Don't Look Back In Anger

Parent complaint: "Everytime I ask my three year old to do something he doesn't want to do he flips out. He seems to be full of rage. I'm worried he will turn out to be a serial killer or something. Please FIX HIM."

Diagnosis: Normal

While I can't promise that any given three year old won't turn out to be a serial killer, this behavior definitely doesn't guarantee it.

You may also be worried that they will turn out like this woman:



Again, I can't make any promises. I do have some advice, though. The answer is the same one you hear when you go to therapy for any relationship: communication. Your child still has limited vocabulary and it can be frustrating to want to say something, but not know how. Plus, ever since they were a baby, the way they got attention was by crying. Here's a few tips to help your toddler/preschooler with their 'rage' issues (actually most of these work at any age):

- Help them identify their feelings by pointing them out yourself. Example, "It looks like you are really disappointed that you can't have any more red hot Cheetos."
- It is important that you remain unemotional in your exchange. It shows your child that emotions don't have to heightened for every trivial matter. Plus, yelling at them only seems to fuel the fire at times. (My wife will readily admit that this is one area I have the hardest time with)
- Encourage them to 'use their words' instead of tantruming. Only give them what they want when they ask in a calm voice. Example, "It seems like you want these red hot Cheetos, but you can only have them if you uses your words in a calm voice." If you give them what they are 'raging' over without improving their behavior, you are just rewarding their rage, and it will be harder to overcome later.... which leads to my next point.
- Ignore. We've heard this one from when we were kids. "Why can't you just ignore your little brother, he's only doing it to get attention." Well you'll find its even harder as a parent to ignore it. There may be a component of attention-getting to their behavior. The less attention they get, the less reward they get. My parents always tell a story of a preschooler tantrum I threw at a movie theater once laying on the floor and kicking. They said they just left me there and walked away. I stopped my tantrum, jumped up and ran after them. Apparently that was my last tantrum.
- Work on your own feeling communication. Explain to your child why you are doing what you are doing. Don't say, "because I'm the daddy, that's why." Say, "I don't want you to have any more red hot Cheetos because you've already eaten a lot, and we are going to eat dinner soon."
- Positive reinforcement. When they respond in a 'grown up' way give them a reward. A sticker. A healthy treat. While they usually won't choose it over the other things, physical affection (a hug, etc) seems to work best of all. "I'm so proud of you that you were able to talk in a big boy voice instead of whining" (accompanied with a hug). Kids are suckers for that crap.

The good news is most people grow out of it (ignore the woman in the airport above). Through your excellent parenting skills you can help them get there sooner rather than later.

Fell free to add any comments of methods you have used to share...

Flu update

There have been many developments on the 'swine flu' front, so I thought I'd give my readers an update... I guess we are now calling it H1N1 to start off...


I'll be honest and admit that there was a much more significant outbreak this summer than I expected. It is still about equivalent to the regular flu for your average healthy individual. Here are some numbers you may be interested in: H1N1 deaths in the US = about 300. Number of deaths of regular flu per year in the US = 36,000.

We have learned a few things about this new strain of flu: It seems to be harder on pregnant women than previous strains of flu. There seem to be some concerns that it is easier to develop secondary infections (like pneumonia) from this strain than the average American strain. This risk seems to be increased in the teenage/20-something age group than 'regular' flu.

Things to do to protect yourself now, and during flu season
1) Get vaccinated (more on this later)
2) Be free with the hand sanitizer/hand washing especially before touching your eyes, nose or mouth (they both work!)
3) DO NOT wear a mask. There are very few masks (which are currently in low supply) that work for more than a few minutes against flu particles. In fact, wearing a mask in public may increase your risk of getting it, because it may make the flu particles get lodged between the mask and your face, increasing exposure time. You can wear a mask if you think you have swine flu to keep it from spreading to others, but do yourself and others a favor and just stay home (the CDC recommends staying home until your fever is gone for more than 24 hours).
4) Take antiviral medication. One of the antiviral medications appears to be more affective against this strain than others, but it is in short supply, so you may not be able to get it unless you are at high risk of developing severe disease. Ask your doctor if you are concerned.

5) Get plenty of rest, exercise and a healthy diet while you are well to keep your immune system up. Always good advice!

Should I vaccinate my family?
Unfortunately the regular flu shot isn't very affective against H1N1, and as of this year, the H1N1 strain is too new to be added to this year's flu shot. They are, however, feverishly working on developing an H1N1 flu shot. Which means this: you will have to get multiple shots to be protected from all strains of flu this year. It will likely be combined in the future, but not now.

Some people feel it isn't worthwhile to get vaccinated against something that probably won't kill you, since you are healthy. In fact, there's a good chance you won't even catch it. You may be right, unfortunately, your kids don't fit in that group. I highly recommend getting the flu shot (flu shot's' this year) if you are a kid or have kids. ESPECIALLY if you are pregnant or want to become pregnant. 6% of the swine flu deaths have been pregnant women. Here are the target groups the CDC gives for those who should be vaccinated this year:

- Pregnant women
- People who live with/provide care for infants besides being a pediatrician - and everyone knows pediatricians love to torture children with needles): kids are the vectors! Studies have shown that just vaccinating school age children signficantly decreases the load on ALL OTHER demographics. Kids spread germs. That's the reality. You decrease the germs amongst the kids, and everyone is better off.


For more info, see the CDC webpage on H1N1
http://www.cdc.gov/h1n1flu/

Senses working overtime

"Doctor, my 3 year old totally has ADHD. He cannot sit still. He has a hard time concentrating and staying on task. Can I get something to help with him? Please FIX HIM!"

Diagnosis: normal 3 year old.

ADD/ADHD (I'll just refer to it as ADHD from here on out because I'm lazy) seemed to be all the rage in the 90's. Seems to now to have taken a back seat to 'Autistic Spectrum Disorders'. It is still relevant, and while it doesn't get the press/publicity of autism, it is definitely more common.

First question: Does it really exist, or is it just a reflection of a generation of bad parents?
First answer: Yes, it does exist.

There are many kids that seem to very obviously have this diagnosis. The medication to treat is consists of a group of stimulants. If you give someone a stimulant and it CALMS THEM DOWN, I'd say that's pretty good evidence that they have some 'crossed wires' so to speak. It is a highly genetic situation, so kids with it are likely to have parents that suffered similarly as a child (and some continue to as adults).

Second question: Does my child with ADHD need medication?
Second answer: Maybe.

Parenting plays a large roll in ADHD. No, a bad parent cannot make a child get ADHD. There is something that genetically predisposes these children to behave they way they do, but poor parenting can really bring it out. Parent training has found to be so beneficial that many kids not longer need medication after their parents learn the right way to 'parent' them. Most of this training focuses on teaching the child organizational skills including making daily schedules/routines, simple and CONSISTENT house rules, close supervision, and a reward system that focuses on effort, not necessarily results. Sleep schedule is extremely important, as lack of sleep really exacerbates the symptoms. In fact, sometimes obstructive sleep apnea is misdiagnosed as ADHD. So if you have a hyper child that snores, get that checked out. After all that, though, there will still be a quite a few children that will need medication to function well.

Third question: Isn't it just easier to give them a pill to pop than to learn how to be a better parent?
Third answer: Yes.

Studies clearly show that even with medication, proper parenting techniques are invaluable. Do your kid a favor and get the training you need in order to give them the best chance to succeed. I will admit, though, I have had some parents that are so disorganized and ADHD themselves (its genetic, remember) that I don't even bring up parent training, because I don't believe in exercises in futility.

Fourth question: If I eliminate sugar from his diet, will he be normal?
Fourth answer: Probably not.

There are may people out there trying to sell their diet plans to help with ADHD. There is very little scientific basis for this. Most of the time, it is the case of a person who wants to prey upon someone else who is desperate for help (which describes pretty much any parent of an ADHD child). That doesn't mean they don't help at all. There may be a diet component, but I think these dietary needs can vary wildly between children. I don't see any problem trying different diet routines, as long as it doesn't but an undue financial (or other) stress upon your family. NONE of the diets work for every child. The parenting techniques described above help to some extent for EVERY child. Start with those, then consider diet therapy, but keep your expectations low and your wallet tightly closed.

Brain of J.

Ok, folks, I've officially emptied my brain of the original pediatric ideas I had for my initial blog postings (don't worry, more diet reviews to come). So I'd like to open it up for questions... Any recommendations for other subjects? What have you always wanted to ask your pediatrician but where afraid to ask?

There is an old adage, "There are no dumb questions." I'll be honest and say I don't believe in it. There are plenty of dumb questions, but don't worry, I won't tell you if your question is dumb. Plus the dumb ones may be the same things that everyone is wondering about, but doctors don't bring it up, becuase they think everyone knows it...

Jenny (867-5309)

I thought I'd start a series of diet reviews to evaluate the pluses and minuses of each of the popular diets available.... I'll rate each on ease of following, medical safety, and chance of keeping the weight off.

The first 'diet' I'll start with are the prepared food plans (like Jenny Craig, Nutrisystem, Weight Watchers, etc).

***the funny thing about this ad, is it says 'results not typical'. I've seen that disclaimer on the 150 pound losers, but 30 lbs? It's not typical to lose 30 lbs?

The basic plan is to eat the food they have prepared for you, and if you only eat a certain amount of it, you will lose weight. Honestly, I'm sure it's clear that this is just a low calorie diet (as I have said previously is the best) where they count the calories for you. Most of these diet plans are based on an 1800 calorie a day intake. If you learned to count calories yourself and kept to 1800 calories a day, you would lose weight for free. But, yes, that does take a lot of work at first, and these companies eliminate that work for you.

Ease of following: Pretty easy, as long as you have to money to pay for it. You do have to buy food to eat anyway, so its probably not exorbitantly more expensive than regular food. In fact, if you eat a Claim Jumper for every meal, I'm sure it is cheaper. The big problem with its 'ease' is it is a little restrictive; ie, if you wanted to Taco Bell for lunch, you can't. And if you like fresh food from your garden, that's not part of the plan either. Its mostly frozen food from the microwave.

***mmm looks delicious

Medical safety: Very safe.

Chance of keeping the weight off: Good until the money runs out, or you get bored of their food. Actually, 80% of Jenny Craig's business is repeat. In fact, if she got everyone to lose weight and keep it off, she would go out of business. She wants you to depend on her. (I shouldn't be too hard on Jenny Craig keeping people fat, so she can have business, as my grandmother thinks doctors keep people sick, so they will have business!)

Conclusion: Learn about what you are putting in your mouth! Learn how to count calories yourself and plan your own meals with your own food (and even Taco Bell's food, if you'd like). Plus you develop a life long skill and habit (if you get really good at it) that will help you be healthy FOREVER (well at least until you die).

Blister in the Sun

Alright, its summertime, and time to worship the sun god.

A very popular question we hear in the clinic is, "How much SPF do I need?" There's nothing America likes more than hysteria and overdoing it... Let me give you some data to chew on... the SPF of a 100% cotton shirt has been sited to have an SPF of somewhere in the range of 4-15. (Yes, don't you love the exact answers science likes to give us.) So if I'm being really honest with you, if you don't get a sunburn with a t-shirt on, you probably don't need anything more than SPF 15. But, doctor's aren't above the hysteria apparently, because I still recommend about SPF 30 for most kids. Anything over that really is overkill, so don't waste your money. Of course if the SPF 100 is on sale and cheaper, feel free, but I haven't heard of any real added benefit over SPF 30.

.

The next question of course is: Can I put sunscreen on my infant less than 12 months of age?

My answer to this question is avoidant and simple: The best sunscreen for a baby is SHADE. Please, people, does your baby really need to lay out in the sun? If your family is enjoying a day out in the sun keep your baby covered! Especially if they are less than 6 months. A sunburn can be very severe in this age group, so don't mess around. Plus, they'll probably end up sucking the sunscreen off of their hands anyway, which are probably the most exposed part of the baby's body. Keep your kids in the shade until they are old enough to move around and play in the sun on their own, then hit them with the SPF 30. If you don't think you can keep your baby in the shade there are a million baby sunscreens you can try, and they are probably fine, but just be really safe and stick with the shade.

Let's Go To Bed

Just a quick post on a subject that bothers me because the danger of its practice still doesn't get universal acceptance in the pediatric community: co-sleeping. This is probably because a major pediatric celebrity (Dr Sears) still hold fast to the notion that it is alright, even beneficial. I will have to beg to differ on this subject. I spent a month in autopsy while in medical school. We would get about a baby a week, and most of the ones I had seen were victims of cosleeping. All of them were at least victims of being put to sleep in an adult bed.

.

Just to be clear: co-sleeping is having your baby sleep in bed with you. Most other doctors (besides Dr Sears) believe that adult beds are death traps for babies with or without an adult in them. Even when Dr Sears went on Dr Phil, Dr Phil had to 'respectfully disagree' with him on the subject. And Dr Phil usually slurps his celebrity guests, so to make a stand, I was impressed. If you read Dr Sears website, he will make some convincing arguments and even state some evidence. But trust me, the evidence to avoid adult beds for babies far outweighs any studies he quotes.

.

Since I've been at my current job, I've gone to 3 'codes' in which a baby arrived dead to the ER. Also, all three of these were in adult beds, some with other sleepers.

.

Without the risk of death, I have to admit I have other concerns of the baby interfering with the parents' relationship. Sometimes bedtime is the only time parents get a chance to converse and touch base. Throw a baby in the middle, and you get no alone time for the two.

.

Bottom line for me: leave the baby in the crib.