The Over Achiever

Typical parent’s frustration: aimless, lazy child. Doesn’t want to go to school or do homework, avoids or procrastinates with chores, whiles away hours aimlessly on video games or social media. “The idle mind is the devil’s playground.”

As with everything, too much of a good thing is problematic as well.   The other end of the spectrum: the intense, hyper-focused child who has to take every AP and ace EVERY test, play every sport(often simultaneously) and ALWAYS finish first, works long hours in after school jobs to buy a new car that an adult professional might envy.  We know that type as well.

As parents and (for me) the pediatrician, we must be on guard for that troubled lifestyle as well. It is essential to teach children as they grow into adolescents and young adulthood the value of ambition and the pitfalls of perfectionism. The latter causes internalized stress and disruption of normal life functions like rest, relaxation, unstructured recreation, fulfilling family and peer relationships.  Their aspirations(and at times there isn’t even anything specific identified) can become totemic goals that may or may not be attainable but ultimately are largely besides the point.  One need not have all the highest grades to get into a good college and achieve career success.  Athletic scholarships are nice but uncommon, and the vast majority will pay at best a modest portion of college costs.  Over the years I’ve seen many more overuse injuries from hyper-training end young athletic careers than scholarships attainted.

And let’s not forget another fraught psychological component: we as the adults cannot and must not seek to redo our own missed opportunities, disappointments, or failures(or successes!) through them.  We’ve had our youth–its a fool’s errand to try and live their’s.

So what to do?  A few simple suggestions:

  1. Failure is fine.  Always try your best, but people fail. It happens, it’s a good teacher and a great way to learn fortitude as well as strategies for success next time.
  2. Perspective–have self awareness.  As an example: there are few D1 NCAA basketball players at 5’7″ and NOBODY in the NBA like that now.  So your slick ball handler should try hard but remember those realities. I say: play D3, start a business, make millions and BUY the NBA franchise. Therefore:
  3. Varied interests–play different sports, pursue different interests( music, volunteer). A well balanced life. I hate to admit this, but lighthearted, unfocused entertainment–video games with friends–is OK (moderation!)
  4. Rest–adolescents need > 8 hours sleep nightly. If her day is so crammed that she isn’t sleeping that much MOST NIGHTS she is over-scheduled.  Time to step in and:
  5. Be Parents!!  Teach them specifically the above. Enforce rules that promote those principles as you would to prevent laziness or disrespectfulness. Engage with them and be involved–and NOT only with that (perhaps over) focused sport.
  6. Watch out for warning signs: sleeplessness, fatigue, social withdrawal or isolation,   prolonged bouts of irritability, negativity, or hopelessness, panic attacks, weight loss (especially girls).

I tell my very ambitious teens: don’t go looking too hard for adult responsibilities–they will find you soon enough anyway.  Be a kid: when you are older you’ll want to be one again.

If you have concerns about these tendencies in your children please give me a call.  Thanks for following

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Penicillin Allergy (yes and no)

Obviously, penicillin is a very important and useful drug.  Most studies cite 10% of Americans identify as being penicillin allergic (pcnA).  However, later studies now suggest that this number is likely grossly overstated.  The actual number is likely around 1%, and 95% of pcnA diagnoses are inaccurate.

How does this happen?  Not infrequently, people self report their child as pcnA because one parent is so diagnosed.  However, most evidence indicates only a slight increase in risk–2 or 3%– with one parent allergic.  There is a somewhat greater risk if both parents are pcnA; however even in this instance guidelines do not recommend assuming allergy or avoiding use of penicillin, but rather test for accurate diagnosis.

A second problem is symptoms.  pcnA is caused by developing specific antibodies (“IgE”)to the penicillin molecule, causing hives, blisters, wheezing, joint inflammation, and, more ominously, swelling of lips, tongue, or throat.  The danger here–besides their own problems– is the risk that subsequent exposure can result in life threatening anaphlyaxis (shock, collapse).  Other symptoms often associated with use of penicillin(as for most antibiotics)–headache, nausea, abdominal pain, diarrhea–while upsetting and uncomfortable –are not caused by IgE, are not “allergic”,  and carry no risk of anaphylaxis.  But people may tend to conflate those other unpleasant but less dangerous side effects and will report that experience as “allergy.” So we doctors must look at these reports carefully.

Another cause can be timing.  Most URI’s–at least 95%–are viral. Recent studies find that urgent care centers  prescribe antibiotics for up to 40% of children treated there for these conditions.  Now, many of these viruses progress over 3-5 days and will then resolve with the breakout of a rash (for example, roseola–but there are lots of others).  So many of these kids can be seen at urgent care on, say, day 2 of the roseola like viral illness, diagnosed (over diagnosed?) with bacterial infections like otitis media, and then subsequently break out in the typical illness ending rash on day 4 or 5–the next thing you know, 2+2=3 and we have an (erroneous) diagnosis of pcnA.  This is just one more example of how temporal association does not establish causality, and, I say, another reason to access these establishments with caution.

This is not a trivial matter.  pcnA patients treated with alternate drugs after surgery tend to have more complications and poorer outcomes than those treated with penicillin.  pcnA patients have to take other, more “broad spectrum” type antibiotics which place them at greater risk for serious–sometimes life threatening–secondary infections like MRSA, clostridium dificile (“Cdif”), or “VRE”–vancomycin resistant enterococci.  Moreover, recent data indicate that up to 80% of people with actual IgE mediated pcnA will lose their sensitivity over time, enabling them to take penicillin again safely.  I will note here that, given the risks, this must be evaluated carefully beforehand to assure patient safety.

So if you have concerns about pcnA in your child let me know.  We can discuss it, test or refer to clarify this important issue.  Thanks for following.

Avoid Toxins

Nutritious  food and a safe environment is, of course, a basic requirement for a healthy upbringing.  Currently there are > 10,000 chemicals allowed as additives in food and food contact materials in the US.  There is growing evidence that at least some of of these products pose significant health risks for children.  There are several reasons why these chemicals are riskier for kids.  Children are smaller so the per kilogram ingestion dose is typically larger; their organs are still developing; and lastly children will likely carry these ingested materials internally for decades longer.

Questions raised by some of the newer research involve odd sounding chemicals with even stranger spellings–bisphenols, phthalates, perfluoroalkyls, perchlorates–used to enhance the functionality of food storage products made of plastic or metal, that may seriously impair  the function of endocrine, neurologic, or metabolic function.  The American Academy of Pediatrics feels that the Food and Drug Administration needs to take additional steps to “raise its game” with respect to these and many other additives. Some of the steps recommended include update and strengthen the “generally regarded as safe (GRAS)” process, prioritize retesting of previously approved agents, leverage expertise across agencies to streamline communication for better policymaking, dedicate more resources ($) to the effort, expand the scope of research and testing, and expand efforts at transparency of information for the public.

Under the current federal Administration, the present priority is clearly in the opposite direction towards cutting back on research and regulating these products as they feel that those steps are burdensome to industry and thus a drag on economic development and job creation.  I will limit my political commentary about that here to pointing out that generally the AAP does not agree with that priority and feels that children’s health is placed at risk by that approach.  Suffice to say that it is unlikely that we will see these policy preferences, as expressed by the AAP, become reality any time soon. Thus it is left to us to take the initiative to shield children from exposure to these potential hazards.  Keep the following in mind:

  1. Prioritize consumption of fresh or frozen fruits and vegetables when possible and support that effort be developing a list of low cost sources of that type of produce.
  2. Avoid processed meats, especially maternal consumption during pregnancy.
  3. Avoid microwaving food or beverages (including infant formula and pumped human milk) in plastic
  4. Avoid placing plastics in dishwashers.
  5. Use alternatives to plastic, such as glass or stainless steel, when possible.
  6. Check the recycling code on the bottom of products to find the plastic type, and avoid products with recycling codes 3(phthalates), 6(styrenes), and 7(bisphenols) unless they are labeled “biobased” or “greenware” indicating that they are corn based and do not contain bisphenols.
  7. Encourage hand washing before handling  foods and/or drinks, and wash all fruits and vegetables that cannot be peeled.

Bottom line: be aware that as a matter of public policy in the present environment it is largely up to you to monitor the safety of the products used for your children.  Keep that in mind during future political campaigns.

Thanks for following.

Toys and learning

Kind of “a day late and a dollar short” after Christmas–let’s discuss best toys for child learning and development.  The American Academy of Pediatrics recently published new data on this (we are not directly addressing toy SAFETY here).

Firstly, if you like computers and tech–great.  However, recall that extended screen time has numerous disadvantages–limits imagination and creativity, can disrupt sleep and cause headaches.  To say nothing of expense! AAP guidelines suggest NO screen time < 2 years, 1 hour/day thereafter(excluding screen communication like Facetime with grandparents!).  Many of these toys claim to be “educational” but that is of questionable validity.  How are we defining the term?   Increased screen time may compromise impulse control, critical thinking, problem solving, and imagination (the program often does things for you) as well as language skills development.  Humans learn to interpret language in conjunction with cues like tone, volume, facial expression, body stance and position(“body language”).  Staring at a screen provides nothing here and may even inhibit that learning.  As so much of screen time is still a solitary endeavor it adds little to social interaction learning as well.

A related issue is “bells and whistles.”  Toys with lots of lights, sounds, actions/movements can be fascinating; but can do “too much”–distracting the child and preventing free imagination and creativity, again, doing those things for the player instead of the player doing it himself.  Often the fewer moving parts/components the better.

So what do good toys do?  Basic principles like cultivating good fine and gross motor function, language and social interaction skills are a good starting point.  It should allow her to play, explore, stimulate imagination and creativity, cultivate problem solving and critical thinking skills. Principles like “imitation” and “approximation”–aka “make believe” –mimicking adult daily activity and functioning skills are beneficial.

More specifics?  Blocks, shapes, balls of all sizes, push/pull/ride on toys promote gross motor development.  Puzzles, interlocking objects, toys with sand and water benefit fine motor skills.  Art objects are terrific–paint, crayons, colored pens and pencils, coloring books, play-doh, “silly putty”–provide endless possibilities to explore and create.  Traditional board games (“Chutes and Ladders”, “Candyland” checkers  for younger kids, “Monopoly”, “Clue”, “Life”, chess for older kids–lots of others) and old fashioned playing card games can enhance math, strategy, even team work as well as social exchange.  Imitation objects like tea and/or kitchen sets, make believe cleaning objects (brooms, vacuum cleaners),  toy tools, dress up objects, even SIMPLE action figures like toy soldiers and cowboys or dolls are flexible and versatile play enhancers/stimulators.

See?  Look how much you’ve done without logging on or using any electricity!

Bottom line? The key component to make a toy “educational” is YOU.  I always say–you are your child’s best teacher and their best toy.  So whether a computer or just a cardboard box–the more you engage, interact, participate in their play, the more educational the toy becomes.  Best of all-you’ll HAVE FUN, and create happy memories for you both while doing it.

Happy New Year to all, and thanks for following.

Discipline: Do’s and Don’ts

A “disciple” is a student, and “discipline” is “teaching”–not “punishment.”  Doing it properly is straightforward, but hard.  Implementing effective methods vary with a child’s age, development, and temperament.  Support for the statement “a good hard spanking is sometimes necessary to discipline a child” has dropped from 84% in 1986 to below 70% in 2012, and <50% of parents <36 years report EVER having spanked their child.

This is a positive trend.    The American Academy of Pediatrics officially opposes all forms of corporal punishment(CP)–parents should NEVER hit, slap, threaten, insult, humiliate, or shame their child.  There is sound reason for this.  A 2016 study found no evidence of long term benefit to the child from CP and only one study from 1981 could demonstrate any short term advantage.  A 1998-2000 study of >5000 children showed increased aggressiveness among 3 year olds subjected to CP with increased externalized behaviors and lower vocabulary scores by 9–they acted out more and communicated less.  Other studies associate depression in either parent with more negative appraisals and increased frequency of CP.  And there were these increased risks:

  • physical injury
  • more negative parent/child interactions
  • increased–not decreased–levels of defiance
  • mental health and learning disorders
  • child abuse
  • conduct problems in adolescence
  • adverse events(suicide, substance abuse) in adults

There were even biologic consequences–decreased brain volume(both white and gray matter) as well as higher cortisol levels (toxic stress hormones).

So what does work? Basic principles for younger children, but with applicability across the age spectrum include:

  1. “Show and tell”–explain “good” behaviors.  Note that this should be done at a “calm time”–when parent and child’s tempers are under control–NOT when the offense has just occurred and everybody is upset.
  2. Consequences should be clear, relevant, and explained at the same time and in the same way–calmly, when things are under control.  Emphasize the situation and not the child (“if things go well/badly”–NOT “if you are good/bad”)
  3. Appropriate intervention–“the punishment should fit the crime”(so to speak).  Don’t overdo.  If the child breaks something they must make restitution–simple. The intervention should have a beginning, middle, and END. Adjust attitude and MOVE ON.
  4. Say what you mean and mean what you say.  Threats are counterproductive, especially when not fulfilled.  “If you don’t hurry we aren’t going to Grandma for Christmas.” STUPID–you ARE going to Grandma’s, of course.  So you cannot back up that statement.  You just lost the battle, and the war. The kid now KNOWS he can call your bluff. And threatening the same thing repeatedly without desired result is similarly foolish–if that intervention did not produce success before, time to think of a new strategy, not just repeating the same thing LOUDER.
  5. Never lose an argument: don’t start something you cannot finish. Example–you cannot make her eat, so don’t endlessly argue over it.  But she cannot make you give her dessert, so when she melts down just ignore her, saying “tomorrow if you eat a good dinner you can have dessert.”
  6. Be prepared–many adverse behaviors are predictable.  You often know when/where they will misbehave.  Yelling and hitting is usually a tantrum on the parent’s part. Know what you are going to do when it happens, explain it (as above) and then calmly implement it when necessary. This is CONTROL.
  7. Ignore tantrums–NEVER try and”get them out of it.”  You cannot–they are unreachable then.  Put the child in a safe place(playpen, bedroom)–“when you calm down we will talk.” Let it blow over.  Then deal with the problem.
  8.  Nobody is perfect about discipline, and everyone will do better and worse at times.  It’s a daily process. So do your best, every day.

Finally–perspective, and humility.  They are children; misbehavior happens. They’ll NEVER be as perfect as we were back then, right? Just ask Grandma!

Thanks for following.

Holiday Safety

Happy Holidays to all! As a Jewish American, I still, like everybody else, so enjoy seeing all of the holiday decorations coming out. Who doesn’t get excited about this time of year?

Let’s review some highlights for indoor holiday decoration safety.  My advise about outdoor decorations is actually very simple–the younger the child, the less involved in the decorating process, the better.

  1. Trees
  • if using “artificial” make sure they are “fire resistant”
  • For live trees–fresh trees are green, have some sticky resin on the trunk, needles don’t snap in half when bent and don’t fall off if the tree is shaken.
  • Cut off approximately 2″ from the base and keep in water
  • Keep away from fire or heat source like heaters, radiators
  • Keep away from traffic areas like doorways.
  • Secure to walls with thin wire for stability

2. Trimmings

  • use only non-flammable
  • avoid sharp or breakable objects
  • avoid leaded materials (note–besides patriotism, “Made in America” is usually, but NOT ALWAYS, best)
  • Avoid small parts
  • avoid artificial candy or food

3. Candles

  • Keep away from trees
  • Keep away from paper
  • Non-flammable holders
  • Extinguish all flames if you go out or retire for the evening (this means YOU, fellow Jews celebrating with the Hannukah menorah!)

4. Lights

  • Check for broken or cracked sockets
  • Check wires
  • Never use electric light on metal tree–the tree can conduct electricity causing shocks or fires
  • Shut off all electric ornaments upon retiring for the evening
  • Do not overload sockets–no more than 3 standard light sets per extension cord

5. Paper

  • Don’t keep paper by open flame like fireplace or candles (DUH!!)
  • Do not burn used wrapping paper in fireplace

6. Spun glass–“angel hair” decorations of sprayed artificial snow can be inhaled and              cause serious lung injury

7. Poinsettias are poisonous–is it really necessary to include them in decorating your              house when there are young children around?

Bottom line that I remind all patients : Christmas decorations, and in particular, the tree, are the definition of “attractive nuisance”–little kids are drawn to them.  I mean–that’s the point, isn’t it?  So you cannot keep the child away from the tree.  You must endeavor to keep the tree away from the kid.

Please keep all of these things in mind.  And let’s make this the Happiest and HEALTHIEST Holiday Season yet!!

Send along questions and comments and thanks for following.

 

Safety Update

Let’s take note of 2 consumer products with troubled safety records for children.

The first is instant soup/”ramen” noodle preparations for microwave ovens.  An 11 year study finds that 20% of all scald burn injuries presenting to the ER, 9500 children aged 4-12 each year, are caused by microwaved soup containers.  The peak age is 7 years; girls make up 57% of injuries.  Most burns occurred when the small package was opened after heating, spilling contents on the child, causing burns to the torso (40% of all injuries).  The added water can quickly overheat and when tipped over can cause a scald wound.  While most incidents result in only mild burns with full and uneventful recovery, still up to 10% were more severe, including those requiring scar management and skin grafting.  So prudence is still the order of the day.

The authors recommend that improved product design, like smaller opening and wider base, will help to limit risk here.  But, of course, there is no substitute for common sense: Don’t let younger children handle these products; close supervision for adolescents. Counsel them to focus on the task at hand–PUT THE DARN PHONE DOWN when using microwave and handling hot food.

The other warning references hover boards.  Between 2015-16 researchers report almost 27,000 youth injuries treated in US Emergency Departments.  As one might expect, boys predominate here (52%) wth peak incidence at age 12.  Most injuries involved the upper extremity(34%) with fractures making up 40% of those problems; head injuries were second  but the most common to result in hospitalization (14%). Burns from the board spontaneously catching fire was actually a rare occurrence.  A frequent risk factor was “multitasking” involving–you guessed it–the child trying to use a smart phone or listen to music while operating the hover board.  Wouldn’t it be at least a small  welcome change if reading a book while hover boarding caused some of this problem(sorry, couldn’t resist)?

One added comment: this same study reported >120,000 skateboard injuries in the ED over the same 2 year period; 75% of those among boys.  One word: HELMETS!!

Send along questions and comments, and thanks for following.