Friday, September 24, 2010

Obesity Part II: Early Prevention (Prenatal through Preschool)

Is there anything you can do to prevent obesity in your child? YES, YES, YES!

First, look at your child's risk factors. Family history is important. One study showed that a child born to an obese parent (or parents) has an 80% chance of becoming obese herself. There could also be diseases in the family which are influenced by obesity. These would include diabetes, high blood pressure, cardiovascular disease, and stroke.

Conditions during pregnancy, such as gestational diabetes and maternal smoking, may contribute to a child's difficulty maintaining a normal weight. Babies born small for gestational age may have a predisposition to glucose intolerance. Breastfeeding may help reduce the chance of obesity.

By assessing risk factors I don't mean to introduce more guilt in your life as a parent. We all have a family history, we all have our own health issues, complications occur in pregnancies, and not everyone can breast feed their baby! I know all of this. However, in preventing obesity and its related diseases from happening it is important to know what the risk is from the beginning.

Early in infancy it is important to feed your baby when he is hungry, and allow him to stop when he is full. Watch for signs of hunger such as rooting and crying. Listen for the cry that means hunger, versus the cry that means irritability or sleepiness. Feed your baby "on demand." If the baby just ate and seems to be acting hungry again try cuddling, soothing, swaddling, or a pacifier before offering another feeding. If your baby is bottle feeding, watch closely for signs of her being full. Don't try to get her to just finish that last ounce. If she stops sucking, lets milk pour out of her mouth, or pulls away and turns her head, recognize these as signs she has had enough. Hold your baby when you feed her a bottle. Never prop a bottle for a baby.

As your baby gets older and learns to smile and interact socially, you can try toys and other distractions to keep her happy when she is fussy but not really hungry. The more you interact with your baby, the more you will get to know her and understand what she needs. Often it will be hunger, but sometimes it will be boredom, fatigue, or loneliness that needs to be addressed.

TV is a very poor substitute for interaction with you. Children grow up in the presence of lots of media. They learn to be entertained, rather than to entertain themselves. They learn to be inactive, and to stop using their brains. Developing minds and bodies do not need TV. It does not benefit young children at all. Yes, babies will watch videos, and appear mesmerized and happy, but they aren't learning anything that will help them later. Instead they are learning from an early age to be what we all don't want to be--couch potatoes! Add snacks and beverages consumed while watching TV and we are thoroughly indoctrinating them into the inactive lifestyle led by many Americans. No TV at all until age 2 or older is the best way to go.

In the toddler years trouble spots for weight control seem to center around excessive juice, excessive milk, and "grazing." Grazing is allowing your child to nibble on things throughout the day. Usually these are foods like fishy crackers, cereal, fruit snacks, puffs, pretzels, and other foods that are mostly made up of carbohydrates. Sippy cups allow toddlers to walk around all day sipping on milk or juice. These practices cause lots of eating problems. Children can get too many calories from this constant sipping and nibbling. They never feel hungry, so then they don't eat well and are very picky at meal times. As soon as they are the slightest bit hungry they whine and cry about wanting food. To top it off, they even are learning to treat boredom (and possibly negative emotions) with food.

You can help your toddler control his weight, be less picky, and be hungry for meals by feeding three meals and two or three quality snacks ONLY per day. At other times the kitchen is CLOSED! Also, limiting milk to 16-20 oz. per day, and juice to 4-6 oz per day will help your cause. Make snacks count--serve fruits, cheese, yogurt sweetened with applesauce or fruit, vegetables, hard-boiled eggs, and more at snack time. Don't give your child anything else to drink other than milk, water, and a tiny bit of juice. Pop? Do you have to ask?

Allow your child to become hungry before meals, then serve the stuff that's good for him first! My sister-in-law always dished out big bites of broccoli to her kids and mine while they complained of hunger and the rest of the meal wasn't quite ready. Guess what? The broccoli (or peas, green beans, or carrots) was devoured by many picky little people who were also quite hungry!

Save the empty calories (fruit snacks, fishy crackers) for an occasional little treat, or a difficult part of the week (the check-out line at the grocery store). Allow your child to freely drink water from their sippy cup, and give the milk and juice at meal and snack time. Teach your child to drink milk and juice from a regular cup and ditch the sippy cup as soon as possible.

As your child gets older--into the preschool years--keep up the practice of three meals a day, and two snacks. Make your child what she likes to eat at breakfast and lunch. Then, at dinner (if this is your family meal) serve one meal to your family. Do not make your child a separate meal. A few items in your meal should be kid-friendly. You can always set out some fruit, or a bowl of applesauce. At first, aim for good table manners--no saying "yuck" or throwing or pushing the food off the plate. Your first goal is to get your child to tolerate the presence of the food in front of him. Then you work towards a taste of everything, and then a few bites (cut them very small and ask for three bites from a three year old, four bites from a four year old...) of a less desirable food. If your child leaves the table hungry, there is always tomorrow and a good breakfast around the corner. No guilt here--you served the food, it was your child's choice not to eat it.

Please consider avoiding fast food restaurants. If you can get the food at the drive through window I would really question its nutritional value. Watch the video Super Size Me. I have not taken my own kids to that fast food restaurant (and most others) since I watched that movie! Most toddlers (and definitely preschoolers) recognize the golden arches, and will happily eat a meal consisting of chicken nuggets and fries. But why develop those taste buds when you could be working on the taste buds that some day will hopefully enjoy salad, whole grains, fruits, and vegetables? Why cultivate a taste for fatty, high calorie, high salt food that is low in nutritional value?

Encourage free outdoor play. Allow your young child to run, climb, dig, race, throw and kick balls, twirl, swing, slide, swim, and be free outdoors. Limit time in front of the TV or any media screen to one hour a day on most days, and definitely no more than two hours a day. Try to have twice as much outdoor play time as time in front of the TV. Children under the age of two should not watch TV.
Children should have a minimum of one hour a day of very active play.

Take care of yourself, too. Are you eating healthy food? Exercising? Limiting your time in front of the TV? It is much easier to help your child be healthy if you are also living a healthy lifestyle.

I am trying to give you ideas to help keep your child at a healthy weight with a good level of fitness, to minimize the risk of obesity related diseases, and to promote better self-esteem and enjoyment in life. All of us are a work in progress, and this goal is something to work toward. I hope I have given you something to think about, and some practical ideas you can put to use. As always, the advice in my blog is quite general, and is not meant to substitute for more specifically tailored instructions from your own personal pediatrician! Good luck.

As far as resources I used--the same ones I sourced in my first Obesity blog (Part I) were used here, as well relying heavily on my own experience as a pediatrician in general practice.

Sunday, September 12, 2010

Obesity: Part I

Big boned, husky, chunky, chubby, overweight, obese...we all know it's something we want to avoid. Many adults struggle with their own weight, and all of us worry about our children. We feel better when we are fit, when our clothes aren't too tight, and when we can move and breathe easily.

Screening for overweight and obesity is now a routine part of a pediatric check-up. A Body Mass Index (or BMI) can be calculated for children ages 3 and older. Just like a growth chart, children are compared to others of the same age and gender using percentiles. A BMI that falls into the 5th to 85th percentile is considered a normal weight. A BMI in the 85th to 95th percentile is overweight, and over 95th percentile is obese. If you aren't sure what a percentile is, check the end of this post and I'll do my best to explain it.

To calculate your child's BMI I would suggest a website that lets you plot it on a graph, gives you percentiles, and tells you what kind of calories per day your child needs: (just click on the BMI calculator when you get to the site)

A healthy weight is important not only for a positive self-image, but for the body's current and future health. With one out of three children weighing in with a BMI of 85th percentile or higher our society is seeing problems with high cholesterol, high blood pressure, pre-diabetes, type II diabetes, orthopedic problems, non-alcoholic fatty liver disease, and more--both in adulthood AND DURING CHILDHOOD.

A child who is overweight or obese should have a medical evaluation. Usually this will mean a check-up that will include a detailed history, checking height, weight, and blood pressure, calculating BMI, and a complete physical exam. Blood work is not a routine part of an obesity evaluation in a child, and would be decided upon individually. Family history is important in the evaluation of obesity.

There are some rare genetic syndromes and medical conditions that can make it more likely that a child will become obese, however, it is more common for obesity itself to CAUSE medical problems than the other way around.

The first step in dealing with obesity is recognizing it as a problem. I certainly see it daily in my office. I also see normal weight children who have a family history of obesity, or who have eating and activity patterns that put them at risk. There is much we can do to prevent and deal with obesity. But there is no easy answer, no pill, no surgery. The long-term, sustainable solution involves a change in attitudes, habits, and lifestyle. And solutions like these are always the most difficult.

In future posts I hope to touch on prevention and treatment, as well as recommendations for feeding your child. Dealing with this problem for your child and yourself could be one of the most important, life-changing things you can do as a parent.

I have used the following resources in preparing my blog:

Pediatric Obesity: Prevention, Intervention, and Treatment Strategies for Primary Care, Sandra G. Hassink, American Academy of Pediatrics, 2007.

Pediatric Obesity Clinical Decision Support Chart 5210, Sandra G. Hassink, American Academy of Pediatrics, 2008.

Addendum: Regarding percentiles: If your daughter has a BMI that is at the 50th percentile, this means she is right in the middle for her age (50% of girls her age would have a lower BMI). I also look at it like this: If there were one hundred girls her age and height, 50 of them would weigh less. If your son has a BMI at the 95th percentile, this means that 95% of boys his age have a lower BMI (I like to think of it this way: If there were 100 boys his age and height, 95 of these boys would weigh less).

Sunday, September 5, 2010

Calling the Doctor After Hours

Every time I am on call I answer after hours calls from worried parents. I have been on call, on average, 7 days a month for the last thirteen years. That would be 1092 call nights/days since I joined Trestlewood. If I average 10 calls a night (weekends more, weeknights less, winter more, summer less, but averaging it all out) that means I have answered over 10,000 calls from worried parents so far in my career! I have a lot of experience answering after-hours questions from parents via my cell phone. I know what are the most common reasons people call and what advice to give them. I know what really scares parents in the middle of the night, and how to tell parents what to look for if the illness is getting worse.

Still, after all these years, I greatly prefer that face-to-face contact in the office. It is still sometimes hard for me to figure out how sick a child is when I am talking to a parent over the phone. A description of a rash, swelling, injury or bug bite by the parent, using their frame of reference and experience, may conjure up a completely inaccurate mental picture in my mind when I try to match it to my frame of reference. Thermometers are broken, degrees are added or subtracted from temperatures, weights are not known, allergies are not remembered. Sometimes the person calling me isn't even with the child, so they are themselves telling me information they received from a third party.

And I often think my goals for the phone call and the parent's goals for the call differ wildly. My primary interest is to quickly and accurately provide an assessment of the nature and severity of the illness and whether it is possible to use home/natural methods to provide comfort until the child can be seen in the office. I think many people want more out of the phone call than that--it would be nice to be able to go back a month, or year, or years in the history to be able to arrive at an exact diagnosis, prognosis, and prescription, and possibly a note for school or daycare, and sometimes even a refill on another medication that has run out.

So with that preface I will provide you with my perspective, as an experienced after-hours phone call answerer, of what a parent should expect from the doctor answering the phone after hours.

What to Expect From After-Hours Phone Calls

If your child is an established patient at Trestlewood Pediatrics we want you to feel confident that, even when the office is closed, there is a physician available to help you with urgent questions about your ill child. We wrote these notes thinking it would be helpful for families to understand how our after-hours phone system works. The after-hours phone number for established patients of Trestlewood Pediatrics is available on our office answering machine, and is on our business/appointment cards. As of 2010 there is no charge for an urgent, brief, after-hours phone call. Most calls of this type take less than 3 to 4 minutes.

Office Cell Phone
When you call you will be pleased to notice that we do not use an answering service. Instead you will speak to the doctor on call directly on our office cell phone. If the doctor cannot take the call immediately (perhaps while driving, or taking another call), then the call will be returned using information you have left on our voice mail. We strive to return calls within 30 minutes. Sometimes we are at the hospital or answering other calls, however, and a return call is delayed. You should call back if you have not heard from us within 30 to 60 minutes.

The most important information to leave on the voice mail is your name, your child’s name and age, and your phone number. A few words about the problem can be helpful (“she is wheezing,” “I think he broke his arm.”). If the message is too long it will delay us in returning the call.

Our Goals in Answering Calls
When the doctor talks to you about your child he/she is trying to determine how serious of a problem this is and what needs to be done for it right now. This is called “triage.” For example, is it best to treat this problem at home with over the counter medications or home comfort measures and see the child in the office tomorrow, or should the child go to the emergency room now?

After hours the doctor does not have your child’s medical record, information about medication and allergies, and other important data needed to provide a thorough assessment and treatment plan. While a worried parent might understandably hope for a complete evaluation, diagnosis, plan, and prescription, this is actually very difficult for the doctor to do over the phone. In most cases the doctor’s goal after hours is to get your child through the night in the safest, simplest way we can until we can provide more thorough and personal care in the office.

It would be unusual for the doctor to call in a prescription, such as an antibiotic, without seeing your child in the office.

Calling About Specific Problems
Our web site might be helpful in addressing some simple questions, thus making some phone calls unnecessary. Also, the patient folder has information about common illnesses (fever, vomiting, diarrhea, sore throat, ear pain, pink eye, constipation, coughs, colds). The fever information includes a dosing chart for children under 35lbs. for acetaminophen (Tylenol) drops and suspension, and for ibuprofen (Motrin, Advil) drops and suspension.

Because we can’t see the child, rashes are very difficult to diagnose over the phone. With a rash we will attempt to determine if it represents a serious illness (the child would appear extremely ill in that situation) or if it is an allergic rash (such as hives). To receive a diagnosis beyond this the child would need an appointment in the office.

Saturday, September 4, 2010

Please Wear Your Helmet!

Every day I tell kids they should wear helmets. They should wear bike helmets whenever they are on something with wheels (bikes, skateboards, scooters, rip-sticks, roller-blades...) or ski helmets if skiing or snowboarding. They should wear the appropriate helmet for a motorized dirt bike or for off-road vehicles, as well.

Every day I have small children tell me they don't need a helmet because they never fall. Then I realize I have to convince both child and parent (mostly parents in this age group of kids) that the point of a helmet is to protect in case of an accident. I don't doubt the child's skill on the bike, or the quiet cul-de-sac the family lives on. I say that a helmet is like a seatbelt in the car. You always wear your seat belt in the car, right? But do you really think your Mom or Dad will get in a crash? No! So why wear the seatbelt? Just in case of an accident, in case something happens that we didn't know would happen. Helmets are the same kind of thing. They protect you in case of an accident, and we wear them because we don't know when accidents will happen.

I also tell kids (getting to a little older group now) something Dr. Van Es told one of my girls during her check up with him. I loved this explanation, and now I use it all the time. Doctors are good at fixing broken arms and legs, we just put them in a cast and a few weeks later everything is as good as new. Also, we can put band-aids on scrapes, and sew up cuts with stitches. But doctors are not good at fixing brains. If your head cracks open and you hurt your brain, there isn't much that we can do other than wait and see what kind of damage was done (and I add my own spin on it here, especially for adolescents). For example, a bad brain injury can take away your ability to talk, you might not be able to walk and have to use a wheelchair, you might not be able to control yourself to get to the bathroom and therefore need to wear a diaper, you might not be smart anymore...etc. So the helmet is extra important when you are on your wheels because it gives your brain an extra hard layer of protection in case of an accident.

And after feeling really good about how I have educated everyone I drive home for lunch in the summer and see lots of kids (many are my patients) in my neighborhood biking, skateboarding, rip-sticking, and scootering around with NO HELMETS. And they are in the street!

But street versus sidewalk is worth mentioning when it comes to helmets. The worst head injury from a device in this category of someone in my pediatric practice was a six year old girl who lived across from the elementary school and was a friend of my oldest daughter. She was on her little scooter on the sidewalk in front of her house, unhelmeted. Mom was gardening in the yard, right there to supervise. She hit a little crack or rock, fell off the scooter and hit her head hard on the pavement. Forty-five minutes later she was vomiting and very drowsy and lethargic, and within another hour or two was in the operating room having the bleed into her brain drained by a neurosurgeon. She is ok, but fortunate to have such a good outcome. Probably this was preventable if she had been wearing a bike helmet.

It is not enough to just tell kids to wear their helmets. They don't believe they need helmets because they don't think they will fall. As parents it is our responsibility to make our kids wear their helmets, with consequences if they do not wear them. We need to get all the parents in the neighborhood in on this rule, so one child doesn't have to feel the stigma of being the only one who has to wear a helmet. And we as parents have to set a good example! We need to wear helmets, too. It's a little funny to see families riding around town with three helmeted kids on bikes, but the parents on bikes have bare heads. How long do you think those kids will be wanting to wear helmets?

The Great Outdoors versus Turtle Salmonella

For me growing up and playing outside was all about seeing what was out there. We caught fireflies, minnows, toads (remember that warm wet feeling on your hand?), beetles, ants, frogs, and turtles. Today the emphasis is trying to get kids "back to nature." Get them playing outdoors, in nature, whenever possible. Give them free time to just play, make daisy chains and houses for fairies, use a dandelion to make wishes or check to see if you like butter (rub the yellow dandelion on someone's chin, if their chin turns yellow, they like butter), gather acorns and make houses for the acorn family, find bird nests with evidence that chicks have hatched (or have the mama bird swoop at you and scold you to keep away from her babies).

We are also told by health authorities that we shouldn't have our kids touch these animals (especially turtles) because they could be carriers of salmonella. Salmonella is a nasty gastrointestinal illness, and definitely worth avoiding. However, didn't anyone ever think of washing your hands? I think we should tell our children to go ahead and observe and even carefully catch turtles, frogs, toads, and garter snakes! It's exciting to do this and it makes nature more real. Kids can learn about nature and how to be kind to animals by creating their own relationship with them. They can learn about habitats and lifecycles. Protecting the environment becomes more important when we see who lives in the marsh, or even on the side of the road. What is all the trash we just picked up on the lakeshore doing to these animals? And it's all more real because of "Fenton and Frieda" (the frogs in the pictures), or Snakey the garter snake, or Percy the turtle--who all became "pets" for a few minutes before they were gently let go (and the child washed her hands).

Potty Problems: Number 1

I'll try a slightly different format for this one--kind of like Dear Abby. This is a real letter to me from a friend and former mom in my practice, and my actual answer to her (we used facebook!). I changed names (other than mine) to protect the innocent. As always please remember that the purpose of this blog is to provide you with more information and insight into how I personally think about health and illness. I am not trying to personally diagnose or treat your child. For that you need to discuss the problem with your medical professional. Other sources of information on the web could include, or

Hey Stephanie

I wanted to pick your brain a little. I hope you don't mind but I really trust your care for little ones and miss you as the girls' doctor.

So, our little sweetheart is a big three old, 40 lbs, 42 inches. She is potty trained day and night but has a huge problem holding her potty. When she has to go, she has to go NOW or potty comes out, she cries that she can't hold it, etc. At her well child in May I brought it up but she tested clear for urine and blood sugar. Took her in again in August b-cuz it has gotten worse but again nothing wrong with her urine. The doc here says she is just big for age and her bladder has not caught up. What do you think? My mommy intuition is telling me there is something else going on.

Please let me know your thoughts. Wish we could come up to MI and see you. It is very hard having new doctors for my girls.

Thanks, Sweetheart's Mom

Hi Mom:
Interesting problem. And a tough one to sort out. What I can tell you is what is usually the problem in this situation, and what else to look for.

The bladder is designed to be in a relaxed (empty) state. So when it gets stretched it has the tendency to spasm a little and give you the urge to urinate. If it gets overstretched, the problem will be worse, and the person will wet. Good bladder habits involve emptying the bladder regularly, or the bladder will stay kind of stretched out and having little spasms at unpredictable times.

Commonly there is a point in potty training where a child wants to experiment a bit with how long they can "hold it." Certainly the desire to not interrupt play, or stubbornness about doing what mom or dad want can play a part in "holding." You know how that looks--the bottom is wiggling, feet are moving, sometimes the hand is holding the urine in--but the child says "but I don't have to go." Maturity involves the child knowing themselves and how long it takes to get to the bathroom as well as the bladder physically being able to handle a fuller state.

So when there is a problem like you describe it is BY FAR most commonly resolved with a behavioral approach. Small, immature bladder or not, the behavioral method is most likely to work and doing testing is hardly ever helpful. And, thankfully, there is physically RARELY anything wrong (and if there is, behavioral approaches are usually best!).

What I normally tell a parent in your situation is that you have to go back to potty training (but now it's RE-training). The bladder needs to be emptied at regular intervals. It will have a harder time producing spasms that way and make accidents less likely. At first, the intervals need to be close enough together to capture the accidents (keep her dry). Set a kitchen timer, or your digital watch for 60-90 minutes. When it beeps you tell Sweetheart that the timer says it's time to sit on the potty.

Initially you might say something like "Sweetheart, we are proud of you and you must be so proud of yourself when you go potty like a big girl, and keep your underpants dry. We think there is a way we can help you get even better at staying dry. The doctor said there is a special way you can do that and we want to tell you how that will work..."

You might need rewards at this stage (something little--a sticker, a cracker), or praise might be enough. Sitting on the potty might have to be timed, or enough distraction provided to get her to relax and actually urinate (read a short book, listen to a song, sing a little song). She might have to think about whether all the urine actually came out.

When this becomes successful in controlling accidents, you attempt to increase the intervals to a more normal level of frequency. That's what I call "potty manners." Potty manners are going potty at regular, convenient times in the day (Pick some of the following: when you get up in the morning, before meals--combine with handwashing before eating, or after a meal, before leaving the house, before or after a nap, as soon as you arrive at a large store where the bathrooms are inconveniently located, as soon as you get to a friends' house--so you know where the bathroom is, bedtime, before you go outside, before you leave in the car on a trip, when you stop for gas, etc.). The point of potty manners is to normalize going potty throughout the day so there is a good habit and little resistance, and to keep the bladder empty.

When you are working on potty manners, EVERYONE makes a show of doing it too. For example, "Sweetheart, it's time for everyone to go potty before lunch, do you want to go potty first, or should I go?

Pitfalls in potty retraining:
1. Letting your child know how important this is to YOU, and how disappointed YOU are when they don't succeed is a pitfall. If your child realizes how they can use this to manipulate you, you'll have a tough time. Bowel and bladder control are something your child should be proud of, for themselves, for growing up. You should be happy for her as she achieves control. ("You must be so happy that you stayed dry on your playdate!).
2. Offering big tangible rewards is a pitfall. The beautiful Halloween costume hanging in the bathroom that she can have if she stays dry all day will quickly become something unattainable to her, or something she decides (after looking at it all the time) that she doesn't really have to have. Potty rewards seem to work best if they are tiny tokens of success (stickers, sugarless gum, a cracker), OR if there is an element of surprise (the potty prize box has 4 or 5 little but exciting rewards in it, and at each success the child opens the box and gets to choose--the key is that after the child chooses, the parent exchanges out some of the items, so the child never knows what will be in the box).
3. Constipation is a pitfall. Being really constipated makes it hard to empty the bladder, so it's constantly partly full. The bladder stays stretched out and spasming off and on, and accidents keep happening. This situation can lead to bladder infections too--and if this is part of your problem, then you should go back to the pediatrician. Stools should be daily and soft in consistency. Stools should not be huge, plugging the toilet. Nor should they be round balls or dry logs with cracks in them.
4. Not being consistent is a pitfall. Training is the key word here.

So what if I am wrong? The big sign would be that you can't get her to be dry even if you reduce the intervals down to 45" to an hour (assuming she is compliant with going potty then). The amount of urine that comes out doesn't necessarily help decide anything. Sometimes the bladder will spasm and just produce a little squirt, and sometimes it releases it all. If it all just doesn't work, the next step would be back to the pediatrician with a discussion of all the effort you put in behaviorally--and consideration of limited testing (maybe just an ultrasound, to stay noninvasive) and possibly a urology referral. But this, again, is hardly ever necessary, and even at the urologist's office you might get similar advice.

I hope I'm not missing anything, since my advice has been somewhat generic--so let me know if there are important details that I haven't considered. Also--you didn't tell me what happens at night (pull-up?).

Would you mind if I used my answer to you on my blog? I'll take out all personal info from you--but I think this might be a good one to post for others since it comes up so often.

I miss you too! Nice to hear from you.


Thank you so much for getting back with me in regards to Sweetheart's potty problem.
We are going to do the re training like you suggested and hopefully it will get her back on track. She has been potty trained since the spring and still could use reinforcement for keeping dry and making it to the potty on time.
I took her diapers away at night about a month ago and she does good but I wake her up before I go to bed and she also wakes up 1-2 times to go. She has also had her share of night time accidents. I will start rewarding her for staying dry at night.
You absolutely can use the question for your blog! I truly appreciate your wisdom. Thanks a bunch.
Have a great long weekend.
Sweetheart's Mom