Corticosteroid Therapy

My son, Max, has just recovered from a viral illness, one that produced noisy breathing in him last weekend.  It was scary, and I suppose anybody reading this would think to themselves, "Wait, she's a pediatrician, she should know how to deal with a child's noisy breathing."  Somehow it is different when it's my own child who's ill, and because I am not so good at making decisions when it comes to my own kids' health, I had my partner look at Max.  We decided to give him a two-day course of oral Prednisone, a corticosteroid, to reduce the inflammation of his airway.  It did the trick and helped him breathe more comfortably.
 
Steroids have a bad reputation with the general public; we hear of doping scandals in the Olympics, and the news media hypes up stories about athletes and anabolic steroids.  But corticosteroids in medicine are in a different class altogether; they are used to treat everything from asthma and croup to lupus and vasculitis.  The main side effect of steroid therapy is stomach irritation, but this can be averted by antacid therapy if needed.  Primarily acting to suppress inflammation, corticosteroids do have great utility and benefit.

Warts

Verruca vulgaris is the fancy medical term for common warts.  And common they are, even in children, and usually found on the bottoms of feet or around the fingernail beds.  Sometimes parents find it difficult to distinguish a wart from a callus.  A wart is characterized by tiny dark specks on it, which are really thrombosed capillaries.  As with many things in medicine, warts are virally induced, and as it turns out, there is no great therapy for them.  A friend of mine showed me her daughter's warts the other day, and I told her she could try an over-the-counter preparation with salicylic acid.  If warts on the bottom of feet start to bother the child, I do recommend a visit to a podiatrist or dermatologist for liquid nitrogen or laser therapy.  But without any treatment, warts can disappear on their own, whether it be next week or next year.  In many cases, I end up telling parents just to wait the warts out; sometimes patience really is the best medicine.

Waxing On About Ear Wax

It's a good visit for me and the patient.  Flushing wax out of a child's ear is far from glamorous, but I find it satisfying when a big ball of wax emerges and suddenly the child says, "Oh, my gosh, I can hear again!"  The parent is usually a little disgusted to see how much wax can emerge from the child's ear; invariably she asks what she can do to prevent the wax buildup.  Relax, I say, God made ear wax for a reason; it helps to keep the pH of the ear canal balanced, and it helps to prevent infections of the ear canal.  If wax builds up such that a child is complaining he can't hear well, a parent can use an over-the-counter solution that softens the wax, which will work its way out of the ear.  If not, it takes about two minutes at the pediatrician's office to flush out the wax.  I do caution parents not to use Q-tips to go digging for wax.  Q-tips cause too many ear canal abrasions from forceful probing by parents.  In fact, Q-tips usually push the wax in further.

So ear wax is your friend, I always tell parents.  It's a good thing; don't do battle with it, and certainly not with Q-tips.  In the not-so-common instance when the buildup actually prevents a child from hearing well, a pediatrician will find it very gratifying to flush it out.

Childhood Vaccination - It's A Very Good Thing

I understand parental anxiety.  I'm a parent who worries about everything about my kids.  But there is one thing I have never worried about, and that is giving vaccines to my children.  I'm a big proponent of vaccines and the world of good they've done and continue to do in reducing mortality, morbidity and misery.  Imagine what it would be like to fear your child becoming crippled from polio.  Imagine your child contracting measles and developing encephalitis from the infection.  Imagine your son becoming sterile from a mumps infection.  Today's parents don't have to fear such diseases because of childhood vaccination.  Because these diseases now seem so antiquated and remote to parents of our generation, it has become easy for some moms and dads to be cavalier about vaccines.  Oh, my child isn't going to get polio or measles, they say.  I'll just count on everyone else getting vaccinated, and that will protect my child indirectly.  Selfish argument?  Absolutely. 

Then we have the group of parents who believes their child will become autistic if they get too many vaccines.  The group of researchers from Britain who started all this vaccine and autism talk in the 1990s recently retracted their statements.  Hallelujah, we pediatricians cried, when that announcement was made.  There is no good science to support any link between vaccines and autism.  Some parents also worry that the number of vaccines we give can overwhelm the immune system.  My partner, Dr. Michael Segarra, likes to tell moms that a child's pacifier introduces more antigens into the body than the vaccines we give at one visit!  He's absolutely right. 

I know that there are parents out there who will remain skeptical of vaccines no matter how much information we pediatricians give them, but I also like to tell these parents that if I didn't think vaccines were safe and necessary, I certainly wouldn't have given them to my kids.  I think that says a lot.

Cell Phone Use in the Doctor's Office

When a mom's cell phone rings in the middle of an office visit with me, she's usually apologetic.   But I tell her to answer it, especially if she's got other kids.  Don't feel bad, I say, the school might be trying to get in touch with you, or maybe your husband is.  I understand; I've had to answer a call in the middle of a visit to my doctor before.  But yesterday, I had one mom whose behavior really amazed me.  I walked into the exam room, and she was deep in the middle of a conversation.  I eventually gathered that her call was not of a very urgent nature, because I got to hear the next five minutes of it.  She smiled at me, as I talked to her five-year old for the duration of the call, but she made no attempt to get off the line until she finished chatting.  I like her, and maybe she feels so comfortable with me that she didn't feel like she needed to get off her phone.  Maybe she felt it was a good opportunity for me to converse with her child.  But ultimately, I think such behavior was just rude.  I would never have dreamed of continuing a call with my doctor or dentist waiting for me, and I hope that most people out there will continue show some respect when it comes to cell phone use.

Let The Baby Cry, or To Ferberize or Not to Ferberize?

Friends of mind have a nine-month old baby who isn't sleeping well.  For the sake of anonymity, I'm going to call them Rich and Grace.  They are first-time parents, and like all new parents, their world has revolved around their little girl from the minute she was born.  She's been rocked to sleep every night and for every nap, and now she can't go to sleep without being held by mom or dad.  She wakes every three hours or so and protests loudly when she discovers that she's in her crib and no longer in those warm arms of her parents.  To get her back to sleep, they give her a bottle of warm formula; then she's rocked in a parent's arms again before they gingerly put her back into her crib.

Rich and Grace are exhausted.  They remind me of my sleepless nights with my first child.  At Sophia's nine-month well-visit, my partner, Dr. Katz, asked me how she was sleeping.  I admitted that I was still up every few hours and confessed that I couldn't ignore her cries at night.  He looked at me quizzically, and said, "Come on, you know what you have to do.  Put her down when she's still awake, so that she gets used to soothing herself to sleep, and don't rush to her room when she cries in the middle of the night.  And God forbid that you feed her every time she wakes up!"  I knew he was right, although that didn't stop me from feeling affronted when I read what he wrote in Sophia's chart under the "Sleep" column: "Still wakes at night; Mother can't ignore." 

But I have to admit Dr. Katz had a point.  We finally approached sleep the way the famous Dr. Ferber championed.  By ignoring Sophia's cries in the middle of the night, we trained her to sleep.  It took hardening my heart and shutting my ears to ignore her pitiful cries, and I spent some nights with my pillow over my head when I heard her crying for me.  But the torture paid off, and she learned to sleep well.  For Rich and Grace, I would tell them to place the baby in her crib when she's awake so that she learns to put herself to sleep.  For the first week, they can allow themselves to pick her up when she cries in the middle of the night.  But by no means should they continue feeding her through the night.  And after that first week, they shouldn't even go into the room.  Some pediatricians would advise going into the room every ten minutes of so just to pat the baby on the back, but I always found that showing up in Sophia's room without actually picking her up made her cry even harder.

The crying is so hard to hear, but it really doesn't do the baby any harm.  And when it does stop and the baby learns to sleep through the night, it's a blessing for everyone involved.  Imagine how good it feels to sleep through the night, I always tell parents.  Well, a baby reaps the benefits of a solid night's sleep as well.  I hope Rich, Grace and their little girl get some good sleep soon.

Ear Infections

I was on call last night, and I spoke to a grandmother of a nine year-old who had fever and ear pain.  Her low-grade fever had just begun; the grandmother wanted to know how much Motrin to give.  I discussed the dose and told grandma to give the child lots of fluids, but I also told her that the child would have to be examined before any antibiotics were prescribed.  The grandma understood, which was a relief to me, because at the first twinge of ear pain, some parents think that their child needs an antibiotic immediately. 

On examinatin, thick, cloudy fluid behind the ear drum or a red, bulging drum suggests middle ear infection, or otitis media.  Clearish fluid behind a slightly red ear drum is more suggestive of a concurrent upper respiratory tract infection, most often caused by a virus.  When a child has an examination consistent with a viral etiology, I tell the parent that an antibiotic is not the answer, that watchful waiting is prudent.  Sometimes, depending on the exam, I do give a "safety-net antibiotic prescription," explaining that many ear infections clear on their own, but if the child's symptoms were to worsen, the parent should then fill the antibiotic.  Antibiotics are overused.  Waiting 24 -48 hours to see how a child's symptoms evolve can prevent unnecesary medicine use and halt the development of further resistance to antibiotics.  I've found that just having a prescription reassures the parents, especially since they won't have to bring the child back to the office if the pain worsens.  But in most cases when I give the "safety-net" prescription, I am happy to report that the child doesn't eventually need the medicine. 

Cough Medicines

School has been in session for a few weeks, and cough and cold viruses have begun to circulate again now that kids are back in close quarters.  When a child comes in with symptoms of cough, congestion and runny nose for a few days, and his physical exam is normal, I reassure the parent that the child is most likely suffering from a virus.  That means no antibiotics, just fluids and rest.  Time, I say, the child just needs some time to recover from the virus.  If the child is under 4, I also stress that no cough and cold meds are approved by the FDA for this age group.  And for the older kids, the plethora of cold and congestion meds that are sold as over-the-counter preparations may make a parent feel better that she's tried something, but the cough syrup probably isn't going to make the child feel any better.  I understand how a parent needs to feel she's doing something for her child by offering some sort of medicine, but as a pediatrician, I emphasize that clinical research points to little utility for cough and cold preparations.  Thankfully, most parents can appreciate that a child shouldn't be needlessly medicated.  Sometimes the best medicine for a cold really is chicken soup.

Lice, Lice, Dreaded Lice

The American Academy of Pediatrics recently stated that schools should not have "no nits" policies.  Since lice is not felt to be a public health threat, this statement by the AAP means that children should not be excluded from school once they have been treated for lice just because they still have nits in their hair.  Nits are the egg casings of the lice and are difficult to manually remove.  I'm so glad the AAP has this laissez-faire attitude to lice.  Parents get hysterical about lice and often need to be reminded that there are far worse diagnoses that children receive.  A few weeks ago, I saw a little girl in the office who complained of an itchy head.  She had lice crawling at the roots of her hair.  The mom was horrified, in shock.  I told her that it was, after all, just lice; it wasn't leukemia or lymphoma or diabetes that we were talking about.  You should wash out your linens, I told her, but lice should be treated as an inconvenience and nothing else.  And don't feel like your family is dirty or unclean in any way, I continued, because lice doesn't discriminate; it affects kids from all socioeconomic classes. 

After calming this mom down though, I thought about how I would react if one of my kids got lice.  I have to admit that the sight of the bugs crawling in the child's hair did make my stomach turn.  Come to think of it, I probably wouldn't react so well either.  I'm just going to hope that lice won't invade my house any time soon.

When Should Breastfeeding End?

My sister is still breastfeeding her 16 month old, and her husband thinks it's time to stop.  She can't resist her child's pleas to nurse before he sleeps; her husband feels the breastfeeding should end now that their child enjoys sips of diet Coke and can chomp readily on pretzels.  My brother-in-law asked me what is the oldest age I know of when a child was still breastfeeding.  I answered, flippantly, "Well, our dad nursed until he was four, but it was World War II then, Singapore was under siege by the Japanese, and his mom had no other choice."

I do see my brother-in-law's point, though; there is something remotely distasteful about a toddler or an even older child sucking on his mom's breasts.  But I also understand how hard it is to stop because the breastfeeding bond is such a strong one between mom and child.  I loved nursing myself, and I was loath to say goodbye to breastfeeding because it meant the end of a unique and special stage of babyhood.  The American Academy of Pediatrics encourages breastfeeding for as long as possible, above and beyond the baby's first year of life if the mom is willing.  But for my sister and brother-in-law, I told them that the decision to stop breastfeeding was ultimately a very personal one, one that they would have to resolve by themselves.

Wake-Up Calls

Max flung himself on me this morning at about 6:45, and a few minutes later, I heard Sophia's footsteps race down the hall to our room.  Wishing so desperately for a few more minutes of sleep, I knew the day had begun as I made space for them in bed.  And then I thought of a mom of two college-aged boys who I saw in the office a few weeks back.  She had said that she can't believe how quickly time flies, that she hates saying good-bye to her sons at the end of the summer, that sometimes in the mornings, she lies in bed and wishes that her boys were little again so that they could could running to her room in their PJs.  What she said hit home with me this morning.  Instead of groaning for more sleep, I told myself to appreciate little moments like I had at 7AM, when the kids snuggled up against me.  I know there will come a day when my kids won't need me the way they do now, and then I will want to turn back time.  But when that day comes, I do hope I'll be getting more sleep.

Obsessing About Weight

I saw a teenaged patient this past week who started crying when we talked about her weight.  She had put on about ten pounds since her last checkup, but by no means does she qualify as overweight.  Amidst her tears, she told me that she hated the way she looked and that she was willing to do anything to lose weight. We talked about healthy lifestyles and how I wanted her to focus on healthy eating and exercise for a healthy heart and body, not for some number on the scale.  Since I've been thinking about obesity lately, I find it ironic that the patients of mine who don't need to lose weight are the ones usually willing to make the lifestyle changes necessary to do so. 

Whenever I sense that a patient might be getting a little carried away with weight concerns, we talk about the importance of three healthy meals a day and a modicum of exercise rather than overdoing the workouts.   And I try to emphasize how it is wrong to feel guilty for eating the occasional sweet treat.  Unfortunately, there are some girls out there whose obsession with their weight becomes a mental disease, and these are the anorexics and bulimics who need intensive psychotherapy and sometimes medical hospitalization.  But extremes aside, it is sad that our society, which idolizes paper-thin models and actresses, has created a culture in which most adolescent females worry about their weight.  As parents, it should be our goal to instill self-esteem and healthy eating habits in our young girls so that they grow up happy with their looks and comfortable in their bodies.  A tall order, perhaps, but a goal to strive for nonetheless.

Obese Kids

My sister and brother-in-law came to visit us this week, and on the plane, they were seated next to a teenaged boy who was so fat that he spilled out of his seat.  They thought he was about 13 years old, and my brother-in-law noticed that he drank regular soda and snacked continuously on the flight over from Chicago.  When we were kids, I don't remember many overweight classmates at all.  Within a span of just one generation, it seems that American children have piled on the calories and put on the weight.  I'm seeing more and more patients who are overweight, and these children are at risk for future health problems like high blood pressure and diabetes.

In an effort to offer some concrete advice to overweight patients and their parents, I ask if portion control is an issue.  In today's society, it almost always is.  We are blessed and cursed that in this country, we have too much relatively cheap food.  People from other countries of the world would be astounded by the bounty of food available in the local Stop 'n' Shop.  I always ask if a child drinks a lot of soda and juice, sources of unnecessary calories for so many kids.  The amount of snacks that we give our children is also out of control although I feel hypocritical when I discuss snacking, being an inveterate nosher myself.  Lots of today's kids, my own included, have become accustomed to snacking every two hours, instead of saving their appetites for three healthy meals a day.  Bedtime snacks too should be banned.  Brush your child's teeth after dinner, I advise, and then only allow water after dinnertime.  And last but not least, I try to stress the importance of exercise, especially for this generation of kids who loves Nintendo, cable and computer time.  All of this is, of course, such easy advice to give but often so difficult to implement and enforce.

Juice Is The Devil

A mother questioned me on the subject of juice last week.  But, why, she asked, why do you say that I shouldn't give juice to my kids?  Because you don't want to get them hooked on that garbage, I replied.  Your twins are only 15 months old.  Don't let them get used to the taste of juice because eventually they'll reject milk and water.  So many kids in this country can't drink plain water by the time they're five years old and then it's a slippery slope to drinking sodas and iced teas.  The mother continued to press the subject by saying that she thought water was so boring.  Think about tooth decay, I had to say, and the unnecessary sugar calories that you'll be saving your kids.  Apparently, 10-15% of calories a day in an American diet come from sugary drinks.  Even the drinks that proclaim themselves to be 100% juice just encourage a sweet tooth.  A child is far better off eating a piece of fresh fruit than sucking on a sippy cup filled with juice.

I had to invoke my own children to try to convince this mother about the evils of juice; I told her that Max would drink juice all day if I he could, but if no juice is in my fridge, he drinks milk or water.  With vitamin D and calcium defiencies being hot topics in medicine these days, it's especially important to make sure that kids get their three dairy servings a day.  After all this discussion, the mother didn't look entirely convinced.  I wonder if she left my office to head to Shop Rite to stock up on Kool Aid.

Too Much TV?

The American Academy of Pediatrics recommends limiting a child's television viewing to one to two hours per day.  By ten o'clock this morning, my kids already had their day's fill.  I remember one of my mentors during residency telling a mom that the TV should never function as a babysitter.  He was an older pediatrician, and now that I use the TV so readily when I need a moment to empty the dishwasher or clean up the kitchen after breakfast, I wonder about his words.  Did he ever have to care for his kids by himself?  Maybe his wife dealt with all the child care in his house.  Perhaps he was never left alone with two young children when the hours stretched ahead endlessly.  There are only so many coloring and art projects that I can do.  I also hate to admit it, but I am not the best "player" in the world.  Sometimes I just don't relish getting on the ground to push trucks around and around nor do I love spending hours rearranging furniture in a doll's house.

I am determined, though, not to feel guilty.  There are so many things that make moms feel guilty these days, but I don't think letting my kids watch TV should be one of them.  I know I try.  I spend as much time with my children as a I can, and they know I love them to bits.  If I need the TV to give myself a break every now and then, so be it.  As a pediatrician, I tell moms what the AAP recommendation is for limiting screen time, but I also let them know that for the sake of a mother's sanity, it is only a guideline.

Faking Illness

I saw a little girl in the office today who had been complaining of ear pain at home. Her exam, though, was perfectly normal, and the mom sighed when I told her so.  I thought so, she said; my daughter has learned to say her ear hurts when she doesn't want me to go to work.  Then I have to take time off, she continued, and now I'm just going to reinforce her behavior because it's lunchtime, and she'll love going out to lunch with me.  Take it as a compliment, I told her; she just loves being with you. 

When Sophia complained of a sore throat a few weeks back, I thought she was faking it too.  She started whining about not going to camp, and I sent her to her room to simmer down.  Imagine my guilt when I finally looked into her throat.  Turns out it didn't look normal after all, and Sophia ended up staying at home for a few days.  Sometimes it is so hard to distinguish whether a child really is sick or whether there are ulterior motives involved.  I'm still feeling bad that I didn't believe her.  With this guilt weighing upon me, I've resolved to follow the example of the mother I saw today, even if it did mean an unnecessary trip to our office for her.  But that mother listened to her child, and I hope I'll remember that the next time Sophia tells me something hurts.

It's Flu Shot Time Again

Get your flu shots now!  Flu shots here!  I feel we should post a sign in our office window proclaiming the start of flu shot season.  Most parents don't realize that administration of flu shots can begin in late August when the first shipments come into doctors' offices.  We've already started to give out the intranasal vaccines and are anticipating the arrival of the injectable vaccines any day.  The good news is that the H1N1 strain is included in this year's seasonal vaccine.  That means we won't have to give everyone two types of flu shots like we did last year.

When parents ask me what I think of the flu vaccine, I always tell them that my kids are regulary vaccinated every season, as soon as we get the shots into our office.  Not only is a flu shot safe for most kids (a few kids can't receive it if they have an egg allergy), it can prevent a great deal of morbidity and even mortality.  So call your doctor's office, beat the rush, and get your children vaccinated now.

Activities, Activities, Activities

September is rolling around again, and I've just received an email about potential cooking and art classes for Sophia.  Both Soph and Max are already signed up for soccer on Saturday mornings, and I'm wondering whether Sophia should continue her tennis lessons.  A friend just asked if Max would like to play T-ball with her son.  Another friend is enrolling her son in karate and wondered if Max would do that with him.   Now I just have to figure out when, what, where, and how.

Parents frequently come to our office, frazzled, trying to squeeze in a doctor's appointment between dance or swimming or gymnastics.  I always swore I wouldn't be one of those parents who overschedules her kids.  During well-child visits, I sometimes ask if the child has some time to relax if I get the feeling it's always go, go, go for the poor kid.  Everyone, at every age, needs some down time to themselves.  Truth be told, though, I now know why a mom might plan a slew of activities.  Quite honestly, the thought of entertaining the kids myself during those long empty hours after school is a little daunting.  I think I'm just going to suppress my twinges of guilt by telling myself how much these activites will enrich my kids' lives.

The Gender Divide in Parenting

If a mom can't make it into our office for an appointment, very often her husband will come with a list of his wife's concerns.  He'll hand me the notes to read, to make sure he's not forgotten anything he was supposed to ask.  In a similar vein, when I call a mom back about a sick kid and if the dad answers the phone, many times he'll say, "Oh, just hang on a moment, I'll get my wife on the line."  And while I wait, I'll wonder why he can't describe his child's symptoms to me.  The old feminist in me used to get irritated with such interactions, but being a wife and mom has mellowed me.  Dads are just more relaxed when it comes to their kids.  It doesn't mean that a father loves his child any less than a mother does, but moms do worry more.  Gross generalization?  Perhaps.  But motherhood and my experiences in pediatrics have convinced me of this.  If I were to send my husband with Sophia on a visit to her eye doctor or her allergist, I think I would make a list myself, to make sure he got all my questions answered.  Rob's a physician too, but when it comes to my babies, I want and need to be fully involved, with all my concerns addressed.

A Third Child?

Sometimes I think I want a third child.  Both my husband and I come from families of five, and five strikes me as a really cozy family unit.  But this week I had an epiphany.  While Max was busy at camp on Monday, Sophia and I ran errands, went out to lunch, and had a great time.  But when I'm out with both of them, my stress level invariably rises, with the inevitable fighting on their end, the refereeing on my part, and just having to keep an eye on two kids at a time.  Should I really add a third child to the mix?  When a mom comes to my office with three kids in tow, she almost always looks stressed.  I silently commend her bravery in venturing out with three young ones, but I'm guessing that in most of these situations, she has no choice, with no available sitter who can help.  It takes a calm woman to keep her cool when she's out and about with three youngsters, and I am not one of these women.

I felt like a good mom when I shared some alone time with Sophia as we talked and laughed on our day out together.  I'm afraid there would be fewer moments like that if I were to be stretched too thin if we had a third.  I guess I should just call it a day, recognize my limitations as a parent, and try and do the best for the two kids I already have.

A Message Marked "Personal"

The office staff left a message on my desk today with a note to call Mrs. N. back about a "personal" matter.  Messages marked "personal" never bode well; the parent usually wants to talk about a problem at school, an impending divorce, or worst of all, a recent death in the family.  I called Mrs. N back with some trepidation, bracing myself for some bad news, but it was a wonderful surprise when I heard her voice, brimming with laughter, saying, "I brought something back from Indonesia for you!"  She had remembered our conversation from months ago, about how much we both loved pempek, Indonesian fish patties.  I had told her how my grandma used to make them, and I couldn't have been more touched that Mrs. N had taken the trouble to bring some back for me from halfway around the world.  She showed up later in the day with an enormous bag of food; along with the pempek, she also brought some specialty fish crackers from Jakarta and a homemade sauce of hers to eat the pempek with. 

Somedays I leave the office frustrated or anxious, with challenging cases or difficult parents on my mind.  But today, today was an especially good day, thanks to Mrs. N.  It is gratifying to know that true generosity and kindness really does exist.  Plus, I fried up a batch of that pempek tonight, and it was delicious.

A Weekend In The Hospital

This past weekend I had a patient admitted to the hospital with a cellulitis of his knee.  He needed IV antibiotics for this infection of skin and soft tissue.  A perfectly healthy 2 year old, he had presumably sustained a bug bite a few days prior, and the area around the bite got swollen, hot and tender.  Cellulitis is a run-of-the-mill diagnosis on the general pediatrics ward; it usually takes just a few days of IV antibiotics before the child is able to go home again.  But meeting with the mother at her son's bedside on Saturday and Sunday morning reminded me of how difficult it is for a parent to see her child, small and vulnerable in a hospital bed, hooked up to an IV pole.  I understood exactly what this mother was going through as Max was hospitalized with cellulitis of his arm over New Year's 2008.  That experience of being the parent rather than the physician was an eye-opening one.  I learned first-hand what patience and fortitude it takes to pass long hours in the hospital, praying for antibiotics to work their magic.  And most of all, I gained a true appreciation of the anxiety a parent suffers when her child is sick enough to be admitted to the hospital.  I hope my experience with Max has made me a more empathetic physician.

A Dinner Fight

Ah, the food battles in my house.  Last night Max refused his dinner of a delicious beef stew and pasta.  It took a threat of throwing out his newest DVD and the bribe of ginger ale to successfully get him to eat about eight bites.  I hate threatening him, especially when he cried so pitifully at the thought of his DVD going into the garbage.  But mealtimes can be frustrating, and I find myself losing my temper easily when I see plates of food going untouched by the kids.  I remember reading somewhere that a parent should consider herself lucky if her young child eats one good meal a day, and I know that I really have nothing to worry about as both my kids are growing beautifully.  For the parents who complain to me that their kids don't eat the way they want them to, in most instances I can reassure them by showing them their children's normal growth charts.  It's just a phase, I say; the picky eater you have now will probably become the sushi eater when he's eighteen or the lover of Indian vegetarian cuisine when she's a college student.  Kids' taste buds and palate preferences do mature and change as they grow up.  But as a mom, it's so difficult to lay out a meal and have both children spurn it.  I'm going to strive to be more patient at mealtimes.

Learning To Follow My Own Advice

A mom called last night, frantic and weeping.  Her seven-month old daughter had rolled off the bed.  The child hadn't lost consciousness or vomited after the accident and now seemed fine.  But this poor mother was the one crying even though her baby had calmed down.  I reassured her as best I could, telling her to call me back if the baby developed lethargy or vomiting.  I tried to make her feel better by telling her how Sophia had rolled off our bed at about the same age.  But it's so much easier to tell someone else to calm down; I remember how upset I was when Sophia had fallen.  The worst part about Sophia's accident was that it had been my fault and only my fault.  My husband had been in another room, and I had turned my back for one second after placing Sophia in the middle of the bed.  The guilt that consumed me was only magnified by the fact that I always warn parents never to leave their babies unattended on beds or changing tables or any high surface.  I did not like learning the hard way to practice what I preach.

Newborn Nursery Rounds

I went to the hospital this morning to see a newborn.  The well-baby nursery must surely be the happiest place in the hospital.  The vigorous cries of the babies, the new moms strolling the halls, the flowers and balloons on the ward all contribute to a joyful energy.  There is such promise in the air, of happy homecomings and the anticipation of all that lies ahead for these infants.  I sometimes think back to those first babies I cared for as a pediatric intern.  To think that I had the privilege of examining their tiny bodies before they left the hospital to begin the rest of their lives.  They're teenagers now; what has become of them?  Hopefully they have brought their parents much love and joy.  Back then, during my first year of training, a new mom laughingly told me, "I want you to tell me he's going to grow up and get into a great college and find a beautiful wife and just be happy!"  I hope she'll get her wish.

A Battle With Lymphoma

It's August now, and a special patient of mine will be starting college this month.  This past spring she showed up in my office complaining of fatigue and a lump in her neck.  For the first time in my career, my hands started to shake after I examined a patient.  Not only did she have a large lymph node above her shoulder blade, I also felt multiple, enlarged lymph nodes scattered all throughout her neck region.  I had to compose myself as her mother asked what I was thinking.  I told that the very best diagnosis we could hope for would be mononucleosis; at worst, I was thinking about lymphoma.  I choked on that dreaded word, and the mother's face registered shock as I sent them off to the ER to be evaluated by the oncology team.  By the next day, her diagnosis of Hodgkin's lymphoma was confirmed.  By the next week, she had already begun the first of three rounds of chemotherapy.  What I'll always remember about this young lady was the smile on her face when she welcomed me to her bedside.  While her parents told me they felt like they were living in a nightmare, this girl kept her spirits up.  Her bravery, and perhaps the resilience of youth, helped her through her chemo regimen.  Her prognosis is excellent as her cancer responded well to her therapy.  Now she's off, onwards and upwards, ready to start her freshman year of college.

The Girls From Residency

It's been awhile, but this weekend brings Natascha, Karen, Mimi, Allie and me together again.  We are just missing Abby.  These are the girls I laughed, learned, suffered, and cried with throughout our 3 years as pediatric residents.  It was over a decade ago, and none of us had children then.  Now between us, there are thirteen kids and maybe more to come.  This is a special group for me because these girls understand that being a pediatrician doesn't make it easier to be a parent.  Yesterday Mimi was worried about her youngest who was suffering from a fever.  If we had been with other friends, there might have been a comment, "Oh, you're lucky, Mimi.  You're a pediatrician.  You know exactly what to do."  Yes, we can all dose Tylenol in our sleep, but that doesn't mean we have a crystal ball into the cause of the fever or how long it will last.  And our training doesn't mean we worry less when our own children get sick.  But with this group of girls, I share a unique bond, because we know that pediatric training and the grueling years of residency are no match for the challenges of motherhood.

Separation Anxiety

On our well-child checklist at the 9 month visit, I ask parents if their baby is developing separation anxiety.  Does he cry when he's taken from your arms?  Does she get upset when she's in the care of an unfamiliar person?  I tell the parents it's all part of normal development.  The child will outgrow it like every other phase of infancy and babyhood, and someday this kid will be the one who doesn't look back when he checks into his college dorm.  Far from their college years, though, Sophia and Max are already so well-adjusted that they didn't even shed a tear when I said goodbye to them for a weekend away.  Are these the same children who once wailed and cried when their babysitter took them from me?  Sophia and Max were perfectly happy to say, "See you Monday!", while I was the one sitting on the airplane, thinking about how much I was missing them.  Who's got the separation anxiety now?  As children grow up and start making their own way into the world, it just gets harder and harder for a parent to let go.

A Baby Period

I'm on call tonight, and I got an anxious page from first-time parents of a five-day-old baby girl.  They had noticed some slight bleeding from her vaginal area, and the mom said she had broken down into tears when she saw the blood.  I quickly reassured her that this bleeding is not uncommon in newborn girls.  The baby is just responding to hormonal changes as she adapts to life outside the womb, just as mom's hormones are also fluctuating wildly in her postpartum state.  The falling levels of maternal hormones in the baby's bloodstream affects the uterus and creates the "baby period."  But at 10 PM at night, in her sleep-deprived state with her C-section wound still hurting, all the mother heard was that the bleeding was normal.  Her relief was palpable even over the phone.  I hope she can get a few hours of rest now.

Bedtime Rituals

I make it sound so easy.  Bedtime rituals for young children, as I always tell parents, should be consistent.  Toothbrushing followed by a story or two then good-night kisses and lights out.  Parents need to establish a routine and follow it.  Very simple.  Somehow, though, I can't parlay my advice into reality; in my household, bedtime has become such a long, drawn-out, often stressful process.  First, there's the cajoling to get everyone upstairs, then the pleas from us to cooperate with tooth brushing, then the kids' agonizing choices of which books to read, then our begging them to lie quietly in bed.  Getting Sophia and Max to bed takes at least an hour every night.  I tell myself this is not going to last forever; I know that someday I will want to turn back time to when my children needed me to brush their teeth and read books to them.  But right now, in my present day, I wish I could get some advice on getting MY kids to sleep.

How Old Is Too Old To Drink From A Sippy Cup?

That is a question a parent posed to me the other day, and quite frankly, I had never given that question much thought in the past.  I blurted out, "Don't get rid of your sippy cups until you can trust your kid not to make a mess when she drinks from a regular cup."  I think the parent thought she was going to get an answer based on my pediatric knowledge, but the mommy in me answered instead.  Sophia, who is entering first grade, is more than capable of drinking from a regular cup and has been for a few years now, but there is no way I would let her sit on our new couches in the family room while drinking from a regular cup.  Unless she's seated at the kitchen table, Sophia still uses the sippy cup with its ingenious valve because I am too afraid of a mess if her milk or water accidentally spills.  I told the parent that using a sippy cup isn't going to hurt her child's development in any way, so if she needs to continue the sippy cup to protect her furniture and keep her house clean, go right ahead!

Looking Back on Toilet Training

We were at my in-laws' summer house for the weekend, and Max found his old floor potty to use as a stepstool.  What a relief it is to be done with toilet training.  Last summer, that potty consumed much of my time, sitting by it, praying that Max would pee in it, cleaning poop out of it, moving it from the upstairs bath to the downstairs one and back.  A year later, Max is fully trained, and I think back to the angst and pressure I felt to get him trained.  The pressure was on because he had to be trained to start preschool last fall.  Funny, parents come to me and talk about their toilet training struggles, and I always reassure them that it'll all fall into place.  Don't stress, I say, I can almost guarantee that your child will not be pooping in his pants when he graduates from high school!  But of course I stressed with my own kids, and I feel a little silly now that Max so naturally tells us he needs to go and takes himself off to the bathroom.  He's even taken to asking for privacy when I follow him in. 

That toilet training so consumed us last summer and now the old potty is being used merely as a stepstool makes me think of a quote a friend of mine posted on Facebook.  She wrote about the days going slowly and the years going quickly when you have young children.  How true.  Although it's so easy to get caught up in the day-to-day struggles of child-rearing, I think that most parents would agree that we have to make the most of these special years with our kids.

Cucumbers for Allergic Eyes?

I recently saw one of our pediatric neurologists in our office.  She had brought in her son for his swollen, irritated eyes.  In the realm of conjunctivitis, I entertain the possibilities of allergic, bacterial or viral etiologies.  With allergic conjunctivitis, the patient's eyes are usually swollen, sometimes red, with lots of watery discharge.  Usually the parents will also report sneezing and runny-nose type symptoms as well.  With cases of bacterial conjunctivitis, or classic "pink eye," the child has red eyes and thick yellow-green discharge.  Viral conjucntivitis commonly accompanies a cold, with milder symptoms of redness and discharge.  It may be difficult to distinguish a bacterial from a viral conjunctivitis.

The pediatric neurologist's child was clearly suffering from allergies, and she had been trying her own home remedy for him, applying cucumbers to his eyes at night.  We both laughed, as I jokingly told her, "I'm going to tell my patients that our esteemed pediatric neurologist treats her child with cucumbers."  But all kidding aside, I wonder if we discount home remedies too often.  It's so easy in modern medicine to place all faith in FDA-approved drugs, with their researched half-lives, dosage guidelines, and side effect profiles.  And likewise, it's easy to dismiss alternative treatments and home remedies.  Problem is, medical school training and residency teaching does not focus on such therapies.  The cucumbers probably did help, with their cooling and astringent effects.

But then, ultimately, the child needed more than the cucumbers.  I prescribed him allergy eye drops and recommended Claritin or Zyrtec, and I am glad to say that they relieved his symptoms.

A Diabetic Patient

One of my favorite moms was in the office yesterday.  She was still smiling, despite the fact that her three-year-old son was diagnosed with insulin-dependent diabetes earlier this month.  I hadn't seen her nor him since their hospitalization over the Fourth of July weekend, and thankfully, she was in good spirits.  I couldn't think of much else to say except to reassure her that she was in good hands in the care of the pediatric endocrinology group that I love.  We talked about how her son would likely live a long full life, especially with all the recent advances in diabetes care and research.  I reminded her of the million other diagnoses that would have been infinitely worse, like leukemia or lymphoma.  If I were in her place though, I'm not sure I would have found that statement all that consoling.  Diabetes does take over every aspect of a child's life, from what time he can have a snack, what the snack should be, whether he got too much insulin for the two bites of diiner he ate.  If this had been Max, and there is something about this little patient's smile and pudgy legs that remind me of Max, I don't know how I would be coping.

Waiting for the Doctor

Sophia and I waited a half hour to be seen at her eye doctor visit yesterday.  Not bad, I think, in the realm of waiting times for a doctor's office.  I wonder what most patients consider intolerable for a wait time.  45 minutes?  An hour?  People defnitely start to pace at the 45-minute mark and then begin to get very angry when it's been a hour.  What most patients don't realize is how badly a doctor wants to stay on schedule.  I absolutely abhor running behind; I hate keeping my patients waiting, but somehow, somewhere along the line, the practice of medicine has become such that it's practically impossible not to fall behind with every patient a doctor sees.  To survive, to keep our office running, to pay the malpractice insurance, the staff, their health insurance, not to mention the electric bills, we have to book patients every 15 minutes.  But can a well-visit for a child ever take just 15 minutes?  Only if the parent has no questions or if I don't engage the child in conversation.  And I refuse to do that!  And for a sick visit, it takes time to examine a screaming, crying febrile toddler.  In between these visits, there are phone calls to return, school and sports forms to fill, and consult letters to be read. 

So I desperately try to stay on schedule but invariably fall behind.  Sometimes I can sense the ire of the waiting room as I patiently coax a child to open her mouth in an exam room, but I've learned to stay calm, proceed as efficiently as I can, and hope that everyone will understand. 

A Work Day

Busy day at work today.  Lots of school and sports physicals, and sometimes it feels like my head is spinning.  But I have to say that as the years have gone by here, I've gotten attached to a lot of my families.  It's very gratifying to watch my patients grow up, and I love this time of year when the soon-to-be college freshman come in and tell us where they'll be going in the fall.  So exciting for them.  Sometimes I think I would love to be seventeen again, bright-eyed, so eager, with it all ahead of me.  But it's six o'clock now, and time to go home.  Maybe I don't want to be seventeen again, because then I wouldn't have Sophia and Max running to the door when I get home; I do love that moment of the day when I walk in and they come hurling themselves at me.

Visiting Night at Camp

I'm so looking forward to Sophia's visiting night at her day camp this evening.  It's her first year there, and finally I get to meet her counselors and her group leader.  She doesn't tell us much about her days at camp, although I'm always trying to eke info out of her.  What did you do today?  How was lunch?  Who did you sit next to at lunch?  Who are you playing with?  If she doesn't say much, does that mean she's happy?

I scan the daily photos the camp posts on the Internet, and in a few, I've noticed Soph standing on the side of the group.  Am I overreading them?  Don't overreact, I tell myself.  Her group leader has left two messages for us in the last three weeks, saying Sophia has been having a good summer.  I've resisted the urge to call back, not wanting to look like the anxious parent I am, but today I called, just to check in.  Apparently, Sophia is quiet but participates in everything.  I briefly mentioned that I noticed Sophia on the fringe of the photos without trying to sound too neurotic, but the group leader reassured me that all the girls play nicely together.  Can't wait to see my baby girl (can I still call her that now that she's going to 1st grade?) tonight amongst her friends.

It's so hard being a mommy, and it's so hard not to be an anxious one!  I feel like I'm always telling parents not to be anxious because anxious parents make kids anxious.  I am determined to try and follow my advice on this one.

Check Out The August Issue Of Parents Magazine!

Very touched that a friend from residency sent out an email telling mutual friends to look out for my essay on discipline in the August issue of Parents magazine.  Thanks, Karen!

I Think He's Got A Cold

Well, Max, you are sound asleep, thankfully resting comfortably but still a little stuffy and congested.  So much for my hopes for Claritin.  I hate the idea of you coming down with a cold!  I hope that it'll last just for a few days; I'm going to hold back from checking your ears and throat myself.  I'm going to go through the proper channels and just bring you to see my partners if this lingers for more than a few days or if you get a fever.

Sophia, I took a great picture of you today to commemorate the 18th of the month.  I take a picture of you every month on the 18th and one of Max on the 26th. (Yes, that's right, Soph was born on October 18 and Max on June 26).  I paste these photos in my journal, and I love looking back to see the progression of the photos over the months and the years.  I remember laughing at one of the moms in the practice who wanted us to rewrite the slip of paper detailing her son's height and weight at his 15-year well visit.  Why?  So that she could paste it into his baby book!  But now I understand.  I wonder how long I'll be able to keep up with this monthly photo archiving.  I guess time will tell.

Could This Be Allergy?

Max, my baby Max, yesterday you seemed stuffy, kind of congested.  This morning you came to our bed, sneezing away.  Allergy?  Beginning of a summer cold?  Hope it's allergy.  Now I understand why all the parents want to think their child has allergies and not some sort of acute illness.  Allergies are somehow more benign, less threatening - then there's no fear of impending fever, dehydration, a week of misery, etc.  So I made you take a Claritin, Max, and I'm hoping for the best.