction in relation to atopic dermatitis and atopic sensitization". Zutavern A, et al. Pediatrics, February, 2006, pp.401-411.

Related Topics: New Clue on How Babies Learn Words, Studies Short on Soy Formula Risk

Technorati Tags: parenting, infants, newborns, feedingsolids, foodallergies

Green Our Vaccines?

2008-06-20T09:30:00.003-04:00

Two well-publicized events caught my attention last week. Each is terribly sad in its own way, but each offers insight into what remains a contentious issue: the safety of vaccines for children

Story #1: On May 28, 2008, a thunderstorm knocked out the electrical power in Memphis. Unfortunately for 61-year-old Dianne Odell, the emergency generator in her house also failed. Tragically, her family was unable to keep the iron lung - in which she had lived for the past 58 years - working, and the last polio victim in America still using an iron lung to breathe, died.

Story #2: Exactly one week later, on June 4, 2008, celebrities Jenny McCarthy and Jim Carrey sponsored a "Green Our Vaccines" (GOV) Rally in Washington (attended by either 1,000 or 8,000 people, depending on whom you believe). Its goal, they insisted, was simply to make vaccines safer by taking the 'toxins' out of them and by delaying some immunizations.

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For me, these events offer an instructive point-counterpoint.

Ms. Odell's death reminded me of how lucky we are to be free from the diseases that have been eliminated by childhood vaccinations. I'll bet you have never known anyone who had polio or smallpox or diphtheria or tetanus or whooping cough or... When I was in pediatric training, H Flu bacteria frequently caused meningitis and other fatal infections. I well remember a two-year-old patient in my private practice who went stone cold deaf after such an infection. Now our pediatric residents may never see a single case.

In addition to the millions of children who owe their lives to vaccines, UNICEF estimates that more than one third of the 10,000,000 children who die world-wide every year would live if they were properly vaccinated. Let me repeat that: 3,000,000 kids a year wouldn't die if they were given the immunizations that the GOVs decry.

There is zero doubt: childhood immunizations are one of the great inventions of the 20th century (really in the history of mankind). Their stunning success, however, has spoiled us and, especially if you lack imagination and a historical sense, you might not grasp what a blessing they are. You might even argue that children would be safer without them because of their rare (real or imagined) side effects and because you have never seen a child suffering with measles. It's a profound miscalculation, with potentially devastating consequences.

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Enter the "Green Our Vaccines" campaign.

First: a brilliant name! After all, who is against 'greener' (i.e., safer) vaccines? Who does not want to make our already very safe vaccines even safer? Sign me up on that one. But if you object to their movement (as I do, for reasons I'll explain), their clever name makes you appear to be anti-green (would that be 'brown' or 'puce'?) and a heartless advocate of loading kids up with nasty toxins.

Their name, however, is the only brilliant thing about this 'movement'. The rest is sadly misguided. I take no pleasure in saying this, as these parents (mostly of autistic children) are just being admirably she-bearish about their kids. But in doing so, they have taken a wrong turn, with the potential to cause great collateral harm to their naive followers. Here's why.

Their agenda is more than anti-preservatives, it is anti-immunizations. Here's what Jenny McCarthy had to say in an unguarded moment: "I am surely not going to ask anyone to vaccinate. But if I had another child, there's no way in hell...for my next kid - which I'm never going to have - there's no way." I suspect some of the sponsors of GOV see the elimination of 'toxins' as a first, more acceptable step in eliminating vaccines altogether via scare tactics.

They rally for "100% safe immunizations." While the rate of side effects (mostly minor) is not zero, there is no such thing (nor will there ever be) a 100% safe vaccine (nor a 100% safe car, nor a 100% safe medicine, nor a 100% safe life). Of course we can and should seek - as we have - to make them safer. However, if one objectively weighs the benefit/cost ratio of current vaccines, they (along with clean water) remain the greatest health boon for children in the proud history of medicine.

The GOVs continue to argue that vaccines and/or the preservatives in them cause autism. There's not enough space here to refute this argument (see my blog + see the reports from the FDA + Institute of Medicine on this). Suffice it to say that, given how much damage would be visited upon unimmunized kids, you would think they would muster very strong evidence to support their hypotheses. In fact, the preponderance of studies show them to be mistaken (for example, the incidence of autism has not declined with the withdrawal of thimerosal from most vaccines). But scientific evidence does not dissuade the GOVs from their absolute certitude. I find their apparent indifference to the potential consequences of their anti-vaccine screeds to be irresponsible and, in the end, unconscionable.

They promote distrust and paranoia about the "establishment." If you do not accept their view, you are the bad guy. Perhaps you are part of the vast profit-over-well-being pharma industries. Perhaps you are part of the FDA, which has vested interest in not being proved wrong after all these years. Perhaps you like making money off autistic kids. Any way you slice it, you're just another conspiratorial evil-doer.

They claim that the sheer number of immunizations (which I view as a blessing) somehow overwhelms the immune system, so immunizations should be spread out or postponed. Sounds reasonable. Could be true. The problem with this interesting hypothesis is that there is no evidence that it is true and accumulating evidence that it is not. Therefore, why postpone and thereby increase the potential risks for our children?

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I can't help but wonder what Ms Odell might have said to the Green Our Vaccine parents and to all parents who are reluctant to immunize their kids. Of the many gifts you give your children, being a fully immunized human is right up there at the top.

Related Topics:

Technorati Tags: vaccines, immunizations, autism, Green Our vaccines, Jenny McCarthy, Jim Carrey, pediatrics, healthy children

The Potty Whisperer

2008-06-13T17:05:00.004-04:00

As some of you know, many years ago I was a fellow in developmental and behavioral pediatrics with T Berry Brazelton at Boston Children's Hospital. Among his many accomplishments, Dr. Brazelton is the populizer of the "child-oriented" approach to toilet training, which has become the standard toilet training in the U.S.. Basically, it involves watching for developmental signs of readiness for toilet learning and to proceed slowly, with no pressure, at the child's pace. (For much more of my scoop on poop, go here)

During my fellowship training, a curious article was brought to my attention. In it, the authors described the "toilet training" (actually no toilet is involved!) practices of the East African Digo tribe. The Digo begin toilet training in the first weeks of life by making whooshing sounds whenever their diaperless infant shows signs of impeding pee or poop. Then they whisk the infant out of doors where, in his mother's arms, he happily relieves himself in the dirt. With this "nurturant" conditioning approach, night and day dryness was accomplished by 5 or 6 months, a far cry the method I was being taught by Dr. Brazelton (which typically doesn't start until about 2 years of age)!

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As if to prove there is nothing new under the sun, enter the latest rage: The Potty Whisperer(http://www.pottywhisperer.com/). I've come to learn that "whisperers" are really big these days and, not coincidentally, a marketing force to be reckoned with.

[Quick digression. If you Google the word "whisperer" you'll get 9,660,000 hits. Just for fun, here are some of the whisperers already out there: "The Horse / Dog / Cat / Pet Whisperer" (correct the animal of your choice), "The Angel Whisperer" (vibrational healing - don't ask) , "The Plot Whisperer" (for writers), "The Wood Whisperer" (for woodworkers), "The Breast Whisperer" (not porno, but a lactation consultant), "The Boss Whisperer" (tame your abrasive boss), "The Baby Whisperer"(how to calm, connect and communicate with your infant), and my favorite "The Maui Horse Whisperer Experience" (which combines horse whispering, equine facilitated learning, equestrian skill building and corporate training in leadership).]

Anyway, the Potty Whisperer, is catching parents' attention, so I've done some investigative reporting on it for you.

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As far as I can tell, the Potty Whisperer has simply appropriated the Digo method! The "whisper" part of it is the Digo's whooshing sound associated with the impulse to pee or poop. Motivated parents can attempt to train their infant to be dry in the first year of life. For later starters, the Potty Whisperer recommends the Toilet Training in Less Than A Day method to get the job done quickly and efficiently. One way or another, the diaper dependency days of your little poopster are numbered .

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You may be surprised to hear - aside from the wacky name - I'm pretty OK with the Potty Whisperer's techniques and advice, just as I am with Dr Brazelton's. Here's why.

In big letters at the very front of their web site are the "Potty Whisperer's No-Nos":

no punishment

no pressure

no coercion

no shaming

no competition

no showing off

no obsessing

no perfectionism

no rushing toilet learning

no attachment to time goals

no negativity

I completely agree with this terrific list! (Of course, it's a bit ironic they are recommending "no rushing toilet learning" to parents who are interested in potty training their 6 month old infant! Perhaps I should become "Dr. P - The Fetus Whisperer" to start the whole process in-utero.)

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In my view, when and how potty training is initiated is far less important than making sure the process is not distorted by one or more of the above no-nos. As long as it is a positive experience for the infant or toddler, as long as it is not done to win a competition, as long as it is done with humor and flexibility, as long as the child's needs and abilities are respected, as long as it doesn't somehow have a negative impact on your relationship with your little poop machine, it's going to turn out OK, almost no matter how you play it.

Freud was wrong. Except in extreme nasty cases, toilet training is just not a big deal psychologically and has no lasting effects on our personalities. So how it's done is not a life and death issue (unless, I must reiterate, it engenders bad feelings, low self esteem, and/or a contemptuous relationship that persists).

So avoid the no-nos and feel free to pick the time and place and method of toilet training that best fits with your beliefs and with your heart and with your child's development and temperament. I guarantee, like pretty much every other human in the history of the world, your child will - sooner or later - master this earliest of the developmental challenges of childhood.

Related Topics:

Cognitive development in infants

2008-06-11T20:40:00.001-04:00

Dr. P's favorite quote of the week

Children are born true scientists.

They spontaneously experiment and experience and reexperience again.

They select, combine, and test, seeking to find order in their experiences -

"which is the mostest? which is the leastest?"

They smell, taste, bite, and touch-test for hardness, softness, springiness, roughness, smoothness, coldness, warmness:

they heft, shake, punch, squeeze, push, crush, rub, and try to pull things apart.

-R. Buckminster Fuller

U.S architect and engineer (1895-1983)

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Among the joys of parenthood for you, I hope one will be the thrill of observing how your child learns to make sense of the world ("cognitive development").

If you are interested, there is a great book on the subject: "The Scientist in the Crib" by Gopnick, Meltzoff and Kuhl. In it, the authors explain how your infant learns so much so fast:

S/he has a brain which is ready to solve problems and process information and make hypotheses on how the world works
S/he has great teachers (that would be you!).
(Most surprisingly), infants are already born with a good deal of knowledge.

All of this ordinary eternal machinery is our evolutionary heritage. There is no need for extra stimulation: the little scientist will learn to figure things out in the "ordinary expectable environment", with "good enough" (i.e., not 'super') parents.

Of all the motivations for your infant and toddler's behavior mentioned by the gurus, the drive to understand - to make sense of the world - is vastly underrated and neglected. If you realize, for example, that your oppositional 2 year old is really conducting a legitimate social experiment and not being 'terrible', that will go a long way in helping you figure out what is really going on and how to respond in a constructive way.

Children are not little, unformed adults. They make sense of the world in fundamentally different ways than us. Your job as a parent is to discover - not invent - your child. Learn how you can support your little scientist's quest for understanding by learning more about his/her cognitive development.

Does having kids make you happy?

2008-06-10T21:03:00.000-04:00

Dr. P's Pediatric Journal Club

The study

In 1987-1988, the National Survey of Families and Households interviewed and tested 9,000 people for:

--> Whether they had children (= 3/4) or not (= 1/4).

--> Levels of depressive symptoms.

--> Data on socio-economic status.

What the study found

--> Higher rates of depression were seen at younger ages, in women, in Blacks, in persons with less education, in those not employed full-time, in those with lower family incomes, and in non-married adults.

--> As a group, parents reported significantly higher rates of depression, compared to childless adults.

>> This was especially true of parents with young children.

>> On the other hand, "empty nesters" reported the same levels of depression as childless adults.

What this study suggests

Parents, especially those with young children, report higher rates of depression compared to childless adults.

Dr. P comments

OK, by now you have given up the myth of parenthood being a time of uninterrupted bliss and joy.

More likely, especially if your kids are young, aside from the fun and excitement and good times and joy, it is a time of relentless demands and responsibilities and dilemmas and worries. It's a stressful time - at least to some extent - no matter what your life circumstances might be.

Add to the mix a general lack of appreciation (by partners, families, friends, society) of how hard and how important a job parenting is. Is it any wonder that most parents become depressed some of the time?

I have no pat explanations, except to say that we in the U.S. provide less support for parents (time off work, high quality child care, resources for parents who choose not to work outside the home) than all the other industrialized countries. I wonder: is the level of parental depression in those cultures less than in ours?

Other than moving to Finland, any suggestions that might help? Here are some things I have learned:

>> Children are best served when their parents are living happy and fulfulling lives, whether that means engaging in full time work outside the home or devoting full time as a stay-at-home parent or a combination of the two.

>> Parents often become depressed when they make the mistake of giving up all the things that used to be meaningful to them in their childless days: keeping close friends, working on maintaining and making time for a loving supportive relationship with their partner, keeping up with their long term interests in the world, etc. In short, having a life outside of the kids.

>> Parents may become depressed if they are consumed with the notion of "infant determinism" - a theory popularized by some parenting gurus - i.e., the need to be a perfect parent because every little thing one does with your child is fraught with significance for their long term development. One false move and the child will be an endlessly neurotic, unhappy adult. Since the perfect parent has yet to exist, guilt is inevitable.

>> Parents may become depressed when they view themselves inadequate to provide their child with the skills needed to overcome the new threats to children of the 21st century, threats which were inconceiveable and largely unknown when we were kids (drugs, early sex, early exposure to inappropriate content on the media, etc.)

The good news of this study for you should be a confirmation of your complicated feelings about being a parent. Don't get me wrong, there is (I hope) plenty of joy and fulfillment coming your way. But so too is there almost always a downside, one that parents are rarely given permission to talk about or even feel.

Anyway you look at it, parenting is a tough job. Sure, you get depressed and stressed. But, as this study tells us, you are not alone. In fact, you're not even weird. You're just human.

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Article cited:

"Clarifying the relationship between parenthood and depression."

Evenson R and Simon R.

Journal of Health and Social Behavior. December, 2005

http://www.asanet.org/galleries/default-file/EvensonSimonJHSBDec05.pdf

Related Topics: How to Be A Positive Parent, Welcome to Parenthood

Technorati Tags: parenting, depression, stress

Q & A: Help! My child hates me!

2008-06-09T07:00:00.005-04:00

Q: My 4 year old has started to say, "I hate you," to his brother and to me. He acts proud when he says it, as if he has power over me. Should I just overlook it?

A: Heaven protect us from the bright 4 year old who has learned the power of words!

This is a very common and very normal scenario. Let's see if we can figure out what's happening here. Your little guy has learned an exciting new way to push your buttons, this time by merely saying three little words. It's likely at this age he doesn't know what "I hate you" even means. What he does know is that you think it's a bad thing to say and, when he does say it, people respond in a very lively way. Sure, it's not a positive response, but that's beside the point, because the ability to generate any intense response gives you some power over your little world.

Think about it. The world of a 4 year old is generally one of powerlessness. You have to eat what your parents feed you and sleep when they dictate. They choose if you go to school or stay home. They pick your clothes. You're dependent on them to explain to you how the mystifying world works. There is very little over which you feel you have much control.

Then you find some simple words that confer onto you a power that is as irresistible as it is rare, and therein lies the fun. Of course your son doesn't really "hate" you. If you responded the same way if he said, "You're a potato," then that's what he'd be saying when he became frustrated. By the way, it's the same story when children begin to use swear words. It's the response they're looking for -- they have no real idea what the words mean.

Fortunately, it's a habit easily broken by simple ignoring. If no one moves a hair whenever he says,"I hate you," -- no response, no acknowledgment, no anger, no time-out, no laughter, no nothing, as if he hadn't said anything at all -- the fun's over and soon he'll stop saying it.

Of course, then he'll look for other creative ways to gain a measure of control over his world, so be prepared for what he comes up with next!

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